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The last few years, a series of Guidelines, Reports, Review and Recommendations have confirmed that the scientific world is focusing on Cardiac Rehabilitation and Secondary Prevention. However, despite the scientific evidence, cultural problems, apparent economic limitations and organizational difficulties, continue to slow the development of Cardiac Rehabilitation. The main fault lies with the medical community and its cultural preparation. In the past 10 years the attention of the cardiologist has been focused on the early thrombolytic treatment and on primary coronary angioplasty while the secondary prevention has not always been a priority. Despite the many barriers against the development of Cardiac Rehabilitation, it would seem that it is important to improve the training of the future doctor and cardiologist by including the primary and secondary prevention and the clinical application of physical therapy in the university studies and in the courses of specialization. If the politicians are aware of the reduction in costs, even the cardiologists should realize that certain results can be obtained in a cost-effective manner, and surely that Cardiac Rehabilitation is more cost-effective with respect to thrombolytic treatment, bypass or hypolipidaemic drugs.

Background: Coronary angiography is an invasive procedure that is relatively expensive and that requires an appropriate indication., Methods: Utilization rate and the appropriateness of the use of the coronary angiography have been compared in two defined populations, namely residents from the city of Padua (group A), and subjects from the local health unit of Cittadella (group B), who underwent coronary angiography between June 1, 1992 and May 31, 1993. Appropriateness was evaluated both by comparison with the AHA/ACC guidelines and by observation of the outcome following diagnosis one year after the coronary angiogram was performed., Results: One hundred and seventy-one patients in group A and 100 patients in group B underwent coronary angiography: both groups had similar age and sex distribution. Utilization rate was 8 per 10,000 inhabitants in group A, and 10 per 10,000 inhabitants in group B. Appropriate coronary angiography, evaluated by comparison with the AHA/ACC guidelines, was 69.9% in group A and 68% in group B. Coronary angiogram showed at least one stenosis > or = 50% in 133 patients from group A and in 66 patients from group B. These patients were followed up for at least 12 months. Of 13 deaths, 12 occurred as fatal cardiac events, while of the 147 surviving patients who had complete follow-up data, 114 (77%) improved. The outcome was measured through symptoms and stress test. In addition, subjective improvement was measured in group A using the "Nottingham Health Profile"., Conclusions: Criteria of appropriateness for an invasive diagnostic procedure such as coronary angiography, which is a determinant "entry point" for revascularization procedures, is based on common clinical knowledge that may be evolving with time. Based on these data, it seems that the current guidelines could be modified, especially for indications within the setting of myocardial infarction.

A 64 years old patient performed a maximal exercise testing 13 days after inferoposterior myocardial infarction (no thrombolytic treatment had been performed). The patient presented at days 1-4 an intermittent Mobitz 1 and 2:1 heart block, with normal ventricular rate. No other complications were present. The ECG at entry and before stress test showed a complete right bundle block. The test was stopped at 30 sec of 75 watts. The systolic blood pressure increased from 130 to 155 mm Hg and heart rate from 84 to 145/min (93% of predicted heart rate). No arrhythmias and anginal pain were noted. The leads with pathologic Q wave showed elevation of the ST segment, whereas V1-V2 and aVL leads a depression of the ST segment. During recovery the patient developed electromechanical dissociation. The echocardiogram showed significant pericardial effusion. Cardiopulmonary resuscitation and pericardiocentesis were ineffective. Necropsy confirmed left ventricular inferior wall rupture and haemopericardium.

In recent years there has been a steady increase in number of coronary angiography procedures and coronary angioplasty. Since these interventions are relatively expensive, we tried to evaluate the appropriateness of coronary angiography indications. A retrospective pilot study was undertaken on all residents in Padua who had had a coronary angiography performed in 1988. In order to take into account patients who, although resident in Padua, had a coronary angiography performed outside Padua or even abroad, all Italian Hemodynamic Centers and the Office for Foreign Cures Authorization of ULSS 21 were contacted. Follow-up was stopped on April, 1991. Patients were first checked if living by consulting the Register's Office of the Community of Padua; they were then interviewed by letter on state of health. One hundred twenty-four patients underwent 138 coronary angiography. Utilization rate is 5.6 per 10,000 people (CI 4.6-6.6). This figure is lower than the present USA utilization rate, and is similar to the rate of late 70's. From patient records, 3 out 8 groups emerged as predominant indication for coronary angiography: unstable angina (37%), valvular heart disease (20%) and recent myocardial infarction (20%). According the ACC/AHA guidelines, indication was considered "appropriate" in 69%, "inappropriate" in 7%, "doubtful" in 20% and impossible to evaluate in 5% of cases. Although this classification may have been built up with incomplete information, it is note-worthy that the percentage of inappropriate indication is comparable to that of other reports. A further observation is that not in every case the treatment assigned at the time of diagnostic angiography was really carried out on the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Single-vessel coronary disease has been considered so far a benign condition, for which the medical therapy may represent the optimal treatment. In order to assess the effectiveness of this approach, we studied 323 patients who had come to our attention for ischemic heart disease and resulted affected by single-vessel coronary artery disease. From our data it appears that single-vessel coronary artery disease is frequently associated with myocardial infarction and post-infarction aneurysm. Coronary angiography indicated that left anterior descending coronary artery is the most frequently affected vessel, and that its involvement is often associated with lethal outcome. Forty-two out of the 323 patients underwent coronary artery bypass surgery; the remaining patients were medically treated. Surgical patients showed a better improvement respect to the medical group, while survival was not statistically different. An unexpected result was the relatively high risk in circumflex artery lesion. These data may justify a broader utilization of invasive therapy in recent onset angina, in light of the excellent results recently obtained with percutaneous transluminal coronary angioplasty.

The efficacy of a new calcium channel blocker, gallopamil, has been tested via a single blind, self-controlled versus placebo protocol in 9 consecutive patients admitted to our Coronary Care Unit because of repeated daily attacks of Prinzmetal variant angina. Exclusion criteria were age (greater than 65 years) bradycardia (less than 50 beats/min), recent myocardial infarction, heart failure, sinoatrial or atrioventricular block. After a 24 hours run-in period on saline drip, gallopamil was administered as 0.03 mg/kg bolus followed by continuous infusion at 0.02 mg/kg/h for the first 24 hours and 0.03 mg/kg/h for the last 48 hours. Treatment was then stopped and the patients were again kept on saline infusion for the next 30 hours. Holter monitoring was recorded during run-in, on third day of treatment and 6 hours after gallopamil withdrawal. Anginal attacks were significantly reduced in number by therapy (-63%, -91%, -84% in the 3 days of treatment). Holter monitoring during gallopamil infusion showed a statistically significant reduction in silent (-98%) and symptomatic (-93%) ischemic episodes (IE). During the last 24 hours of the washout period we observed a statistically significant increase in silent ischemic episodes. While no transient ST segment elevation was recorded in 3 patients, in 1 patient symptomatic IE were increased of 150% with respect to the run-in period. On the whole we observed complete suppression of IE in 7 patients (78%) at the third day of treatment with gallopamil. In 2 patients (22%) a greater than 75% reduction was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

The study group consisted of 47 consecutive patients (38 men and 9 women) aged between 16 and 56 years with dilated cardiomyopathy studied invasively between January 1980 and December 1986. Follow-up observation (40 +/- 29 months) showed that 28 patients were mildly symptomatic (group 1) and 19 patients were severely symptomatic (group 2: eight of them died due to intractable congestive heart failure). At univariate analysis, group 2 was characterized by higher pulmonary vascular resistance, larger end-diastolic and end-systolic left ventricular volumes, increased left ventricular mass, lower ratio of mass to volume index, depressed angiographic ejection fraction, lower ratio of end-systolic stress and peak systolic pressure to volume index. Multivariate analysis was used to determine which combination of factors might be a better effective predictor of prognosis in these patients: the most important factors were mass to volume index ratio (M/V) and end-systolic stress to volume index ratio (sigma TS/VTS). An equation was developed that can be applied to the prognosis of patients with dilated cardiomyopathy (F = 7.41573 M/V + 0.87805 sigma TS/VTS - 10.34571). A score system was devised on the basis of the summed-up value of these two parameters. When the patients were assigned (according to the score) to one of the previously mentioned two groups, the classification proved to be correct in 98% of the cases. Thus, these factors can accurately predict the development of congestive heart failure or the risk of death in patients with dilated cardiomyopathy, who are reasonable candidates for cardiac transplantation.

The internal mammary artery, when used as a conduit for coronary artery bypass, offers a better long-term patency and survival rate than the saphenous vein. However, concern exists that the flow through the internal mammary artery may be inadequate during periods of peak myocardial demand. This flow was investigated in 18 consecutive patients who were selected for coronary bypass of the left anterior descending artery using the internal mammary artery. All patients were evaluated post-operatively within 12 months by means of graded maximal stress test, cardiac catheterization and exercise thallium-201 scintigraphy. Significant improvement in work capacity, maximal rate-pressure product, effort angina and ECG abnormalities during exercise stress testing were observed following internal mammary artery myocardial revascularization. The patency rate for internal mammary artery grafts was 100% (vs 85% for vein grafts); during the followup period, occlusion of a saphenous vein bypass or development of a new stenosis in a native coronary artery was noted in five patients, and two patients were classified as having partial revascularization. Ischemia, demonstrated by perfusion deficits at peak stress which disappeared in the 3-hour delayed film, was documented in 7.4% (4/54) of the areas supplied by internal mammary artery grafts, compared to 31% (13/42) of the regions revascularized using saphenous vein conduits. Although this result was not statistically significant, a definite trend is suggested. We conclude that ischemia demonstrated by stress thallium scintigraphy in the post-operative period is uncommon when an internal mammary artery graft has been used. This suggests that adequate coronary flow exists at peak myocardial demand during exercise.

The internal mammary artery (IMA) is being increasingly utilized as a conduit for myocardial revascularization, based on its higher long-term patency. The aim of this study is the serial assessment of the changes of native coronary vessels after IMA coronary anastomosis. Twenty-six consecutive patients (24 males and 2 females, mean age 56.4 years) received an IMA graft on the left anterior descending (LAD) artery. IMA coronary anastomosis was single in 11 patients and double (LAD and diagonal branch) in the remaining 15 cases. In 23 patients (88.5%) at least one associated saphenous vein graft was inserted. Post-operatively, no new Q waves or low-output syndromes were observed. Follow-up angiographic study, including selective opacification of the IMA graft, was carried out after 1 month and after 1 year. The cumulative patency rate of IMA grafts was 97.7% after 1 month. The LAD stenosis proximal to the IMA anastomosis progressed to total occlusion in 6 patients (28.5%), all of them with a preoperative stenosis ranging from 90 to 99%; its diameter remained unchanged in 6 patients (28.5%), while a reduction of the coronary narrowing greater than or equal to 20% was observed in 9 patients (43%). Preoperatively, the LAD stenosis of the latter groups ranged from 70 to 90%. Severity of residual stenosis and relative diameters of LAD artery and IMA graft influenced the competitive flow distribution through these vessels.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of mitral valvular disease in which spontaneous return of sinus rhythm occurred after 12 years of atrial fibrillation is reported. The course of the disease, complicated by A.V. and intraventricular conduction disturbances which made the insertion of a pacemaker necessary, suggests that return to sinus rhythm should not be considered necessarily an improvement in the clinical picture and in the prognosis in such patients.

The aim of our study was to evaluate the significance of coronary arteriography in young asymptomatic patients after myocardial infarction. Among a total of 586 consecutive patients who underwent left ventriculography and coronary angiography because of coronary heart disease during the period from January 1984 to June 1986, we selected 51 patients (8.7%) under 45 years of age (range 28-45 years) and without angina, dyspnea or electrocardiographic signs of myocardial ischemia during bicycle ergometric stress test. These patients, 50 males (98.0%) and 1 female (2.0%) were angiographically evaluated from 1 to 12 months after a first myocardial infarction. Coronary occlusions greater than or equal to 70% were found in 44 patients (86.3%): 36 of them (70.6%) had single-vessel disease, 6 (11.8%) double-vessel disease and only 2 (3.9%) triple-vessel disease; no coronary obstructions greater than or equal to 50% of the left main coronary artery were found. Among the 7 patients without critical stenoses (13.7%) 3 had "normal" coronary arteries, 3 noncritical stenoses and one presented an anomalous origin of the left circumflex artery from the right sinus of Valsalva. Only 1 patient underwent surgery. In conclusion, in young asymptomatic patients after a myocardial infarction coronary arteriography may identify a small group either without or with minor atherosclerotic involvement of the coronary tree, while the presence of a localized disease is confirmed in most patients. Therefore, in this selected subgroup, coronary angiography has a limited usefulness in defining high-risk patients possibly requiring surgical treatment.

In order to compare the effectiveness of different therapeutic regimens in reducing infarct size serial determinations of CPK activity (at 4 hourly intervals in the first 48 hours from the admission to CCU, at the 72th and at 120th hours) were performed in 100 patients with transmural AMI (53 anterior and 47 inferior) with no obvious evidence of LV failure and basal CPK levels lower than 50 U/L. 20 patients (control group) have been treated with glucose-insulin-potassium (GIK). 20 patients have been treated with GIK plus Verapamil (GIK + V). Verapamil was administered at the dose of 50 mg in continuous drip. 20 patients received GIK plus digoxin at the dose of 0.25 mg b.i.d. (GIK + D). 40 patients received GIK, Verapamil and digoxin at the above doses (GIK + V + D). Different values of CKr and infarct size (IS.) show a statistically significant difference between the various regimens, which is more evident if we consider the whole series. Infarct size was greater in patients treated with digoxin with respect to controls, while it was smaller in patients treated with Verapamil. Combined Verapamil-digoxin therapy is associated to an enzymatic behaviour not different from controls. Authors emphasize that in uncomplicated AMI digoxin causes an increase in infarct size while Verapamil reduces significantly it. Association of Verapamil allows the use of digoxin, if clinically justified, without increase in infarct size.

The behaviour of some serum enzymes (CPK, LDH, alpha HBDH, SGOT) in 50 patients after permanent pacemaker implantation is outlined. Changes of each enzyme were analyzed statistically by applying Student's t test. Most significant changes are represented by the increase in CPK serum concentrations (19 cases). In 14 of them LDH isoenzymes were evaluated and in 4 patients alteration of LDH1/LDH2 ratio suggestive of cardiac "injury" were observed.