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Aims Ventricular tachycardia spreading from the anterior or posterior division of the left bundle branch is generally called fascicular tachycardia (FT). We will present our experience with FT, a type of ventricular tachycardia not necessarily implying the absence of heart disease and/or sensitivity to selective antiarrhythmic drugs, but only particular routes of left ventricular depolarization. Methods Since 1981 we have had the opportunity to study 10 cases of FT (nine men and one woman; aged 28-77 years, mean ± SD 55 ± 18.6 years) by means of echocardiography, coronary angiography (seven cases), endomyocardial biopsy (five cases), signal-averaged electrocardiogram (SAECG, nine patients), electrophysiological and electropharmacological evaluation. Results Seven patients had paroxystic, extrastimulus inducible FT that was sensitive to verapamil given intravenously (group A); three patients, on the other hand, showed repetitive or incessant FT, not modifiable by stimulation techniques and sensitive to class 1 antiarrhythmic drugs (group B). Patients presented histologic substrates ranging from the absence of heart disease to previous myocardial infarction or myocarditis. FT spontaneously disappeared within 2 years in group B, while frequently persisted in the long term in group A. Conclusions FT is not a homogeneous group of ventricular tachycardia, as patients may differ according to clinical presentation, mechanisms that are involved in the genesis of the arrhythmia and natural history; the histologic substrate is highly variable, ranging from the total absence of heart disease to severe forms of myocardial involvement.

BACKGROUND: The impact of diabetes in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI) is unclear. The benefit of abciximab in this subset of patients remains controversial. METHODS AND RESULTS: Three hundred and twenty-seven consecutive and unselected patients with acute AMI treated with primary PCI were included in our single-center retrospective registry, 103 diabetic (31%) and 224 nondiabetic (69%). Abciximab was given at the physician's discretion. Diabetic patients were older (mean age 68.5±11 vs. 65±12 years; P=0.009), had an increased prevalence of hypertension (73 vs. 54%; P=0.001), a decreased prevalence of smoking (31 vs. 45%; P=0.02), a longer duration of symptoms before hospital admission (190 vs. 143 min; P=0.031), and a higher number of stents implanted (1.4 vs. 1.2; P=0.04). Other clinical and angiographic characteristics were comparable in the two groups. Diabetic patients had a higher incidence of the combined end-point of death and reinfarction rate at 30 days (18 vs. 10%; P=0.04) compared to nondiabetic patients. Abciximab treatment was associated with a lower in-hospital (23.8 vs. 5%; P=0.005) and 30-day (23.8 vs. 6.6%; P=0.012) mortality, and a lower incidence of death and reinfarction at 30 days (33.3 vs. 9.8%; P=0.003) in diabetic patients. In nondiabetic patients, abciximab was not associated with improved outcome measures. Advanced Killip class (III and IV) and abciximab were found to be independently associated with 30-day death or myocardial infarction [respectively, odds ratio (OR) 6.075, 95% confidence interval (CI) 1.59-23.218, P=0.008 and OR 0.177, 95% CI 0.034-0.938, P=0.042] in the propensity score-matched populations of diabetic patients. Advanced Killip class and thrombolysis in myocardial infarction score index were found to be independently associated with 30-day death or myocardial infarction (respectively, OR 6.607, 95% CI 1.5-29.106, P=0.013 and OR 1.094 95% CI 1.042-1.148, P

In a prospective study on 340 cases with primary myocardial disease, eight patients (six males, two females, mean age 36 years, range 24-47) with an idiopathic left ventricular aneurysm were observed. All patients had normal coronary arteries, no angina or history of myocardial infarction; all but one had no risk factors for ischaemic heart disease; all had normal right ventricles; one patient had a history of familial dilated cardiomyopathy, two of 'flu-like' syndrome at the time of first symptom and two of alcohol abuse. All patients had ventricular tachycardia (VT), five sustained (of right bundle branch block morphology in three, and of different morphologies in two), three non-sustained. Patients with sustained VT had inducible VT (resembling the clinical one) on electrophysiological study. Electrocardiogram (ECG) showed an infarction pattern in three cases. Aneurysms were of limited size (2.1 +/- 1/11 segments on echocardiography) and were located in the septum, apex or posterior wall. Left ventricular ejection fraction (LVEF) was reduced (0.50) in six patients and was not correlated with the aneurysm size. The duration of illness was inversely correlated with LVEF (P0.05). Endomyocardial biopsy showed evidence of diffuse pathological changes in all cases (cell hypertrophy, myofibrillar lysis, mitochondriosis). During follow-up (64 +/- 32 months), patients were successfully treated with anti-arrhythmic drugs: no patients required surgical treatment to control ventricular arrhythmia. Considering the clinical and pathological features of idiopathic left ventricular aneurysm, this primary myocardial disease could be classified as a novel peculiar form of cardiomyopathy.

Angiotensin-converting enzyme (ACE) inhibitors reduce mortality, the development of remodeling, left ventricular (LV) dysfunction, and ischemic events, both when administered alone as long-term treatment in patients with impaired LV function and/or heart failure (HF) and as short-term treatment, early after acute myocardial infarction (AMI) and/or HF. The few data available on the use of ACE inhibitors in the elderly after AMI are conflicting. Nothing is known about the effects of ACE inhibitors in elderly postinfarction patients with preserved LV function: these patients have a remarkable medium- to long-term mortality and HF incidence after infarction. The aim of this study is to evaluate, in patients with AMI agedor =65 years, the effects of Perindopril on the combined outcome of death, hospitalization for HF, and heart remodeling, considered to be aor =8% increase in LV end-diastolic volume (LVEDV). Secondary objectives include the same factors listed in the primary end points but considered separately. In addition, safety of the drug, ventricular remodeling, and adaptation are being evaluated. A total of 1100 patients with AMI (first episode or reinfarction), agedor =65 years, and preserved or only moderately depressed LV (LV ejection fractionor =40%), are to be enrolled and randomly assigned to treatment (8 mg for 12 months of Perindopril or placebo, in double-blind conditions). Clinical assessment is performed at fixed times, and periodic evaluations of (1) ventricular shape, dimensions, and function by quantitative 2-D echocardiography, and (2) heart rate variability and arrhythmias by ambulatory electrocardiographic monitoring are anticipated. The results and conclusions will be available by 2002 year.

In order to investigate the anatomic substrate of 'idiopathic' ventricular tachycardia (VT) 10 patients with chronic recurrent VT and no apparent sign of heart disease underwent an echocardiographic, haemodynamic and histologic study (5 males, 5 females: mean age = 40 +/- 11 years). In the patients with a left bundle branch block morphology of VT (7 cases), four showed findings compatible with an arrhythmogenic right ventricular dysplasia or a right ventricular cardiomyopathy. In the other three all examinations were normal with the exception of endomyocardial biopsy, which showed slight non specific changes in two. Of the remaining 3 cases (characterized by a right bundle branch block morphology of VT or by the presence of polymorphic VT) one had histologic evidence of myocarditis while another developed dilated cardiomyopathy. Macroscopic and/or microscopic ventricular abnormalities are frequently found in patients with VT which appears idiopathic. In these cases myocardial disease is frequently progressive, despite optimal control of VT.

Chest thump is a simple method of treatment of some paraxysmal arrhythmias. Its therapeutic efficacy, electrophysiological bases and clinical utility have been studied in 17 patients during 45 episodes of ventricular tachycardia (VT). Thumping the precordium interrupted the VT in 22 episodes. Three types of interruption of VT have been observed: (1) In 15 episodes, single ventricular premature beats induced by the blow, occurring randomly in the cycle, stopped the arrhythmia; (2) In 5 episodes, a run of premature beats, induced by a rapid succession of blows, interrupted the tachycardia; (3) In 2 episodes, chest thump caused a short period of asystole followed by sinus rhythm. Chest thump is an antiarrhythmic treatment of definite clinical utility. The complications are rare, although there is a possibility of ventricular fibrillation. Therefore, it should be performed only under careful supervision.