Search

Background: There are no recommendations about admission to an ICU after a major lung resection and there are considerable differences among institutions in this respect. Objectives: To audit the practice of admission to an ICU after a major lung resection and evaluate factors predicting the need for intensive care. Methods: Clinicalrecords of all patients who underwent major pulmonary resections in a 14-month period were reviewed retrospectively. The criteria for postoperative admission to the ICU were: (1) standard pneumonectomy if comorbidity index (CI) >0 and/or ASA score >1, and/or abnormal spirometry or arterial gas analysis; (2) extended pneumonectomy; (3) lobectomy if CI ≧4 and/or ASA ≧3; (4) lobectomy if FEV1 1 is between 60 and 80% and hypercapnia. Results: Among the 49 patients postoperatively admitted to the surgical ward, only 1 needed late intensive care. Among the 55 patients admitted to the ICU, 25 did not require specific intensive care and were discharged 24 h postoperatively, whereas the remaining 30 patients required specific intensive care. Multivariate analysis identified ASA score, predictive postoperative DLCO, and predictive postoperative product (PPP) as independent predictors of a need for admission to an ICU. Conclusion: This empirical protocol was useful in identifying patients not likely to need admission to the ICU. ASA score, predictive postoperative DLCO, and PPP are independent predictors of a need for admission to an ICU.

to confirm the diagnosis of 21-hydroxylase deficiency (21-OHD) by the analysis of CYP21A2 gene in infants with clinical and/or biochemical features of 21-OHD in order to clarify which patients to submit to genetic analysis; to analyze the genotype-phenotype concordance in these infants.We studied 25 children with clinical and/or biochemical features of 21-OHD. All of them and their parents were submitted to genetic analysis of CYP21A2. Patients were classified in 3 groups according to mutations' severity: severe (group A), moderate (group B) or mild (group C).CYP21A2 gene mutations were found in 17 children. Whereas all infants of groups A and B presented a classical form of 21- OHD, children of group C had a non-classical form of 21-OHD. Four infants resulted heterozygotes and 4 children were wildtype. A girl clinically presenting a non-classical form of 21-OHD resulted compound heterozygote with one of the mutations not described in literature (R25W) and whose residual enzymatic activity is not already known. All affected children presented a 17-OHP level after ACTH stimulation greater than 100 nmol/l. We found an optimal concordance between 17-OHP levels after ACTH test and genotype.CYP21A2 analysis permitted to confirm the diagnosis of 21-OHD in 68% of our children. To improve this percentage we suggest to perform the CYP21A2 analysis only when 17-OHP after ACTH test is greater than 100 nmol/l. Moreover, we found an optimal genotype-phenotype concordance in the 21-OHD patients.

Although many previous reports showed a worse outcome after rescue compared to primary coronary angioplasty, a direct comparison of these two strategies in the era of stenting is lacking.Fifty patients treated with rescue stenting were retrospectively compared to 61 patients treated with primary stenting during acute myocardial infarction over a 4-year period in our Laboratory.Baseline demographic and angiographic parameters were not significantly different in the two groups. Despite a significantly longer time-to-reperfusion in rescue stenting (4.7 +/- 2.7 vs 2.8 +/- 2.1 hours, p0.0001), procedural success rate (98 vs 97%), in-hospital mortality (6 vs 11%) and target vessel revascularization at 6 months (8 vs 10%) were similar in rescue compared to primary stenting.These data suggest that stenting may help improve results of rescue angioplasty, and support the concept that aggressive treatment after failed thrombolysis can be pursued with satisfactory results.

Although a large number of studies have investigated the relationship between atrial natriuretic peptide (ANP) concentrations and circulatory abnormalities, it is presently unsettled as to whether this parameter provides valuable information in unselected patients with heart disease of different etiologies regardless of the presence of left ventricular dysfunction or heart failure.The aim was to evaluate the correlation between ANP, hemodynamics and parameters of ventricular function in a large series of consecutive patients and to define the predictive value of ANP for the identification of specific circulatory abnormalities.Cardiac catheterization was performed in 167 consecutive patients (62% males; mean age 62 yrs; range 18-85) and ANP serum levels were determined concomitantly by single antibody immune assay. Underlying etiology was: ischemic (67), valvular (72), idiopathic (12) and miscellaneous (16). Data management included: comparison of patients according to ANP valuesor50% percentile of the cumulative distribution curve (i.e. 140 pg/ml); analysis of ANP concentrations according to the presence of normal or abnormal ventricular filling pressures; correlation between hemodynamic parameters and ANP concentrations; correlation of ANP with ventricular function in the whole population and in subgroups; calculation of sensitivity and specificity of ANP for the identification of abnormal filling pressures.Mean ANP concentration was 181 +/- 139 pg/ml. Patients with ANP140 had significantly lower right-sided pressures but similar ventricular volumes and ejection fractions. By multivariate analysis, the single independent predictor of ANP was wedge pressure (p0.0001). Regarding etiology, severe mitral regurgitation was associated with the highest ANP levels (259 +/- 122 pg/ml), although the difference was not significant. The presence of abnormal left and right ventricular filling pressures was associated with significantly higher levels of ANP (p0.0001). A level of 125 pg/ml proved to be fairly sensitive (79%) but poorly specific (66%) for the detection of an abnormal wedge pressure. ANP was related to ventricular function only in the small subgroup of patients with dilated cardiomyopathy, where a significant negative correlation was found with both left ventricular (r = -0.72; p = 0.008) and right ventricular ejection fraction (-0.71; p = 0.01).In unselected cardiac patients, ANP is confirmed to be a marker of left ventricular filling pressure in spite of poor specificity. Ventricular function appears to be related to ANP concentrations only in the subgroup of patients with pure heart-muscle disease.

Right ventricular (RV) function and morphometric quantitation of interstitial fibrosis in idiopathic dilated cardiomyopathy (IDC) have not been the subject of specifically designed clinical observations. In particular, their role in routine assessment and prognostic evaluation of patients (pts) with IDC remains to be settled.Eighty-one consecutive IDC patients (63 M, 18 F; mean age 52 +/- 11 yrs) with left ventricular (LV) systolic dysfunction (angiographic ejection fraction - EF -55%), normal coronary arteries and no histologic evidence of myocarditis were studied. Cardiac catheterization and endomyocardial biopsy (EMB) were routinely performed in all cases. RV volumes and EF were obtained by angiography according to Ferlinz' method and interstitial fibrosis was quantitated by computer-assisted morphometric analysis. These data were analyzed in order to study correlations with hemodynamic parameters and to assess their prognostic value in a long-term follow-up.In the study population, right ventricular EF was significantly lower than in normal controls (35 +/- 11% vs 53 +/- 6%, p0.0001) and showed a significant positive correlation with LV EF (r = 0.54; p0.0001), and a weak but significant negative correlation with fibrosis (r = -0.29; p = 0.03). RV volumes, but not EF, were significantly related to mean pulmonary pressure. At multivariate analysis, RV end-diastolic volume (EDV) and EF were the two independent predictors of severe heart failure (NYHA class III-IV). After a mean follow-up of 64 +/- 36 months, 20 pts died and 9 had heart transplantation, for a 63% transplant-free survival rate (TFS). Multivariate analysis identified three independent predictors of TFS: LV stroke work index (p0.0001), RV stroke work index (p = 0.02) and RV EDV (p = 0.03). Fibrosis was predictive of survival only in the subgroup with LV EF20%.Assessment of RV function provides useful information in the evaluation of hemodynamic profile and prognosis of pts with IDC. Quantitation of interstitial fibrosis by morphometry provides little additional data.

Cardiac troponin I, a specific and sensitive marker of myocardial damage, was detected in the blood of 6 of 26 patients studied in our Heart Failure Clinic. In these patients functional class, ventricular function, and prognosis were significantly worse than in those without detectable troponin I. This study suggests that troponin I may represent the biochemical marker of myocardial damage occurring in severe heart failure.

The development of methods for the detection of circulating CK-MB mass, cardiac troponin T (cTn-T) and troponin I (cTn-I) has increased the diagnostic potential in the identification of myocardial damage. Coronary angioplasty (PTCA) represents a widely accepted revascularization procedure and a clinical model of induced ischemia. Using these new biochemical markers, we evaluated the incidence and the clinico-procedural correlates of minor myocardial damage (MMD) in a series of patients treated with PTCA in our Department. In 57 consecutive patients (75% males; mean age 58 years; range 35-80) undergoing elective PTCA from March 1 to June 30, 1995, serum levels of CK-MB mass, cTn-T and cTn-I were measured at baseline and at 6, 12 and 24 hours after the procedure. Seventy-eight coronary stenoses were dilated (mean 1.4 lesion/patient), 17 of these were in infarct-related vessels; 8 were total occlusions and 2 were located in saphenous vein grafts. Twenty-two procedures were completed by coronary stenting (17 elective). cTn-T and cTn-I were considered abnormal when serum levels were0.2 ng/ml and0.6 ng/ml, respectively. CK-MB mass was also determined in all patients (abnormal5 ng/ml). No patients had clinical or electrocardiographic evidence of myocardial infarction after the procedure. Overall, 16 patients (28%) developed biochemical evidence of post-procedural MMD (defined as the presence of at least one abnormal sample of any among the three markers tested). Four (7%) had abnormal CK-MB mass (at least one sample), 9 (16%) abnormal cTn-T, and 15 (26%) abnormal cTn-I. When CK-MB mass was elevated, both cardiac troponins were also elevated. In patients positive for MMD and abnormal CK-MB mass, peak cTn-I was significantly higher than in patients with normal CK-MB (3.02 +/- 1.07 vs 1.02 +/- 0.11 ng/ml; p = 0.009). The difference was not evident when comparing the same groups of patients for cTn-T (0.26 +/- 0.04 vs 0.18 +/- 0.10 ng/ml; p = 0.16). Also, peak cTn-I but not peak cTn-T had a positive correlation with peak CK-MB mass (r = 0.89; p0.0001 and r = 0.23; p = 0.40). The elevation of either marker of MMD was not related to clinical, angiographic or procedural variables. A possible interpretation for MMD was found in 2/3 of cases: bail-out (2); late occlusion (1); minor side branch occlusion (3); distal embolization from saphenous vein grafts (2) or total occlusions (2). In our series, MMD after PTCA occurs in 28% of cases and is unrelated to clinical, angiographic and procedural variables. Both cTn-T and cTn-I increase the sensitivity of CK-MB mass in the detection of MMD after PTCA, cTn-I being the most sensitive marker. In about 1/3 of cases, the presence of MMD remains unexplained. The prognostic implications of MMD are as yet undefined.

Improvement in cardiac function and clinical status has been described in subgroups of patients with dilated cardiomyopathy (DCM), but predictors of favourable outcome have not been unequivocally established. In 33 patients with DCM followed up for a mean of 23 months (range 3-68) a full non-invasive and invasive diagnostic work-up, including endomyocardial biopsy, was performed. At the end of the follow-up, 13 patients (39%; Group A) showed a significant improvement in their clinical status (or = 1 gain in NYHA functional class) and cardiac function (0.10 increase in echocardiographic ejection fraction), while 20 (61%; Group B) either stabilized or deteriorated (5 died and 4 underwent successful heart transplantation). Clinical, hemodynamic and morphometric data of the 2 groups were compared. Only lower systemic vascular resistance (Group A 2,836 +/- 637 versus Group B 3,637 +/- 1113; p = 0.025) and higher prevalence of alcohol intake80 g/day (Group A 85% versus Group B 40%; p = 0.03) were significantly associated with improvement. Discriminant analysis utilizing these 2 variables along with cardiac index, mitral regurgitation, pulmonary resistance and cardiothoracic ratio reached a discriminant power of 72% (p = 0.0014). The above results suggest that, in our series, relatively simple data provide the most accurate assessment of prognosis. Yet, prediction of favourable versus unfavourable outcome remains uncertain, since an incorrect prognosis will be made in 28% of cases. Morphometric analysis of endomyocardial bioptic specimens does not provide significant prognostic information. The identification of a high alcohol intake has a clinical relevance, since abstention from alcoholic beverages is significantly associated with a favourable outcome in our patients.

A random sample of 2,854 subjects aged 35-64 was examined in the town of Vicenza (Italy) as part of the 'Hypertension Management Audit Project'. Pearson's correlation coefficient and multivariate analysis considering systolic and diastolic blood pressure, age and body mass index (BMI) were performed. SBP was more closely correlated with age than DBP. BMI correlated with both SBP and DBP, but very little with age. Fifty-seven percent of the men had a BMI of 25.5 or more and 49% of the women had a BMI of 24.5 or more. The quality of BP control in the treated patients was worse in the overweight when compared with the lean patients, although overweight and lean patients are treated with the same frequency.

As a part of the "Hypertension Management Audit Project" a random sample of 4070 subjects was drawn from the population aged 35-64 living in the city of Vicenza, in order to assess the prevalence and the level of control of hypertension in the community. 2854 (70.1%) were screened in the first step of the survey. Two blood pressure (BP) reading, height and weight measurements were performed and a short questionnaire filled in. Systolic BP (SBP) and diastolic BP (DBP) were (mean and 95% confidence interval) 143.7 (142.6-144.7) and 88.3 (87.7-88.8) mmHg in males; 137.8 (136.8-138.8) and 84.9 (84.5-85.5) mmHg in females, respectively. The BP value corresponding to the 95 degrees percentile of the cumulative distribution of BP was 180 mmHg for SBP and 105 mmHg for DBP in males; 173 mmHg for SBP and 100 mmHg for DBP in females. Systo-diastolic hypertension was present in 12.3% of the screened population; isolated diastolic hypertension in 9.1%; isolated systolic hypertension in 5.3%; borderline hypertension in 31.6%; severe hypertension (DBPor = 115 mmHg) was present in 1.9% of females and in 2.2% of males. Prevalence in males was significantly higher with respect to females in all three categories of defined hypertension, but not in borderline hypertension. The second step of the survey involved 849 subjects (29.7% of the screened population) who completed two re-examinations because at the screening they had: 1) history of high BP; 2) BPor = 160/95 mmHg; 3) ongoing antihypertensive treatment. At the end of the survey, 772 of these subjects (91%) were confirmed as hypertensives (mean BP of six readingsor = 140/90 mmHg and/or taking antihypertensive drugs). Patients aware of their high BP were 78.8%; aware and treated 51.0%; treated and controlled (BP140/90 mmHg) 19.1%. All indices of control were significantly higher in female with respect to male patients. Treated patients were significantly older than untreated patients; treated females had significantly lower BP than treated males, whereas no difference was detected between untreated patients; patients unaware of high BP had the highest BP values if compared to treated and untreated patients. This survey reveals a high prevalence of hypertension in the adult population of the city of Vicenza; quality of control shows a moderate improvement if compared to previous studies carried out in our country.

Transoesophageal stimulation of the atria combined with bicycle ergometry provides a satisfactory reproducibility of a number of basic electrophysiological parameters at rest and during a load. Due to the good sensitivity and low specificity this test can be recommended in WPW syndrome as a screening examination in particular in active sportsmen and junior subjects. To assess the risk of sudden death in subjects with this syndrome it is, however, necessary to evaluate the complex of all assembled data, as the shortest R-R interval in induced atrial fibrillation is not sufficiently specific.

In order to assess the efficacy and tolerability of gallopamil (D-600, CAS 16662-47-8) by long-term venous infusion in the treatment of spontaneous angina, 15 consecutive patients were studied in a single-blind, self-controlled trial versus placebo. Following a 24-h Holter ECG recording of the patients receiving a saline infusion (run-in phase), i.v. administration of gallopamil was started at a dose of 0.02 mg/kg/h preceded by a 0.03 mg/kg bolus. After 24 h, the dosage was increased to 0.03 mg/kg/h and the infusion was maintained for another 48 h. The Holter ECG recording was repeated in the last 24 h of treatment and after 6 h from withdrawal (washout phase). The reduction in the number of angina attacks, as shown by a comparison between the average of the two placebo periods (run-in and washout phases) and the three days of treatment, was 68.2%, 92.5%, and 87%, respectively. Consumption of glyceryl trinitrate decreased by 92.5% on each one of the three days of treatment. The reduction in the number of ischemic episodes (IEs) with symptomatic (-91.6%) and silent (-98.0%) ST elevation, and with symptomatic (-100%) and silent (-90%) ST depression, also proved significant. Heart rate decreased only moderately. One patient showed a mild first-degree heart block, while another suffered a transient episode of isorhythmic A-V dissociation. In conclusion, when administered by venous infusion, gallopamil has been found to be well tolerated and highly effective in the treatment of spontaneous angina.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report their experience in the determination of the infarct size (IS) by means of enzymatic analysis in a series of 281 consecutive patients (230 males, 51 females) admitted to the CCU because of myocardial infarction (MI), who did not benefit from thrombolytic therapy in the acute phase. To obtain the enzymatic IS, the serum activity of creatine kinase (CK) is determined every 4 hours for 48 hours and after 72 hours; Sobel's formula is used and results are expressed as CK-g-Eq of tissue. The enzymatic IS was compared to the degree of left ventricular dysfunction (assessed by echocardiography); to the electrocardiographic extension of necrosis; to the severity of ventricular arrhythmias (expressed as Lown's class) on 24-hour Holter monitoring; to cardiac mortality at 2 years. Mean estimated enzymatic IS of the population under study was 129 +/- 101 g-Eq. Patients with extensive MI (216 +/- 144 g-Eq) had significantly (p less than 0.05) higher IS compared to patients with inferior (131 +/- 93 g-Eq), anterior (105 +/- 65 g-Eq) and non-Q wave MI (73 +/- 54 g-Eq); also, a statistically significant difference (p less than 0.05) was found between inferior and non-Q wave MI. Patients with severely compromised left ventricular function (defined as an echocardiographic ejection fraction less than 30%), had significantly higher values of IS compared to patients with preserved left ventricular function (171 +/- 130 vs 120 +/- 93 g-Eq; p less than 0.05). A poor correlation was found between enzymatic IS and ventricular arrhythmias documented at pre-discharge 24-hour Holter monitoring.(ABSTRACT TRUNCATED AT 250 WORDS)

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)

Transcatheter direct-current ablation of the atrio-ventricular junction is a recently developed technique in the treatment of medically refractory supraventricular tachycardia. Twenty patients underwent this procedure between July 1987 and May 1989 and were followed-up for a mean period of 8.3 +/- 6 months (range 1-23). Indication for ablation included atrial flutter in 4 patients, atrial fibrillation in 8, atrial tachycardia in 1, atrio-ventricular nodal re-entrant tachycardia in 4, atrioventricular re-entrant tachycardia (concealed pathway) in 2, permanent junctional reciprocating tachycardia in 1. These arrhythmias were resistant to a mean of 3.3 +/- 1.7 antiarrhythmic drugs. A mean of 1.4 +/- 0.59 (range 1-3) electrical shocks, with a mean energy of 285 +/- 135J (range 200-700), were delivered during 1-2 sessions. In all patients a persistent complete atrio-ventricular block was achieved. Immediate complications included transient hypotension in 2 pts, acute pulmonary edema in 1, premature ventricular complexes in 4, non sustained ventricular tachycardia in 4, sustained ventricular tachycardia in 1. Late complications included thrombophlebitis of the right femoral vein in 2 pts; one of them died suddenly as a result of massive pulmonary embolism 10 days after the procedure. Follow-up evaluation reveals chronic complete atrio-ventricular block in all patients. Symptoms related to pre-existing arrhythmia are absent in all pts and none of them is currently taking antiarrhythmic drugs. Two patients with DDD pacing had pacemaker mediated re-entrant tachycardia and 1 patient with VVIR pacing developed a pacemaker syndrome. This experience confirms that transcatheter fulguration of atrio-ventricular junction is an effective technique. However, possible severe complications related to the procedure suggest this approach be restricted to patients with very symptomatic and drug-refractory supraventricular tachyarrhythmias.

Graphical Abstract, Highlights • Multi-Criteria Decision Analysis applied to SARS CoV-2 pandemic • Creating a model to prioritize hospitalization of COVID-19 patients in low- and middle-income countries • Eleven criteria selected considering their feasibility in low-resource settings • Reducing the risk of non-standardised approaches and improving the response of health systems to new pandemics, Objective To use Multi-Criteria Decision Analysis (MCDA) to determine weights for eleven criteria in order to prioritize COVID-19 non-critical patients for admission to hospital in healthcare settings with limited resources. Methods The MCDA was applied in two main steps: specification of criteria for prioritizing COVID-19 patients (and levels within each criterion); and determination of weights for the criteria based on experts’ knowledge and experience in managing COVID-19 patients, via an online survey. Criteria were selected based on available COVID-19 evidence with a focus on low- and middle-income countries (LMICs). Results The most important criteria (mean weights, summing to 100%), are: PaO2 (16.3%); peripheral O2 saturation (15.9%); chest X-ray (14.1%); Modified Early Warning Score-MEWS (11.4%); respiratory rate (9.5%); comorbidities (6.5%); living with vulnerable people (6.4%); body mass index (5.6%); duration of symptoms before hospital evaluation (5.4%); CRP (5.1%); and age (3.8%). Conclusions At the beginning of a new pandemic, when evidence for disease predictors is limited or unavailable and effective national contingency plans are difficult to establish, the MCDA prioritization model could play a pivotal role in improving the response of health systems.

A case of right atrium aneurysm (diverticulum) detected in an asymptomatic 61-year-old woman is described. Diagnosis was made according to echocardiographic and echocontrastographic findings and was confirmed by both angiographic data and surgical pathology. The rarity of this finding and the possibility of a correct non-invasive assessment can be considered the two most peculiar features of this case.

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 intravenous dipyridamole test is considered a safe procedure with a very low incidence of severe cardiac effects and is routinely used in the diagnosis and prognosis of coronary artery disease. We report the case of a 63-year-old female with negative exercise stress test who developed prolonged and extensive myocardial ischemia after the high-dose intravenous dipyridamole echocardiography test. Aminophylline and nitroglycerin were employed but were ineffective and the patient was successfully treated with systemic thrombolysis. At coronary angiography, 48 hours later, a 50% stenosis in the proximal LAD was documented. We stress that high-dose intravenous dipyridamole can induce a severe ischemic response whose occurrence is unpredictable according to the pre-test clinical features.

In 13 hypercholesterolemic children, re-screened for serum cholesterol after a 1-year interval, hypercholesterolemia was confirmed in only 61.5% of the cases. A tentative explanation seems to be the statistical principle of regression towards the mean. The lipid--lipoprotein analysis showed that serum and LDL cholesterol concentrations in the 13 hypercholesterolemic children and their parents were significantly higher compared to controls (children and parents). At re-screening, hyper-LDL cholesterolemia was present in only 8 of the 13 children (61.5%); 4 cases exhibited hyper-HDL cholesterolemia (30.7%). The high prevalence of the parents repeating the lipoprotein abnormality and the electrophoretic pattern found in the propositi (children) confirms the familial aggregation of the hypercholesterolemic states (hyper-LDL and hyper-HDL cholesterolemia). In conclusion the results of our study stress the importance of determining the lipid--lipoprotein composition, rather then merely evaluating total serum cholesterol in order to make a correct diagnosis of the hypercholesterolemic state. It should also be emphasized that the lipoprotein disturbances and their familial aggregation may be detected early in childhood, suggesting that the familial screening for risk factors of atherosclerosis should be done at pediatric age.

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.

We have performed a multi-centre study with 47 outpatients in order to evaluate the efficacy of Verapamil (V) in the treatment of stable effort angina, and to compare the effect of two different doses of the drug (240 and 360 mg/die). The protocol consisted of a first period of Placebo, followed by the double-blind randomized cross-over administration of Placebo (P) and Verapamil (V) in doses of 240 and 360 mg/die. The symptomatology, the consumption of TNG, the ECG pattern at rest and during exercise, the maximum exercise tolerance during exercise and the rate of recovery were evaluated at the end of each 1 month period. V. provided a significant reduction of the number of angina attacks and of the consumption of TNG pills with improvement of symptomatology. The maximum exercise performance improved without changes in maximum rate pressure double product. A decrease of double product was observed at rest and during the recovery period. The higher dose of V. (360 mg/die) provides a better improvement in the number of angina attacks, in the symptomatology, in the double product at rest, and in the rate of recovery than the lower dose (240 mg/die). Thus these data indicate that V. provides anti-anginal efficacy by reducing myocardial oxygen demand, and increases exercise tolerance in effort angina patients.

Four cases of cardiac arrest occurred during Holter monitoring are described. All patients had sustained an acute myocardial infarction thirteen-fourteen days prior to recording and were fully mobilized. In all of them the fatal arrhythmic event was ventricular fibrillation (VF). ECG analysis revealed an increase in heart rate before initiation of VF in one patient only. Warning ventricular arrhythmias were present in two patients. Transient ST segment changes during monitoring were noted in all patients. In three cases the arrhythmia was initiated by an ectopic ventricular beat (EVB) with R-on-T phenomenon; in two of them the EVB occurred after a sinus beat following a long post-ectopic pause. The different electrical events able to induce VF showed a variable and unpredictable pattern of occurrence and association in different patients and at different times in the same patient. Therefore, no specific "trigger" of the fatal arrhythmia could be identified.

The case of a patient with angiosarcoma of the right atrium is described with respect to clinical presentation, hemodynamic and angiographic findings and post-mortem examination. The need of a high index of suspicion when dealing with patients who show evidence of systemic venous congestion is stressed.

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.

We describe the case of a diastolic mitral and tricuspid regurgitation in a patient affected by acute myocardial infarction Ecg showed inferior myocardial infarction complicated by atrioventricular block and a junctional rhythm with frequent premature ventricular beats; the mean heart rate was of about 60 per minute. 2D echocardiogram disclosed akinesia of the apical segments of the inferior septum and anterior and infero-lateral walls. Pulsed and continuous wave Doppler showed mild to moderate mitral and tricuspid systolic regurgitation and diastolic regurgitation through both atrioventricular valves. The diastolic regurgitation always occurred during prolonged diastoles, soon after the blocked P waves. The possible mechanism of this finding and its clinical significance are discussed, drawing the conclusion that the atrioventricular diastolic regurgitation is not diagnostic of a specific valvular disease but can be secondary to other conditions, especially the atrioventricular block.

Natural rubber latex (NRL) is a frequent cause of immediate type I hypersensitivity, but delayed type IV reactions can also occur.

Not available