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Background: In 1986 the Cardiology Department, including an outpatient clinic, was established in the community hospital of Savigliano (Italy). In 1987, as a part of a cardiovascular community prevention program, an epidemiological survey on cardiovascular risk factors was carried out. Similar indicators have been object of the study held in 1998 by ANMCO-Istituto Superiore di Sanità: the Italian Cardiovascular Epidemiological Observatory. So, 11 years later, we have had the chance to compare the changes, in the same community, of three important risk factors: tobacco smoking, arterial blood pressure, and obesity., Methods: The 1987 survey included 280 subjects, aged 20 to 59 years. The 1998 survey has examined 200 subjects, aged 35 to 74 years. In both cases the subjects have been randomly selected from the Electoral Registers; subjects were asked to answer a questionnaire on tobacco smoking; arterial blood pressure measured using a cuff manometer was registered and weight and height have been recorded. In order to have comparable data we have only considered subjects 35 to 59 years old., Results: One hundred and fifty-seven subjects (84 males and 73 females) were included in the 1987 survey and 123 (60 males and 63 females) in the 1998 survey. In 1987, the percentage of smokers was 40.7% (61.4% of males and 17.8% of females), with an average of 23.4 cigarettes/day among males and 14.7 among females. In 1998, the percentage of smokers has dropped to 18.6%, without any differences between sexes, with an average of 11.9 cigarettes/day among males and 12.7 among females. The mean values of blood pressure were lower in 1998 than in 1987 both in males (129.4/85.7 vs 138.0/88.2 mmHg) and females (119.3/80.2 vs 138.4/86.5 mmHg). Although not statistically significant, the percentage of individuals with systolic blood pressure > or = 160 mmHg or diastolic blood pressure > or = 95 mmHg was lower in 1998 (15.9% among males and 14.2% among females) than in 1987 (25.6% among males and 22.8% among females). The mean values of body mass index were unchanged (from 25.4 to 25.2 kg/m2 in males and from 23.4 to 23.1 kg/m2 in females)., Conclusions: The incidence of tobacco smoking and of hypertension has shown a significant reduction in the population of Savigliano between 1987 and 1998. No significant variation was found in body mass index or in the prevalence of obesity. The distribution of these three risk factors seems to be lesser than that reported in northern Italy.

This paper deals with a literature survey on natriuretic peptides (NP) and their clinical use in prognostic stratification and therapy of arterial hypertension and cardiac failure. After a brief historical introduction, the phylogenesis of NP is analyzed and the reasons of their preservation in the evolution are emphasized. The biochemistry of the NP is then treated, and the structure, synthesis, mechanism of cellular action and systems of regulation are analyzed. Subsequently, the authors have analyzed the physiology of the NP as well as their hemodynamic and biohumoral effects and actions on the central nervous system. A literature review on the significance of NP in arterial hypertension, on their usefulness as indicators of damage and on their therapeutic practice is then made. In particular, the possible future applications in the prevention of atherosclerotic damage are analyzed. The significance of NP and of their metabolites in heart failure and the prognostic implication of these peptides particularly in ischemic heart failure are then discussed. The most important papers on this topic are described. Finally the studies on the use of NP in the therapy of heart failure are analyzed and a guide on research of this topic is defined.

Background: Several weeks of prophylactic anticoagulation are routinely prescribed before and after electrical cardioversion of atrial fibrillation. Recent studies have supported the use of transesophageal echocardiography to guide early cardioversion: patients in whom no thrombus is observed are treated with heparin followed by one month of warfarin therapy after the procedure. This kind of treatment requires hospital admission during heparin infusion, because of the need for monitoring partial thromboplastin time., Aim of the Study: To evaluate if a short at-home treatment (three days) with warfarin is sufficient to reach a good level of anticoagulation, in order to permit safe electrical cardioversion in day-hospital for patients who show no thrombi on transesophageal echocardiography., Methods: One hundred twenty-four patients with atrial fibrillation, who were candidates for cardioversion, were treated with warfarin: 10 mg the first and second day, 5 mg the third day in group A patients (n = 79); 15 mg the first day, 10 mg the second and third day in group B patients (n = 45). On the fourth day, INR value was measured and if it was < 2, warfarin therapy was prolonged until patients reached a good level of anticoagulation. Transesophageal echocardiography was performed when the INR was > or = 2, and patients were cardioverted with DC shock if there were no thrombi. The patients were discharged on the same day of the procedure, and warfarin therapy was continued for 4 weeks there-after. If a thrombus was detected, patients repeated transesophageal echocardiography after 6 weeks of warfarin therapy, and were cardioverted if the thrombus disappeared. Otherwise, cardioversion was deferred and they received prolonged warfarin treatment. If there was poor visualization of the left atrial appendage, patients received conventional warfarin therapy for 3 weeks before and 4 weeks after electrical cardioversion., Results: Mean INR value after three days of warfarin treatment was 2.41 in group A patients and 3.02 in group B patients. Twenty-one patients from group A and 3 patients from group B required anticoagulant therapy for a mean of 3.3 and 5.1 days, respectively, before reaching a good level of anticoagulation (INR value > or = 2). Eight patients reverted spontaneously to sinus rhythm before transesophageal echocardiography. Eighteen thrombi (15.5%) were identified on the transesophageal echocardiography, all of which were in the left atrial appendage. In 11 cases, thrombus disappeared after 6 weeks of warfarin therapy. In 7 patients (6%), the atrial appendage was not sufficiently visualized. Electrical cardioversion was performed on 109 patients and was successful in 88 (80.7%). None of them experienced a clinical thromboembolic event., Conclusions: In the majority of patients in atrial fibrillation, a short at-home warfarin treatment is sufficient to reach a good level of anticoagulation in order to permit safe electrical cardioversion in a day-hospital situation. Larger initial doses can achieve even better results. This treatment algorithm minimizes the anticoagulation period, hospital stay, overall duration of atrial fibrillation and the time required for the mechanical function of the left atrium to return.

Background: The MS200 Cardioscope, from MRT Micro as., Norway, is a 12 channel ECG card to be directly inserted into a standard personal computer (PC). The standard ISA Bus compatible half length card comes with a set of 10 cables with electrodes and the software for recording, displaying and saving ECG signals. The system is supplied with DOS or Windows software. The goal of the present work was to evaluate the affordability and usability of the MS200 in a clinical setting., Materials and Methods: We tested the 1.5 DOS version of the software. In 30 patients with various cardiac diseases the ECG signal has been recorded with MS200 and with standard Hellige CardioSmart equipment. The saved ECGs were recalled and printed using an Epson Stylus 800 ink-jet printer. Two cardiologists reviewed the recordings for a looking at output quality, amplitude and speed precision, artifacts, etc., Results: 1) Installation: the card has proven to be totally compatible with the hardware; no changes in default settings had to be made. 2) Usage: the screens are clear; the commands and menus are intuitive and easy to use. Due to the boot-strap and software loading procedures and, most important, off-line printing, the time needed to obtain a complete ECG printout has been longer than that of the reference machine. 3) Archiving and retrieval of ECG: the ECG curves can be saved in original or compressed form: selecting the latter, the noise and non-ECG information is filtered away and the space consumption on disk is reduced: on average, 20 Kb are needed for 10 seconds of signal. The MS200 can be run on a Local Area Network and is prepared for integrating with an existing informative system: we are currently testing the system in this scenery. 4) MS200 includes options for on-line diagnosis, a technology we have not tested in the present work. 5) The only setting allowed for printing full pages is letter size (A4): the quality of printouts is good, with a resolution of 180 DPI., Conclusions: In conclusion, the MS200 system seems reliable and safe. In the configuration we tested, it cannot substitute a dedicated ECG equipment: from this point of view, a smaller PCMCIA-type card with a battery-operated notebook PC will be more suitable for clinical uses. Nevertheless, the possibility to log and track ECG records, integrated into the department informative system, may provide a valuable tool for improving access to medical information.

We present a case of left ventricular pseudoaneurysm diagnosed by chance 6 years after a second surgical intervention on the mitral valve (replacement with a St. Jude prosthesis). A combination of cross sectional and color-Doppler studies led to the correct diagnosis. A transesophageal echocardiographic investigation did not provide further information, while the diagnosis was confirmed by computed tomography with contrast agent. A retrospective analysis of previous examinations revealed that the pseudoaneurysm developed shortly after the mitral valve replacement, remaining stable over the years. The patient was clinically asymptomatic, the size of the pseudoaneurysm did not increase during a 2 years followup, and we decided to follow a conservative treatment.

We analyse subjective and objective clinical manifestations, in 33 patients, among the 63 with "pure" temporal lobe epilepsy, for which we obtained at least a video-EEG or video-stereo-EEG ictal recording. We compared video-EEG recordings (103 seizures, mean 3.9; min 1, max. 23) and video-stereo-EEG recordings (77 seizures, mean 3.2; min 1, max. 13) with anamnestical data, in order to define the degree of reliability of patient and relatives reports. Overall agreement between anamnestic and video-recorded informations is excellent for subjective symptoms, and fairly good for objective signs. Subjective manifestations (reported in 90.1% of this group) are described in detail as well as the objective ones, these latter split divided into early and late manifestations.

Background: Thromboembolic complications after electrical cardioversion (CV) of atrial fibrillation (AF) have been attributed to the dislodgment of preexistent left atrial thrombus during the resumption of atrial contraction. Transesophageal echocardiography (TEE) has been used to identify patients without thrombus, who potentially could undergo CV without anticoagulation. However, embolic events after CV in patients without evidence of thrombus on TEE have recently been reported., Aim of the Study: To evaluate if absence of thrombi or prethrombotic conditions such as spontaneous echo contrast or left atrial appendage disfunction can justify electrical CV without anticoagulant therapy., Methods: Seventy-four patients with AF and candidates for CV underwent monoplane TEE. Patients were cardioverted without anticoagulation in case of: 1) absence of thrombus and/or spontaneous echocardiographic contrast and 2) good visualization of left atrial appendage, with a well defined peak blood flow velocity greater than 20 cm/sec. In all other cases, patients underwent anticoagulant therapy which started 3 weeks before CV and continued for 4 weeks afterwards., Results: Forty-six patients, without thrombus or "prethrombotic" conditions, did not receive anticoagulation, while 28 followed traditional therapy with warfarin. Four patients with a thrombus in the left atrial appendage were identified: 1 died of cerebral embolism 3 days after the beginning of anticoagulation, in another one CV was definitely deferred because of the persistence of thrombus after 1 month of warfarin therapy. One patient, with left atrial appendage disfunction, died suddenly after 5 days of anticoagulation. Two patients reverted spontaneously in sinus rhythm. Two patients refused electrical CV. The remaining 67 patients underwent electrical CV which was successful in 56 of them. Cerebral embolism occurred 24 hours after CV in one patient who did not receive anticoagulation. Repeat TEE soon after embolism showed absence of thrombus or spontaneous echo contrast, but the presence of low flow velocity in the left atrial appendage., Conclusions: In patients in AF candidates for CV, exclusion of thrombi or prethrombotic conditions by TEE does not exclude the risk of thromboembolic events and the need for anticoagulant therapy. Left atrial appendage function can be stunned or impaired immediately after CV, favouring a thrombogenic milieu and subsequent embolic events. Therapeutic anticoagulation at the time of as well as after cardioversion is actually recommended.

Cor triatriatum (CT) is a rare malformation consisting of a fibromuscolar membrane that subdivides the left atrium in a postero-superior (or accessory) chamber and an antero-inferior chamber (true left atrium, containing the left atrial appendage). In its classic form, the accessory chamber receives the pulmonary veins and communication with the left atrium is accomplished by way of one or more fenestrations in the membrane. The malformation is usually isolated, but in about one in four patients is associated with other congenital defects of a complex nature. We describe a case of CT associated with atrial septal defect, in which transthoracic echocardiography failed to document the existence of CT membrane, while this abnormality was clearly seen and defined by use of transesophageal echocardiography. The patient was a 26 year-old girl, presented at our outpatient clinic after an episode of palpitations and dyspnea, which lasted for two hours. She suffered of mild dyspnea on exertion during the last three months. Physical examination revealed the typical findings of an atrial septal defect (ASD), and the electrocardiogram revealed right bundle branch block. The two-dimensional echocardiography disclosed an ostium secundum ASD with left to right shunt; dilatation of the right cavities; paradoxical movement of the interventricular septum. A small linear echo originating from the lateral wall of the left atrium, with no evidence of turbulent flow on pulsed wave Doppler and color flow examination, was interpreted as an artifact. Transesophageal echocardiography clearly visualized a tense, bulging membrane separating left atrium into two chambers.(ABSTRACT TRUNCATED AT 250 WORDS)

After a 3-year (1985-1988) experience of myocardial revascularization using internal mammary artery (AMI) grafts and after having excluded (1986) an higher operative mortality and morbidity, clinical medium-term results have been analysed. The first 144 patients discharged alive after AMI bypass surgery in 1985 were clinically evaluated, with a mean interval of 21 months from surgery (range: 5-29 months). Exercise electrocardiographic test was performed by 100 patients, and angiography repeated in 15. Actuarial survival function was estimated by Cutler-Ederer method: 2-year actuarial survival was 99.3 +/- 0.7% (94 +/- 1.8%, when operative deaths were included). Non fatal myocardial infarction occurred in 3 patients and, at follow-up, 26 were symptomatic for angina: 2 patients underwent re-operation and 2 angioplasty. Two years after AMI bypass surgery, actuarial estimate of ischemic event-free patients was 70.9 +/- 4.5% (67.7 +/- 4.5%, when operative deaths were included): 73 out of 100 exercise tests were negative for both angina and ischemia, although only 43 patients, reached maximal work load; 9 were positive for both angina and ischemia and 18 for ischemia only. All patients who underwent angiographic evaluation (15 patients, 11 of whom because of angina relapse) had AMI grafts open, while in only 4 patients all the implanted grafts were open.

Ten children with chronic hepatitis B have been followed for at least 3 years. All patients received 2 liver biopsies, the first after 1 year of continuous liver disfunction and HBsAg positivity, and the second 2 years after, that showed a mild improvement of the histologic lesions in 4 cases of chronic persistent hepatitis (CPH) and in 1 case of chronic lobular hepatitis (CLH). Three children out of 5 with chronic active hepatitis (CAN) changed to CPH and the other 2 remained unchanged without any evidence of cirrhosis. No patient received any drug for the treatment of hepatitis.

Cardiac involvement is commonly seen in the carcinoid syndrome (C.S.). However echocardiographic observations in this condition are still very scanty. In two patients with the C.S. and clinical signs of tricuspid insufficiency (plus mild pulmonic stenosis in one case) two-dimensional echocardiography showed: 1) right ventricular overload with normal left heart valves and chambers; 2) a peculiar aspect of the tricuspid valve, whose three leaflets were markedly thickened and retracted. The anterior leaflet was almost fixed in a semi-open position while the septal and posterior leaflets appeared as rigid structures fixed in an open position, extending from the annulus into the right ventricular cavity. In both cases only the posterior cusp of the pulmonary valve could be visualized. The afore-mentioned changes exactly reproduce the pathological features of the tricuspid valve in the carcinoid heart disease and so far, have not been observed in other conditions.

On the basis of a personal observation and from a complete review of the existing literature, clinical and instrumental findings of right atrial myxoma are described. The clinical presentation appears to be rather characteristic. The presence of systemic symptoms, peripheral venous hypertension and/or right heart failure without apparent cause are a clue to the diagnosis especially in an adult woman. The presence of abnormal sounds and/or murmurs in the tricuspid area and intermittence of the signs of obstruction are further support to the diagnosis. The diagnosis can always be made non-invasively by echocardiography, though some pitfalls seem to be inherent to the M-mode technique. The accuracy of two-dimensional echocardiography in the diagnosis of the right atrial myxoma is such that no further investigations are necessary before surgery.

Clinical results of coronary artery bypass surgery, have been evaluated by analyzing operative mortality, late survival, late functional results and their related risk factors. Four hundred and thirty-seven consecutive patients who underwent coronary artery bypass surgery between January, 1979, and December, 1983, were the clinical material of this study. The gender of patients was male in 89% of the cases; age ranged from 34 to 78 years with a mean of 54.8 +/- 8.2 (SD). Patients with combined surgical procedures were excluded. Follow-up averaged 55.7 months; 404 survivors have been contacted (97% of the total study population, if operative and late deaths are added); 218 patients underwent a control exercise test; postoperative employment status was determined for 242 individuals. The operative mortality was 5.49% (24 patients). Death was due to cardiac causes in 75% of the cases. The overall actuarial survival rate was 85 +/- 1.9% after 5 years and 83.4 +/- 2.2% after 7 years. When non-cardiac related deaths were excluded the actuarial rates were 88 +/- 1.7% and 87.2 +/- 1.9% after 5 and 7 years respectively. Actuarial freedom from all ischemic events (cardiac related death, late myocardial infarction or recurrence of angina) was 66.1 after five years, and was 70.2% if operative deaths were excluded. Actuarial freedom from recurrence of angina for patients alive at follow-up was 78.7% after five years, actuarial freedom from myocardial infarction was 93.5%. The mortality hazard showed a diphasic response, being higher perioperatively and constant in the following 5 years of follow-up. All ischemic events, both singularly and together, showed an accelerated rate of occurrence at the first and after the fifth postoperative year, the slope of the curve being quite flat during the 1 to 5 year interval. The control exercise test was negative for 62.8% of the patients, positive for 33.5% and undeterminable in 3.7%. Employment status was postoperatively unaffected in 49.6% of the cases, while 27.3% of the patients retired: the remaining individuals had already retired before surgery. Statistical analysis (stepwise logistic regression) identified age (p = 0.002) and cross-clamp time (p = 0.016) as significant risk factors of operative mortality. The ejection fraction showed a value close to statistical significance (p = 0.06).(ABSTRACT TRUNCATED AT 400 WORDS)

Electrocardiographic criteria for the diagnosis of apical myocardial infarction are still debated. Aim of the present study is to evaluate if there is an electrocardiographic pattern useful in the diagnosis of apical AMI using biplane ventriculography as "gold standard" technique. For this reason, we studied 75 patients at the first AMI with a-dyskinesis in the apical zone on biplane ventriculography (segments 3 and 7 according with CASS nomenclature). By the means of ventriculography we have selected 2 groups: a first group of 19 patients with a-dyskinesis confined to apical zone and a second group of 56 patients with a-dyskinesis in the apical zone and surrounding regions. In the 2 groups we found different electrocardiographic changes. In the first group (a-dyskinesis in the apical zone only) we found the ECG pattern of anterior AMI in 14 (73.7%), antero-inferior AMI in 2 (10.5%), antero-lateral AMI in 1 (5.3%) and inferior-posterior AMI in 2 patients (10.5%), respectively; in the second group (a-dyskinesis in the apical and surrounding zones) we observed 31 (55.4%) anterior, 7 (12.5%) antero-lateral, 7 (12.5%) antero-inferior and 11 (19.6%) inferior-posterior myocardial infarctions. Our study did not allow to recognize a "typical" ECG pattern associated with the "apical" infarction seen at ventriculography.

Three cases of giant cell arteritis have been admitted to our Institution from 1985 to 1989, with different diagnoses: aortic dissection, left atrial myxoma and fever of unexplained origin. The diagnosis of giant cell arteritis (GCA)/temporal arteritis (TA), biopsy proven, allowed us to institute an effective corticosteroid treatment. These 3 cases of TA permit us to emphasize the systemic vascular involvement in GCA/TA, with the aorta and its major branches being the districts mainly affected; the polymorphism of clinical manifestations at onset; the importance of constitutional symptoms that can dominate other clinical manifestations. Concomitant involvement of the aorta and its major branches, and of small sized arteries, permits regarding Horton's disease as an overlap syndrome between "pulseless disease" of Takayasu and systemic necrotizing vasculitides of the polyarteritis nodosa group. A prompt diagnosis of this arteritis is needed, because of the good therapeutic opportunities with corticosteroids, and because of the possibility of serious vascular and ocular complications without therapy.

Serum levels of bilirubin and of other four enzymes known to be elevated in liver diseases were measured preoperatively and controlled on the first and fourth postoperative day in 14 children with chronic liver disease and anesthetised for liver biopsy using Ketamine (7 patients, group A) or other drugs (group B). Serum levels of gamma GT, Ph. Alk, direct and indirect bilirubin show neither significant variations nor differences between the two groups of patients. SGOT and SGPT basal levels were similar in the two groups and were rather two-fold the normal values. At the first postoperative day, in group B only SGOT levels increased significantly. Moreover, their increase over the basal levels monitored at the first day was significantly lower in the group of patients anesthetised with Ketamine than in group B. In group A, SGPT values were constant showing a small, non significant decrease, while in group B, above levels present a significant increase at the postoperative day and a significant difference between the two groups. At the fourth day, SGOT and SGPT differences versus basal values were not significant. Our experience shows that - as known by normal subjects - Ketamine has no hepatic toxicity in pediatrics patients affected by chronic liver disease, too. Finally, our study suggests that Ketamine must be used in hepatopath children whenever they have to be submitted to total anesthesia.