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Patients with unstable angina fall into a wide prognostic and therapeutic spectrum but, in general, have great access to specialty care and invasive procedures. In the modern era, in which admissions for unstable angina outnumber those for myocardial infarction, and growing economic pressures are placed on health care systems, cardiologists must re-examine clinical strategies for treating unstable angina in the light of health-cost accounting. The aims of the present study were to examine the current management of patients admitted to our cardiology department and to calculate the medical costs. A patient schedule was drawn up to prospectively register the number and type of cardiac processes carried out during hospitalization for all unstable angina patients in the period between March 1st and May 30th, 1995. Time (minutes) actually spent by both physicians and nurses for each cardiac process were carefully recorded in order to calculate the activity budget. The effective economic budget was built for each cardiac process taking into account salaries, consumable supplies, equipment service contracts, depreciation and indirect medical and non medical costs for CCU and ward. Based to the Diagnosis Related Groups (DRG) system, 53 out of 318 patients (16%) were admitted with documented or suspected unstable angina and allocated to discharge into four DRGs: DRG 140-medically treated unstable angina: 18 patients; DRG 124-unstable angina with angiography: 16 patients; DRG 122-unstable angina evolving in myocardial infarction: 6 patients; DRG 112-unstable angina with angioplasty: 13 patients. The mean cost for hospitalized patient with unstable angina was 5,574,958 Italian Liras (DRG 140 = 2,687,719; DRG 124 = 2,800,347; DRG 122 = 6,086,563; DRG 112 = 12,751,454). The difference in costs was essentially related to the procedures involved in medical care, DRGs with expensive cardiac processes having higher costs. Furthermore, these data show a deep discrepancy between "real" costs and current DRG reimbursement. In conclusion, data show the standard management of unstable angina at our center; calculating the true costs of unstable angina is the first step towards maximizing resources and optimizing benefits.

Transesophageal echocardiography is a new semi-invasive procedure whose practical application has yet to be precisely defined. The diagnosis of prosthetic valve endocarditis is particularly difficult with the transthoracic approach, either by thoracic conformation of patients who underwent cardiac surgery, or ultrasound attenuation caused by the prosthetic material. Transesophageal echocardiography is useful to overcome such limits with a new acoustic window, due to the proximity of the esophagus and the heart. During 15 months 18 patients with suspected prosthetic valve endocarditis were studied using both procedures. In patients with mitral prosthetic valves, transesophageal echocardiography provided information unobtainable by using the transthoracic procedure, while in patients with aortic prosthetic valves it only showed additional information in 1 case of abscess of the posterior valve ring. In conclusion, transesophageal echocardiography is useful to diagnose all patients with suspected prosthetic mitral valve endocarditis and might be performed in patients with aortic valve prostheses if the quality of the transthoracic procedure is poor.

The most frequent diseases of thoracic aorta in the adult population, aneurysms and dissection, can lead to dramatic complications. Therefore in these cases an early and careful diagnosis is required for a correct therapeutic choice. The close distance of the thoracic aorta to the esophagus allows a better visualization by transesophageal echocardiography (TEE) compared with the transthoracic approach (TTE). Aim of this study is to evaluate the diagnostic accuracy of TEE versus surgical data in patients with suspected aneurysms and/or dissection of the thoracic aorta. Eighteen patients with aortic aneurysm, confirmed at surgery, underwent B-mode, pulsed Doppler and color echocardiographic examination either by TTE or by TEE. TEE was concordant with surgical findings in all the cases of fusiform (8 patients) and saccular (2 patients) aneurysms, visualizing aortic wall thrombosis in 4 patients. Furthermore TEE, diagnosed all the type I (4 patients) and type III (2 patients) dissection, and 1 type II, identifying in all cases the intimal tear and, in 3 patients, the false lumen thrombosis; it demonstrated the presence of severe aortic regurgitation in 3 patients and of mild pericardial effusion in 2 patients. Only in 1 case of type II dissection TEE was not diagnostic because it is not able to visualize completely the aortic arch. In our experience TEE allowed accurate information in patients with aortic aneurysm or dissection. TEE can be considered the first choice diagnostic tool in patients with suspected dissection of the thoracic aorta.