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It is well established that left ventricular hypertrophy is a strong and independent risk factor for cardiovascular morbidity and mortality. This study was designed to determine the prevalence and correlates of left ventricular hypertrophy (LVH) among a sample population of 2318 totally asymptomatic men aged 40-59. This sample is a subset of the participants in the ECCIS Project. Left ventricular mass was estimated by echocardiography. The following individual variables were employed in the multiple linear regression analyses: age, diastolic and systolic blood pressure at rest and at peak exercise, body mass index, body surface area, conditioning physical activity. Three indexes of left ventricular mass were used: left ventricular mass/height, left ventricular mass/body surface area and "adjusted left ventricular mass" derived from adjustment, using a regression model, of left ventricular mass by age, body mass index and body surface area. The sample was subdivided in 3 blood pressure classes; normotensive (n = 1605), borderline (n = 390) and hypertensive (n = 323). All the variables considered with the exception of diastolic blood pressure both at rest and peak exercise were significantly correlated with left ventricular mass. Upper normal limits for left ventricular mass indexed to height and body surface area and of adjusted left ventricular mass were 143 g/m, 129 g/m2, and 245 g respectively. The prevalences of left ventricular hypertrophy, as determined by the reference standard of left ventricular mass/height, left.ventricular mass/body surface area and adjusted left ventricular mass, ranged 2.7-3.2% in the normotensive group, 4.2-5.4% in the borderline group and 11.8-14.5% in the hypertensive group, and were lower using adjusted left ventricular mass index. The results of this study show that the prevalence of left ventricular hypertrophy using adjustment by age, body surface area and body mass index reduces variability of left ventricular mass associated with age and body size and may be useful for the correct identification of left ventricular hypertrophy and hypertensive heart disease.

The study of simultaneous variations in heart rate (HR) and systemic blood pressure is of great interest in ergometric practice complementing the analysis of the ST segment by ECG. This paper examines data proceeding from 500 consecutive, normal, exercise stress tests with the aim of offering reference values on the step-by-step behaviour of HR, systolic and diastolic blood pressure (SBP, DBP) during exercise in a normal population. The sample comes from a large epidemiological study (ECCIS Project) conducted on 4842 healthy, working men, aged 40-59, which proposes to identify, by a 3 stage procedure, subjects with totally asymptomatic coronary artery disease (type I silent ischemia). A further aim of our paper is to examine the influence of some physiological variables (age, height, weight, body mass index, resting HR, SBP and DBP) on the response to effort of HR, SBP and DBP; reciprocal HR/SBP adjustment during exercise; maximal attained workload and recovery time. Due to a preliminary observation that the rate of step-by-step increase in HR and SBP is inversely related to total duration, the population was split into 4 groups according to exercise tolerance (defined by maximal attained workload) to elaborate reference values. Furthermore our data demonstrate that: 1) SBP increases more rapidly with respect to HR for older and heavier subjects; 2) Exercise tolerance is inversely related to age, baseline HR and SBP, and directly related to weight and height; 3) return to baseline conditions, during recovery, is quicker for subjects with better exercise tolerance and lower baseline HR, SBP and weight.

Background: The ECCIS project (Epidemiology and Clinic of Silent Ischemic Heart Disease) is an italian epidemiological study based on a population sample of 4,842 totally asymptomatic men aged 40-59 whose primary aim is the evaluation of the prevalence of totally silent myocardial ischemia and silent myocardial infarction., Methods: The systemic search for markers of silent ischemia and infarction was pursued along 3 screening stages: the 1st stage included resting electrocardiogram, hyperventilation test, exercise electrocardiogram and 24-hour Holter electrocardiogram; the 2nd stage included echocardiogram, thallium-201 scintigraphy in conjunction with exercise test or dypiridamole test, exercise radionuclide ventriculography and ergometrine test; the 3rd stage included coronary angiography. After the completion of the 1st stage procedures 439 men (9.1%) with abnormal results and low probability of disease were invited to the 2nd stage and 387 accepted to undergo the diagnostic procedures. After the completion of the 2nd stage, 104 men with moderate or high suspicion of silent myocardial ischemia or infarction were invited to perform coronary angiography but only 62 men accepted to undergo the 3rd stage procedures (participation rate 59.6%)., Results: The final diagnosis of totally silent myocardial ischemia or infarction on the basis of predefined criteria was established in 25 patients. The prevalence of silent ischemic heart disease on the overall original 4,842 men was 0.52% (95% CL, 0.32 and 0.72%), while the final estimate after adjusting for participation rates at 2nd and 3rd stages was 0.89% (95% CL, 0.6 and 1.1%)., Conclusions: The results of the ECCIS study show that the prevalence of silent myocardial ischemia is definitely lower than that revealed by prior epidemiological studies in Norway and in USA.

Three normal individuals and 17 cardiac patients with frequent VPBs were given mexiletine orally for 5 days (400-1000 mg daily in two to five doses). Each patient was evaluated by means of 24-hour Holter monitoring before treatment, on the fifth day and 4 days after the drug was discontinued. In 15 patients mexiletine serum levels were measured before and 2 hours after the first dose given in the morning. Urinary pH was also measured. VPBs were reduced by an average of 67.6%; in 11 patients the VPBs decreased by 92.3%. After treatment was discontinued, VPBs increased by 2.6%. Serum levels of the drug were generally within the therapeutic range (1.05 +/- 0.39 mcg/ml). We conclude that mexiletine is effective in reducing the number of VPBs; Holter monitoring and serum level measurements are both clinically helpful.

The efficacy and duration of the effects of verapamil on angina threshold during exercise were examined in five patients with proved angina pectoris, with the experimental model of a latin square 5 X 5. The effects of verapamil (0,1 mg/kg i.v.) were compared with those of a placebo (20 ml saline i.v.), of isosorbide dinitrate (5 mg, sublingual), of propranolol (0,1 mg/kg i.v.), and of dipyridamol (20 mg i.v.). All the treatments were studied within 20 minutes after administration; the efficacy of the "drugs" was checked against placebo. Verapamil and isosorbide dinitrate significantly prolonged the duration of exercise and total amount of work done before angina and EKG alteration appearance. Similar changes were observed after propranolol, but not significantly different from the effects of placebo. Dipyridamol reduced thw work performance, without significant difference from placebo. The effects of verapamil, though less marked than its peak effects, were still present 70 minutes after administration. The possible mechanism of work performance improvements induced by verapamil in angina pectoris is briefly discussed on the basis of the Triple Product changes observed during exercise.

The in-hospital mortality, the causes of death, the actuarial survival curves were compared in two subsequent groups of patients admitted to our CCU for acute myocardial infarction: the first (group A) includes 791 pts, admitted from september '67 to december '72, the second (group B) includes 542 pts admitted from january '78 to june '80. The in-hospital mortality was significantly reduced in group B (A: 186/791, 23.5%; B: 72/542, 13,3%, p less than 0.01). This could be due to a reduction of the number of deaths for cardiogenic shock (A: 71/791, 9%; B: 30/542, 5.6%; p less than 0.01) and to reduction in the mortality rate for pulmonary oedema (from 6% to 1.5%, p less than 0.01), although the frequency of pulmonary oedema was the same during the two periods (A: 205 pts, 26%; B/156 pts 29%). We did not observe any significant difference in the long-term prognosis (54 months: A 79.3%, B 71.5%). The actuarial survival curves overlapped after the 1st semester after discharge. The most frequent cause of death during follow-up was a new myocardial infarction. None in the group A and only 3% in the group B were referred to the surgeon for coronary artery bypass grafting. We conclude that, in spite of a significant reduction of the in-hospital mortality, possibly related to the evolution in diagnosis and management of the disease, the long-term survival was not improved in a non-surgically treated population with myocardial infarction.

This study includes 290 patients having a 75% or greater stenosis of a sinlge coronary vessel, divided into two groups: 205 cases with isolated lesions of the left anterior descending coronary artery (LAD) and 85 with a stenosis of the circumflex (CF) or of the right (RCA) coronary artery. The following data have been compared in the two groups: -- characters of angina; -- results of stress testing; -- extent of left ventricular contraction impairment; -- natural history of unoperated patients; -- surgical risk; -- long term survival of operated patients; -- effect of medical or surgical treatment on symptoms. Results were as follows: -- LAD patients had slightly more severe symptoms and lower exercise tolerance than CF and RCA patients; -- no significant differences were noted as regards left ventricular contraction; -- five year survival rates were only slightly different both regarding unoperated patients (80 +/- 5% survival in LAD disease group; 86 +/- 5% in CF and RCA disease) and operated cases (83 +/- 5% in LAD lesions, 86 +/- 7% in CF and RCA disease); -- surgical risk was relatively low in both groups; -- progress of symptoms after bypass surgery was very favourable. Based on these results, indications for surgery in single coronary vessel disease are discussed.

A randomized double-blind cross-over trial was carried out in 20 patients suffering from ventricular ectopic contractions (VECs), in order to evaluate the effectiveness of a new antiarrhythmic drug, Propafenone (P), versus Lorajmine (L). The patients were given 900 mg/day P and 600 mg/day L in three divided doses for 3 days. Every patient was evaluated with four 24-hour ambulatory ECGs, the first at the beginning of the trial, the second after the administration of the first drug, the third after the administration of the second drug and the last after wash-out. With P, the average fall in VECs was 70.6 +/- 10.8% with a clinically significant individual response in 14 of the 20 patients (VECs reduction greater than or equal to 75%, VECs mean decrease: 93.5 +/- 2.1%). With L, VECs decreased by 37.4 +/- 14.2% whilst VECs reduction was larger than 75% only in 50% patients (VECs mean decrease 85.8 +/- 3.1%). Lastly, after therapy interruption, VECs globally increased by +5.4 +/- 14.4%. Propafenone is a considerably active drug against ventricular arrhythmias. It proved to be more effective than Lorajmine under our experimental conditions.

Results about an echocardiographic study of 20 patients with Ebstein's anomaly diagnosed by cardiac catheterization and angiography, are referred. In 8 patients an echocardiogram and phonocardiogram were recorded and in five patients an echocontrast examination was performed. The echocardiographic features constantly recorded in Ebstein's anomaly are represented by anterior chamber dilatation, interventricular septum paradoxical movement, anterior tricuspid leaflet wide excursion, decreased diastolic closure rate and delayed closure of tricuspid valve compared to mitral valve. The reduced left ventricular dimension and frequent incidence of "hammock-like" shape of mitral valve during systole and reduced diastolic closure rate of anterior mitral leaflet are pointed out. Possible causes of anterior chamber dilatation, of interventricular septum paradoxical motion and delayed tricuspid closure are discussed. According to the previous study no echocardiographic pattern is surely diagnostic of the disease by itself; a delayed tricuspidal closure (more than 70 msec) when associated to an anterior tricuspid leaflet wide excursion and decreased E-F slope, is of particular value for diagnosis.

Clinical data, EKG and coronary angiography of 187 patients with unstable angina are given. The patients are divided into 4 groups: spontancous angina, spontaneous angina Prinzmetal's variant, "in crescendo" agina, intermediate syndrome. 103 patients were treated with pharmacological therapy only and 84 underwent aortocoronary bypass; 2 of them were operated on for acute myocardial infarction. The clinical and pathologic peculiarities of two groups are not similar and therefore the results are not comparable. There was a mortality rate of 10.3% of patients with pharmacological treatment and the incidence of non fatal myocardial infarction was 10.4%. The mortality during operation was 14.2% and the incidence of non fatal myocardial infarction was 13.1%. The spontaneous angina and Prinzmetal's variant often had normal rest EKG and a very similar coronary angiographic pattern, with obstructive lesions often localized in the proximal part of a single vessel. In 9% of cases coronary arteries were normal. The incidence of serious arrhythmias was higher in Prinzmetal's variant than in other types of unstable angina. The mortality in patients with Prinzmetal's angina was particularly high during the first period of experience (1970-1973) when the operation was performed after a few days of unsatisfactory results with pharmacological treatment; it decreased after patients underwent operation in an attenuate phase of the disease. The rest EKG of "in crescendo" angina was almost always pathologic; these cases presented obstructive lesions of 2 or 3 coronary arteries, functional impairment of left ventricle, collateral circulation. The mortality in patients treated with pharmacological therapy was higher than in other types of unstable angina. The mortality during operation, fairly high in the first period of experience, decreased in this group of patients as well, during the second period of experience.

--123 atrial pacings (AP) performed as diagnostic investigations in patients with chest pains were re-examined. By using floating catheter without fluoroscopic control, this technique is very simple to perform and free from relevant risks. The diagnostic sensibility and specificity of AP were examined in 93 patients in which a coronary arteriography was performed; these figures were compared with the corresponding values observed in 65 patients in which an adequate diagnostic exercise test (ET) was also available. The diagnostic sensibility of AP examined in 63 patients with significant coronary artery disease was 90%; the corresponding value of ET was 79%. In particular, in patients with single vessel disease, the sensibility of AP (90%) was much higher than that observed in ET (40%). The specificity of AP examined in 30 patients free from significant stenosis of the coronary arterial tree was 43%. This value was largely lower than that observed in ET (82%) in the same patients, and appears to be inadequate for validation AP as a diagnostic tool in coronary heart disease. Therefore, AP must be limited to functional, and not diagnostic, evaluation of patients in which the diagnosis of coronary heart disease can be made by other means.

The Authors report on eleven years and six months experience with permanent endocardial pacing in the treatment of various conduction disturbances. This experience relates to 1678 patients, 3617 pacers were used. The age of the patients ranges from 60 to 80 (70%), 30% referring to the remaining decades, minimum 14--maximum 94. Fixed rate pacers were used in 31% of cases, QRS synchronous or QRS inhibited pacers were used in 69%. Average life of the pacers varies from 25 to 29 months; the average life of fixed rate pacer is higher. Complications and causes of failures, among which electrode dislodgement is the most relevant and frequent, as well as the relative therapeutical treatments, are described. Early mortality is about 1% and late mortality 20%; the survival rate calculated altogether after 11 years and 6 months treatment with implantable pervenous pacing is about 16%.

100 patients with mitral prolapse syndrome (MPS) were studied with electrocardiogram, phonocardiogram, thorax radiography and echocardiogram. In 44 of the patients, the effort test and dynamic electrocardiogram were performed; 25 underwent hemodynamic examination, and 10 underwent selective coronarography. The most frequent symptomatologies were palpitations and vertigo; the most-registered electrocardiographic alterations were ventricular extrasystoles and altered electrical repolarization in the inferior seat. The symptomatic patients with rhythm disturbances showed reduced work capacity (RWC) with aggravation of the effort arrhythmias. The phonocardiogram showed variability of the phonoauscultatory reports, not only from patient to patient, but also in the same patient. The apicocardiogram presented a characteristic systolic re-entry which coincided with the non-ejective click. In all cases, the echocardiogram demonstrated a systolic movement backwards from the mitralic strips with different aspects. The endocavitary pressures in the studied cases were normal or only slightly altered. The left ventriculography frequently demonstrated assynergic areas, and constantly, eversion of the posterior mitralic strips in the left atrium. In most of the cases, the selective coronarography showed the absence of the ventricular atrial tract of the circumflex. The sustained role of the mixomatous degeneration in the pathogenetic mechanism of the MPS must be emphasized. The beta-blockers were the most effective drugs against arrhythmias, which in some cases showed themselves impervious to any medicinal treatment. MPS is considered a very diffuse disease which can run its course without detection or which can be accompanied by serious rhythm disturbances that can threaten the patient's life. The importance of echocardiography in the diagnosis of MPS is emphasized. The SPM patient showed undergo a series of wave tests which reveal malignant potentialities, so that the best therapeutic principles, both for the treatment and prevention of the arrhythmias, can be applied.

34 patients have been controlled after beta-blocking therapy, for a mean period of 5 years. Symptoms and evolution: syncope disappeared, angoy passed from 47% to 23%, dyspnea from 65% to 47%, dizziness from 70% to 54%, weakness from 30% to 37%. A systolic murmur was present in 75% of the cases. Two patients died by heart failure. Phonocardiogram: the systolic murmur was unchanged, like the carotid pulse. Paradoxical splitting of the 2 degrees sound was more frequent, atrial sound unimodified, isometric contraction shortened (60%) and the Q-1 degree sound interval prolonged (90%). Electrocardiogram: 1 degree A/V block appeared in 24% of the cases, complete A/V block in 9%, atrial fibrillation in 3%. Left atrial enlargement was more frequent; left ventricular hypertrophy unchanged. Heart catheterization (10 cases, after a mean period of 5.5 years): left ventricular pressure gradient passed from 80% to 90%; a low cardiac index from 20% to 30%; telediastolic pressure of left ventricle was unmmodified in 10% of cases, more elevated in 50%, less elevated in 40%. Chest X ray: cardiac size was unchanged in 65% of cases, enlarged in 32%; smaller in 3%. In conclusion, symptoms improved in most of the patients; no case of sudden death was observed. Some data however show that the evolution of the myocardiopathy goes on to congestive heart failure and arise doubts on the real usefullness of beta-blocking drugs in the disease.

519 patients with angina pectoris studied by selective coronary arteriography and left ventriculogram, were followed for a period ranging from 18 months to 7 years. The mean follow-up was 42.2 months. The patients showed a survival probability of 81% at the 7th year. After 5 years the survival probability was 83.2% for patients with typical stable angina, 70.3% for patients with unstable angina, 96.7% for patients with atypical angina. The survival probability was 78.8% for the male sex and 94.6% for the female (at the 5th year). Age, a long-lasting angina, the presence of: previous infarction, myocardial failure, cigarette smoking, hyperlipidemia, cardiomegaly and an ischemic resting EKG were factors with poor prognostic value. The prognostic value of significant coronary stenosis was confirmed. The survival probability at the 5th year of the patients without critical stenosis was 96.6%, of patients with stenosis of 1, 2 and 3 main coronary arteries was respectively: 87.6%, 79% 54.7%. Significative prognostic differences were observed in patients with normal left ventricle kinesia (survival probability at the 5th year: 90%), compared with patients with severe VS ipokinesia (62.7%) and with VS diskinesia (69%). In the follow-up period an incidence of 9% of myocardial infarctions was observed. The degree of each stenosis and the number of vessels involved, the type of angina, the presence of risk factors or previous myocardial infarction did not affect the clinical evolution of angina.

The authors report on nine years' experience with permanent endocardial pacing in the treatment of various conduction disturbances. Their experiences relate to 1125 patients; 2208 pacers were used. The age of the patients ranges from 60 to 80 (85%), 15% referring to the left decades, minimum 17 - maximum 94. Fixed rate pacers were used in 41% of cases, QRS synchronous or QRS inhibited pacers were used in 59%. Average life of pacers varies from 8.5 to 28.3 months; the average life of fixed rate pacers is higher. Complications and causes of failures, among which electrode dislodgement is the most relevant and frequent, as well as the relative therapeutical treatments, are described. Early mortality is about 1% and late mortality 8-9%: the survival rate calculated altogether after 9 years' treatment with implantable pervenous pacing is about 24%.