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Summary Objective In the SMILE-4 study, zofenopril + acetyl salicylic acid (ASA) was more effective than ramipril + ASA on 1-year prevention of major cardiovascular events (MACE) in patients with acute myocardial infarction complicated by left ventricular dysfunction. In this retrospective analysis, we evaluated drug efficacy in subgroups of patients, according to a history of diabetes mellitus. Methods The primary study endpoint was 1-year combined occurrence of death or hospitalization for cardiovascular causes. Diabetes was defined according to medical history (previous known diagnosis). Results A total of 562 of 693 (81.0%) patients were classified as nondiabetics and 131 (18.9%) as diabetics. The adjusted rate of MACE was lower under zofenopril than under ramipril in both nondiabetics [27.9% vs. 34.9% ramipril; odds ratio, OR and 95% confidence interval: 0.55 (0.35, 0.86)] and diabetics [30.9% vs. 41.3%; 0.56 (0.18, 1.73)], although the difference was statistically significant only for the nondiabetic group (P = 0.013). Zofenopril was superior to ramipril as regards to the primary study endpoint in the subgroup of 157 patients with uncontrolled blood glucose (≥126 mg/dL), regardless of a previous diagnosis of diabetes [0.31 (0.10, 0.90), P = 0.030]. Zofenopril significantly reduced the risk of hospitalization for cardiovascular causes in both nondiabetics [0.64 (0.43, 0.96), P = 0.030] and diabetics [0.38 (0.15, 0.95), P = 0.038], whereas it was not better than ramipril in terms of prevention of cardiovascular deaths. Conclusions This retrospective analysis of the SMILE-4 study confirmed the good efficacy of zofenopril plus ASA in the prevention of long-term MACE also in the subgroup of patients with diabetes mellitus.

Changing axis deviation has been reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. Patients with unstable angina have a higher incidence of left main coronary artery (LMCA) and proximal left anterior descending (LAD) coronary artery disease compared to patients with stable angina pectoris. In 1982, Wellens and colleagues described two electrocardiographic patterns that were predictive of critical narrowing of the proximal LAD artery, and were subsequently termed Wellens' syndrome. The criteria were: a) prior history of chest pain, b) little or no cardiac enzyme elevation, c) no pathologic precordial ST segment elevation, d) no loss of precordial R waves, and e) biphasic T waves in leads V2 and V3, or asymmetric, often deeply inverted T waves in leads V2 and V3. The ECG changes are best recognized outside the episode of anginal pain. Lead aVR and lead v1 ST segment elevation, during chest pain, has been reported in patients with LMCA disease with ST segment depression in leads V3, V4 and V5 (with maximal depression in V4).We present a case of changing axis deviation in a 37-year-old Italian man with a LAD coronary artery subocclusion associated with a LMCA subocclusion. This case focuses attention on the importance of the recognition of the patterns suspected for LAD coronary artery disease or for LMCA disease.

Changing axis deviation has been rarely reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also rarely reported during acute myocardial infarction associated with atrial fibrillation or at the end of atrial fibrillation during acute myocardial infarction. Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. It has been reported that subclinical hyperthyroidism is not associated with coronary heart disease or mortality from cardiovascular causes but it is sufficient to induce arrhythmias including atrial fibrillation and atrial flutter. It has also been reported that increased factor X activity in patients with subclinical hyperthyroidism represents a potential hypercoagulable state. Serum troponin-I is a sensitive indicator of myocardial damage but abnormal troponin-I levels have been also reported without acute coronary syndrome and without cardiac damage. Abnormal troponin-I levels after supraventricular tachycardia have been also reported. We present a case of changing axis deviation in a 49-year-old Italian man with atrial fibrillation, exogenous subclinical hyperthyroidism and troponin-I positive without acute coronary syndrome. Also this case focuses attention on changing axis deviation, on subclinical hyperthyroidism and on the importance of a correct evaluation of abnormal troponin-I levels.

The exercise electrocardiogram is a commonly used non-invasive and inexpensive method for detection of electrocardiogram (ECG) changes secondary to myocardial ischemia. Reversible ST-segment depression is the characteristic finding associated with exercise-induced, demand-driven ischemia in patients with significant coronary obstruction but no flow limitation at rest. The exercise-induced ST-segment depression in inferior leads has been questioned and it has been reported that lead V5 alone consistently outperforms the inferior leads and the combination of lead V5 with II, because lead II has a high false-positive rate. A review of the 12-lead visual electrocardiographic interpretations confirmed that changes isolated to the inferior leads were rare in patients, who had no diagnostic Q waves. Considering the sum of ST-segment depression or the most depression in the three leads representing the three main areas of the myocardium (II, V2, and V5) did not improve the diagnostic capacity of the test. A case is presented to illustrate how in a patient, the ST-segment depression in inferior leads during exercise testing is related with significant coronary artery disease. We present a case of exercise-induced ST-segment depression in inferior leads in a 52 year-old Italian man. This experience demonstrates that ST-segment depression in inferior leads during the exercise testing can have a diagnostic significance.

It has been rarely reported intermittent changing axis deviation also during atrial fibrillation and also during atrial flutter. Intermittent changing axis deviation during acute myocardial infarction and changing axis deviation associated with atrial fibrillation and acute myocardial infarction too have been also rarely reported. Conduction system disturbances have been described during acute myocarditis and it has been suggested that myocardial interstitial edema is implicated in the conduction disturbances that occur in acute myocarditis. Usually, edema is located in the epicardial layer of ventricular wall during acute phase of focal myocarditis and it can't be associated with clear evidence of wall motion abnormalities. It has also been described in a work the report of sequences of alternant normal and Wenckebach beats with alternate and progressive right bundle branch block interpreted as functional longitudinal dissociation in atrioventricular conduction axis during chronic chagasic myocarditis. We present a case of changing axis deviation during acute myocarditis in a 15-year-old Italian man. This case focuses attention on changing axis deviation during acute phase of focal myocarditis in absence of wall motion abnormalities.

Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. It has been reported that sub-clinical hyperthyroidism is not associated with CHD or mortality from cardiovascular causes but is sufficient to induce arrhythmias including atrial fibrillation and atrial flutter. Moreover increased factor X activity in patients with subclinical hyperthyroidism represents a potential hypercoagulable state. It has been also reported an acute myocardial infarction with normal coronary arteries associated with iatrogenic hyperthyroidism and with a myocardial bridge too. It has been also reported an acute myocardial infarction without significant coronary stenoses associated with subclinical hyperthyroidism. Furthermore it has been reported that at highly increased hematocrit levels patients may experience hyperviscosity symptoms. We present a case of atrial fibrillation and acute myocardial infarction without significant coronary stenoses associated with subclinical hyperthyroidism and erythrocytosis. Also this case focuses attention on the importance of a correct evaluation of subclinical hyperthyroidism.

The prevalence of the Brugada-type ECG and its natural history are still unclear. The Brugada syndrome is usually identified by a characteristic Brugada-type ECG that consists of ST elevation of a coved type in the precordial leads V1 to V3 and ventricular fibrillation that can lead to sudden cardiac death, although affected individuals may have a normal ECG. Mutations in the cardiac sodium channel gene SCN5A, which encodes the alpha-subunit of the human cardiac voltage-dependent Na+ channel (Na(v)1.5), are identified in 15–30% of patients with Brugada syndrome. Most SCN5A mutations lead to a ‘loss-of-function’ phenotype, reducing the Na+ current during the early phases of the action potential. Several nongenetic factors have been mentioned in the literature as possible inductors of the ECG pattern resembling Brugada syndrome. As such, a Brugada-type ECG may appear in some patients during febrile states and in those who are under the influence of cocaine and pharmaceutical drugs that have a sodium channel-blocking effect. It has been also reported chest pain and ST elevation Brugada pattern during febrile states. We present a case of revelation of Brugada pattern in a 69-year-old Italian man during a febrile state associated with acute myocardial infarction. Also this report confirms that Brugada pattern should be considered as one of differential diagnoses when we examine the patients during a febrile state.

It has been rarely reported intermittent changing axis deviation also occurs during atrial fibrillation. Intermittent changing axis deviation during acute myocardial infarction and changing axis deviation associated with atrial fibrillation and acute myocardial infarction too have been also rarely reported. It has also been reported acute myocardial infarction during l-thyroxine substitution therapy in a patient with elevated levels of free triiodothyronine and without significant coronary artery stenoses. An acute myocardial infarction due to coronary spasm associated with l-thyroxine therapy has also been reported too. We present a case of changing axis deviation during acute myocardial infarction in a 56-year-old Italian woman with permanent atrial fibrillation and l-thyroxine therapy and without significant coronary stenoses. Also this case focuses attention on changing axis deviation in the presence of atrial fibrillation during acute myocardial infarction and on the possible development of acute myocardial infarction without significant coronary stenoses associated with l-thyroxine therapy.

Thalassemia is a congenital hemoglobinopathy leading to anemia because of impaired erythropoiesis and peripheral hemolysis. Thalassemia major patients are transfusion dependent and it results in iron accumulation. The heart is one of the major organs affected with iron overload and iron induced cardiac dysfunction (pump and conduction abnormalities) remains the number one cause of death among thalassemia major patients. It has been reported that a high ferritin concentration is related to high troponin levels in hemodialysis patients receiving more intravenous iron sucrose. Abnormal troponin I levels have also been reported without acute coronary syndrome. We present a case of abnormal troponin I levels in Thalassemia major patient with high ferritin concentration, permanent atrial fibrillation and without acute coronary syndrome. To our knowledge, this is the first report of abnormal troponin I levels in a Thalassemia major patient with high ferritin concentration and without acute coronary syndrome and also this case focuses attention on the importance of the correct evaluation of abnormal troponin I levels.

Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. It has been reported that subclinical hyperthyroidism is not associated with coronary heart disease or mortality from cardiovascular causes but it is sufficient to induce arrhythmias including atrial fibrillation and atrial flutter. It has also been reported that increased factor X activity in patients with subclinical hyperthyroidism represents a potential hypercoagulable state. We present a case of atrial fibrillation associated with subclinical hyperthyroidism, in a 78-year-old Italian woman. Also this case focuses attention on the importance of a correct evaluation of subclinical hyperthyroidism.

Associated symptoms and conduction disturbances are reported during acute inferior myocardial infarction. Differentiation of right coronary artery from left circumflex artery occlusion may be difficult since both can present an electrocardiographic pattern of inferior myocardial infarction. Paroxysmal atrial fibrillation is considered a frequent complication of acute myocardial infarction and the patients with paroxysmal atrial fibrillation probably should be targeted for earlier and more aggressive treatment. These patients in the thrombolytic era have a better overall outcome than counterparts in the prethrombolytic era. We describe a case of conduction disturbances and paroxysmal atrial fibrillation in a 51-year-old Italian man with acute inferior myocardial infarction and right coronary artery stenosis.

Background Increasing evidence suggests that prostate-specific antigen kallikrein (PSA) relates to the cardiovascular system. Recently, an association between PSA levels and aortic stiffness has been also reported in untreated essential hypertensive males. Elevated pulse pressure, a surrogate measure for increased proximal aortic stiffness, predisposes to myocardial infarction and atrial fibrillation. No studies, to date, have evaluated the relationship between PSA levels and the occurrence of AMI or new-onset atrial fibrillation in hypertensive male patients. Herein, we conducted a study to investigate this question. Methods This work is a retrospective, observational, study. Consecutive male patients were enrolled and divided in two groups: 58 patients with non - ST elevation myocardial infarction (NSTEMI) and 59 patients with new-onset atrial fibrillation. PSA levels gradually change with age and we prefer to use the percentage of age-specific PSA ranges (a.s. PSA) instead of the simple PSA levels. Results At multivariate analysis DM [0.263 (0.105–0.662); P=0.005], dyslipidemia [0.301 (0.105–0.863); P=0.025] and a higher percentage of a.s. PSA [0.908 (0.895–0.970); P=0.000] were significantly associated with the occurrence of NSTEMI. Conclusions The main results of this study showed that a higher percentage of a.s. PSA significantly relates with the occurrence of NSTEMI. In addition, the results of our investigation, also, demonstrate that the significant correlation between higher percentage of a.s. PSA and the occurrence of NSTEMI persisted after adjustment for traditional CAD risk factors (age, DM, dyslipidemia, and smoking). Large studies are needed to further confirm our findings and to elucidate the causes and effects.

Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. It has been reported that subclinical hyperthyroidism is not associated with coronary heart disease or mortality from cardiovascular causes but it is sufficient to induce arrhythmias including atrial fibrillation and atrial flutter. Nowadays, there is growing interest regarding endogenous sublinical hyperthyroidism and the cardiovascular system. We present a case of acute myocardial infarction without significant coronary stenoses in a 75-year-old Italian woman with endogenous subclinical hyperthyroidism. Also this case focuses attention on the importance of a correct evaluation of endogenous subclinical hyperthyroidism.

Changing axis deviation has been reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. We present a case of revelation of changing axis deviation at the end of atrial fibrillation without acute myocardial infarction in a 74-year-old Italian man. Also this case focuses attention on changing axis deviation.

Changing axis deviation has been reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. Left bundle branch block is usually associated with normal or left axis deviation. Rarely the ECG shows a left bundle branch block with changing QRS morphology and changing axis deviation. We present a case of a left bundle branch block with changing axis deviation in an 86-year-old Italian man admitted to the Cardiology Unit with an acute myocardial infarction. Also this case focuses attention on left bundle branch block with changing axis deviation.

Changing axis deviation has been reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. Left bundle branch block is usually associated with normal or left axis deviation. Rarely the ECG shows a LBBB with changing QRS morphology and changing axis deviation. There are several possible explanations for the intermittent shift in the QRS axis in the presence of complete left bundle branch block. The most plausible explanation is the coexistence of left posterior hemiblock and predivisional left bundle branch block. We present a case of a left bundle branch block with changing axis deviation in a 93-year-old Italian woman admitted to the Cardiology Unit with an acute myocardial infarction.

Changing axis deviation has been reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. We present a case of changing axis deviation during atrial fibrillation in a 63-year-old Italian woman. Also this case focuses attention on changing axis deviation.

Signs of plaque inflammation in carotid arteries may serve as a window to the entire cardiovascular system, to identify "vulnerable" patients. Moreover, flow-mediated vasodilation in the brachial artery and intima media thickness (IMT) in the carotid artery could represent a surrogate diagnostic method for assessment of coronary artery disease (CAD) severity. Renal function is an important predictor of the presence and severity of angiographic CAD in patients without severe renal impairment with incremental value over traditional risk factors for CAD and IMT. It has also been reported ,that renal dysfunction may exert differential effects on the development of coronary and peripheral atherosclerosis. An accumulating burden of hypertension, diabetes, and smoking is important in the progression of atherosclerosis from the coronary to the carotid circulation. We present an unusual case of lack of correlation of carotid atherosclerosis and coronary atherosclerosis.

Ventricular septal defects can occur as part of other congenital cardiac malformations or as an isolated finding. Aneurysms of the sinus of Valsalva are rare, most commonly involving the right or noncoronary sinuses. They can be congenital or acquired through infection, trauma, or degenerative diseases. They frequently co-exist with ventricular septal defects, aortic valve dysfunction, or other cardiac abnormalities. More commonly, sinus of Valsalva aneurysms are diagnosed after the clinical sequelae of rupture. Several etiologic factors may lead to the development of pathologic pericardial effusion and the detection of pericardial effusion was one of the first applications of echocardiography to gain widespread acceptance. We present a case of a chance finding of an aneurysm of the right sinus of Valsalva in an 11-year-old Italian child with a ventricular septal defect and a pericardial effusion.

Changing axis deviation has been rarely reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also rarely reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. We present a case of changing axis deviation in a 77-year-old Italian woman admitted to the Cardiology Unit with an acute myocardial infarction. Also this case focuses attention on changing axis deviation and acute myocardial infarction.

Stress echocardiography is today the best possible imaging choice in the field of noninvasive diagnosis of coronary artery disease. Dobutamine stress echocardiography (DSE) and Dobutamine-atropine stress echocardiography (DASE) have been studied. Handgrip (HG) exercise has been rarely studied in stress echocardiography. We present a case of the use of isometric HG exercise with DSE in a 78-year-old Italian man. This case is illustrative of the safety, feasibility and efficacy of the use of isometric HG exercise with DSE and on the fact that it improves diagnostic capacity of the test.

Dissimilar electrocardiographic patterns associated with right bundle branch block have been described. The prognosis of right bundle branch block in the absence of underlying cardiac disease is good but it may be poor in other cases, particularly coronary artery disease. Changing bundle branch block, new right bundle branch block, right bundle branch conduction disturbances have been reported in literature. Changing axis deviation has been reported alone or during acute myocardial infarction also associated with atrial fibrillation. Intermittent right axis deviation has been rarely reported in the presence of left bundle branch block also during atrial fibrillation and with acute myocardial infarction too. Isolated left posterior hemiblock is a very rare finding and transient right axis deviation associated with a left posterior hemiblock pattern has been also rarely described associated with acute myocardial infarction. We describe a case of changing axis deviation with intermittent right bundle branch block in a patient admitted with acute myocardial infarction. Also this case focuses attention on changing axis deviation and intermittent right bundle branch block during acute myocardial infarction.

After mechanical heart valve replacement use of unfractionated heparin is sometimes required because vitamin K antagonists are temporarily contraindicated or to prevent valve-associated thromboembolism until oral vitamin K antagonists take effect. Bridging therapy with a standardized low molecular weight heparin-based regimen has been reported effective and relatively safe in a large cohort of patients with mechanical heart valves. Many cases with mitral mechanical valve prostheses and treatment failure of low molecular weight heparin have also been reported as well as prosthetic valve thrombosis has been reported with adequate anticoagulation. A case has also been reported of well functioning Starr-Edwards aortic prosthesis without anticoagulation. We present a case of cardioembolic stroke in a patient with an aortic mechanical prosthesis in bridging therapy with a standardized low molecular weight heparin-based regimen. This case is illustrative of treatment failure of low molecular weight heparin in a patient with an aortic mechanical prosthesis.

Prostate-specific antigen (PSA) is an established marker for the detection of prostate cancer. Both elevated and diminished PSA have been reported during acute myocardial infarction. It seems that when elevation of PSA occurs during acute myocardial infarction (AMI), coronary lesions are frequent and often more severe than when a diminution of PSA occurs. PSA has been identified as a member of the human kallikrein family of serine proteases. In recent years, numerous observations have suggested that the activity of the kallikrein-kinin system is related to inflammation and to cardiovascular diseases. PSA kallikrein, however, does not seem to have kinin-generating activity. The inactive precursor form of PSA, proPSA, is converted rapidly to active PSA by Human kallikrein 2 (hK2), suggesting an important in vivo regulatory function byhK2 on PSA activity. However, it has been reported that hK2 might not alone be able to activate proPSA in vivo, but there are also other protease/proteases involved in this event. Moreover, it seems that when elevation of prostate-specific antigen occurs during AMI, it seems to relate to a higher occurrence of major adverse cardiac events in the first 8 days after AMI than when a diminution of PSA occurs. It confirms a possible new intriguing scenario of the role of the PSA in AMI. Although these preliminary observations are suggestive, large studies need to be done to confirm these preliminary results.

Randomized clinical studies have demonstrated that tissue plasminogen activator thrombolytic therapy improves functional outcomes. Recently the time window for tissue plasminogen activator thrombolytic therapy has been extended from 3 to 4.5 h after ischemic stroke onset, which will allow more ischemic stroke patients to benefit from this treatment. Healthcare providers should also ascertain whether the ST-elevation myocardial infarction (STEMI) patient has also neurological contraindications to fibrinolytic therapy, including any history of intracranial hemorrhage, significant closed head or facial trauma within the past 3 months, uncontrolled hypertension, or ischemic stroke within the past 3 months (EXCEPT acute ischemic stroke within 3 h). History of prior ischemic stroke greater than 3 months is a relative contraindication. We present a case of tissue plasminogen activator thrombolytic therapy in a 68-year-old Italian man admitted to the Emergency Department with heart failure, ischemic stroke and ST-elevation myocardial infarction. Also this case focuses attention on regression of ischemic stroke symptoms in STEMI patient treated with tissue plasminogen activator thrombolytic therapy.

Accessory pathways have been described as well as their Ecg identification criteria also in pediatric population. Radiofrequency ablation is a curative treatment but its application has been more limited in the paediatric population. The congenital form of junctional ectopic tachycardia was firstly described by Coumel et al. in 1976. It usually occurs in the first six months of life presenting as a persistent sustained form, lasting up to 90% of the time and it is hampered by high mortality. Its clinical presentation may be dramatic, being associated in up to 60% of cases with cardiomegaly and/or heart failure. Secondary dilated cardiomyopathy, ventricular fibrillation and sudden cardiac death have also been reported. We present a case of congenital form of junctional ectopic tachycardia in a 12-day-old newborn infant. Also this case is illustrative of the congenital form of junctional ectopic tachycardia.

Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. It has been reported that subclinical hyperthyroidism is not associated with coronary heart disease or mortality from cardiovascular causes but it is sufficient to induce arrhythmias including atrial fibrillation and atrial flutter. It has also been reported that increased factor X activity in patients with subclinical hyperthyroidism represents a potential hypercoagulable state. Moreover acute myocardial infarction has been reported during L-thyroxine substitution therapy. Far more common and relatively less studied is exogenous subclinical hyperthyroidism caused by L-thyroxine administration to thyroidectomized or hypothyroid patients or patients with simple or nodular goiter. We present a case of atrial fibrillation associated with exogenous subclinical hyperthyroidism, in a 72-year-old Italian woman. Also this case focuses attention on the importance of a correct evaluation of subclinical hyperthyroidism.

Hypertrophic cardiomyopathy (HCM) is classified as a primary cardiomyopathy. HCM is a clinically heterogeneous but relatively common autosomal dominant genetic heart disease that probably is the most frequently occurring cardiomyopathy. HCM is characterized morphologically and defined by a hypertrophied, nondilated left ventriculum (LV) in the absence of another systemic or cardiac disease that is capable of producing the magnitude of wall thickening evident (e.g., systemic hypertension, aortic valve stenosis). Most HCM patients have the propensity to develop dynamic obstruction to LV outflow under resting or physiologically provocable conditions, produced by systolic anterior motion of the mitral valve with ventricular septal contact. The phenotypic features of HCM may develop at any age from infancy to adulthood, and are characterized by a great heterogeneity in the extent, magnitude, and distribution of left ventricular hypertrophy. Hypertrophic obstructive cardiomyopathy (HOCM) often leads to heart failure, severe ischemia, severe symptoms and death. Determination of the exact site of the hypertrophy and of the obstruction of the left ventricular outflow tract, in asymmetric septal hypertrophy, establishes which is the best treatment strategy. In the treatment of HOCM, drug therapy with negatively inotropic drugs, percutaneous transluminal septal myocardial ablation by alcohol-induced septal branch occlusion, surgical myectomy and DDD pacemaker therapy are considered the therapeutical options. We present a case of an obstructive hypertrophic cardiomyopathy in an 84-year-old Italian woman with a left ventricular outflow tract (LVOT) peak gradient with the Valsalva maneuver of 188 mm Hg and with a history of first episode of syncope.

The use of substances as the substrate for atrial fibrillation is not frequently recognized. Chocolate is derived from the roasted seeds of the plant theobroma cacao and its components are the methylxanthine alkaloids theobromine and caffeine. Caffeine is a methylxanthine whose primary biological effect is the competitive antagonism of the adenosine receptor. Normal consumption of caffeine was not associated with risk of atrial fibrillation or flutter. Sympathomimetic effects, due to circulating catecholamines cause the cardiac manifestations of caffeine overdose toxicity, produce tachyarrhythmias such as supraventricular tachycardia, atrial fibrillation, ventricular tachycardia, and ventricular fibrillation.The commonly used doses of inhaled or nebulized salbutamol induced no acute myocardial ischaemia, arrhythmias or changes in heart rate variability in patients with coronary artery disease and clinically stable asthma or chronic obstructive pulmonary disease. Two-week salbutamol treatment shifts the cardiovascular autonomic regulation to a new level characterized by greater sympathetic responsiveness and slight beta2-receptor tolerance. We present a case of atrial fibrillation associated with chocolate intake abuse in a 19-year-old Italian woman with chronic salbutamol inhalation abuse. This case focuses attention on chocolate intake abuse associated with chronic salbutamol abuse as the substrate for atrial fibrillation.

Ventricular septal defect (VSD) can occur as part of more congenital cardiac malformations or as an isolated finding. VSD can be also a serious complication of acute myocardial infarction. It seems that its prognosis improves if the operation can be deferred for 3-4 weeks. The treatment of VSD is changing and the surgical closure should be postponed in order to reduce the mortality risk. The use of Impella Recover left ventricular assistance device allowed to delay the surgery, stabilizing the patient's hemodynamic condition. We describe a case of post-infarction VSD treated with the implantation of Impella Recover, which permitted to postpone a surgical closure for 2 weeks. Our results confirm the improvement of VSD's survival, depending on the use of Impella Recover, which allows to maintain the hemodynamic stability and to delay the operation.

Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. It has been reported that subclinical hyperthyroidism is not associated with coronary heart disease or mortality from cardiovascular causes but it is sufficient to induce arrhythmias including atrial fibrillation and atrial flutter. It has also been reported that increased factor X activity in patients with subclinical hyperthyroidism represents a potential hypercoagulable state. Rarely, it has also been reported intermittent changing axis deviation during atrial fibrillation and during atrial flutter. We present a case of paroxysmal atrial flutter and changing axis deviation associated with subclinical hyperthyroidism, in a 76-year-old Italian man. Also this case focuses attention on the importance of a correct evaluation of subclinical hyperthyroidism.

The exercise electrocardiogram is a commonly used non-invasive and inexpensive method for detection of electrocardiogram (ECG) changes secondary to myocardial ischemia. It has been reported that in patients with a first myocardial infarction and without residual ischemia, exercise-induced ST-segment elevation in Q leads is related to a more damaged coronary microcirculation and to less viable myocardium. Exercise-induced ST-segment elevation is a rare phenomenon in patients without prior myocardial infarction. When occurring purely during exercise, coronary lesions are frequent and often severe, and on the other hand ST-segment elevation of the recovery phase is frequently associated with normal arteries or less severe lesions. We present a case of exercise-induced ST-segment elevation in a 51-year-old Italian man. Coronary angiography revealed a significant left anterior descending coronary artery stenosis, a significant circumflex coronary artery stenosis, a significant first obtuse marginal coronary artery stenosis and a significant second obtuse marginal coronary artery stenosis. Percutaneous transluminal coronary angioplasty with implantation of stents was successfully performed. Also this case is illustrative of the rare phenomenon of exercise-induced ST-segment elevation.

Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation including allergic or hypersensitivity and anaphylactic or anaphylactoid insults. We present a case of recurrent acute myocardial infarction associated with an allergic reaction in an 83-year-old Italian woman.

Dual atrioventricular nodal physiology has been reported. Atrioventricular nodal reentrant tachycardia is the most common supraventricular tachycardia associated with dual atrioventricular nodal physiology. We present a case of dual atrioventricular nodal physiology in a 12-year-old Italian boy.

The prevalence of the Brugada-type ECG and its natural history are still unclear. The Brugada syndrome is usually identified by a characteristic Brugada-type ECG that consists of ST elevation of a coved type in the precordial leads V1 to V3 and ventricular fibrillation that can lead to sudden cardiac death, although affected individuals may have a normal ECG. Mutations in the cardiac sodium channel gene SCN5A , which encodes the alpha-subunit of the human cardiac voltage-dependent Na+ channel (Na(v)1.5), are identified in 15–30% of patients with Brugada syndrome. Most SCN5A mutations lead to a ‘loss-of-function' phenotype, reducing the Na+ current during the early phases of the action potential. Several nongenetic factors have been mentioned in the literature as possible inductors of the ECG pattern resembling Brugada syndrome. As such, a Brugada-type ECG may appear in some patients during febrile states and in those who are under the influence of cocaine and pharmaceutical drugs that have a sodium channel-blocking effect. It has been also reported that chest pain and ST elevation Brugada pattern occur during febrile states. We present a case of revelation of Brugada pattern in a 61-year-old Italian man complaining of pain in the left hipocondrium during a febrile state. Also this report confirms that Brugada pattern should be considered as one of differential diagnoses when we examine the patients during a febrile state.

Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. Paroxysmal atrial fibrillation is a frequent complication of acute myocardial infarction. It has been reported that subclinical hyperthyroidism is not associated with coronary heart disease or mortality from cardiovascular causes but it is sufficient to induce arrhythmias including an increase in atrial fibrillation rate. It has also been reported that increased factor X activity in patients with subclinical hyperthyroidism represents a potential hypercoagulable state. Moreover chronic renal failure presents an increased arrhythmic risk. Apparently spurious result has been reported in a work about mean serum prostate-specific antigen (PSA) concentration during acute myocardial infarction with mean serum PSA concentration significantly lower on day 2 than either day 1 or day 3 and it has been reported that these preliminary results could reflect several factors, such as antiinfarctual treatment, reduced physical activity or an acute-phase response. We present a case of paroxysmal ventricular tachycardia and paroxysmal atrial fibrillation associated with subclinical hyperthyroidism, chronic renal failure and elevation of serum PSA concentration in a 90-year-old Italian man during acute myocardial infarction. Also this case focuses attention on the importance of a correct evaluation of subclinical hyperthyroidism and of chronic renal failure. Moreover, our report also confirms previous findings and extends the evaluation of PSA during acute myocardial infarction.

Changing axis deviation has been reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. Left bundle branch block is usually associated with normal or left axis deviation. Rarely the ECG shows a left bundle branch block with changing QRS morphology and changing axis deviation. There are several possible explanations for the intermittent shift in the QRS axis in the presence of complete left bundle branch block. The most plausible explanation is the coexistence of left posterior hemiblock and predivisional left bundle branch block. Intermittent right axis deviation has been rarely reported in the presence of left bundle branch block also during atrial fibrillation and with acute myocardial infarction too. Isolated left posterior hemiblock is a very rare finding and transient right axis deviation associated with a left posterior hemiblock pattern has been also rarely described associated with acute myocardial infarction. Changing axis deviation with changing bundle branch block and new-onset of atrial fibrillation during acute myocardial infarction has been also reported. Changing axis deviation with intermittent right bundle branch block in a patient admitted with acute myocardial infarction has been also described. We present a case of a right bundle branch block with revelation of changing axis deviation at the end of atrial fibrillation in a 68-year-old Italian man.

The discovery of a left ventricular mass obliges the clinician to perform a differential diagnosis including tumour or lipoma versus thrombus and its assessment presents important clinical implications. Dilated cardiomyopathy has been associated with left ventricular thrombosis which leads to substantial morbidity and mortality as a site for peripheral emboli. There are some studies on patients with dilated cardiomyopathy showing altered hemostasis and platelet behavior despite sinus rhythm. An increased incidence of thromboembolism is also well recognized in patients with left ventricular systolic dysfunction complicating history of myocardial infarction. Clinical dilemmas in treating left ventricular thrombus have been described too. We present a case of a large mobile left ventricular thrombus in a 71-year-old Italian man with dilated cardiomyopathy and history of myocardial infarction.

Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. It has been reported that subclinical hyperthyroidism is not associated with CHD or mortality from cardiovascular causes but it is usually associated with a higher heart rate and a higher risk of supraventricular arrhythmias including atrial fibrillation and atrial flutter. Intermittent changing axis deviation during atrial fibrillation has also rarely been reported. We present a case of intermittent changing axis deviation with intermittent left anterior hemiblock in a 59-year-old Italian man with atrial flutter and subclinical hyperthyroidism. To our knowledge, this is the first report of intermittent changing axis deviation with intermittent left anterior hemiblock in a patient with atrial flutter.

Paroxysmal atrioventricular block has been reported in patients without acute coronary syndrome and without significant coronary artery stenosis, in patients with acute coronary syndrome and without significant coronary artery stenosis, in patients without acute coronary syndrome and with significant coronary artery stenosis and in patients with acute coronary syndrome and significant coronary artery stenosis. Conflicting roles for alternating periods of second degree atrioventricular block (also known as Mobitz I or Luciani–Wenckebach periodicity) have been reported. Both hypotheses have been reported, that paroxysmal Wenckebach periods are compatible with a benign prognosis and that paroxysmal Wenckebach periods are associated with hemodynamic deterioration. We present a case of paroxysmal Mobitz Type-I atrioventricular block Luciani–Wenckebach conduction in a 75-year-old Italian man with acute myocardial infarction and severe three vessels coronary artery disease.

Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. It has been reported that subclinical hyperthyroidism is not associated with CHD or mortality from cardiovascular causes but increased factor X activity in patients with subclinical hyperthyroidism represents a potential hypercoagulable state. It has been also reported an acute myocardial infarction with normal coronary arteries associated with iatrogenic hyperthyroidism and with a myocardial bridge too. Moreover, it has been reported that simply measuring maximum P wave duration and P wave dispersion values, may help to determine the patients with subclinical hyperthyroidism and high risk for the development of atrial fibrillation. We present a case of an acute myocardial infarction without significant coronary stenoses associated with subclinical hyperthyroidism. Also this case focuses attention on the importance of a correct evaluation of subclinical hyperthyroidism.

Paroxysmal atrial arrhythmias especially atrial fibrillation are frequently encountered in adult patients with atrial septal defect. However, the diagnosis of atrial defect can be difficult. Thransthoracic echocardiography, the mostly utilized cardiac technique, has shown a limited ability to identify small atrial defects. Transesophageal echocardiography has shown high accuracy to identify but it isn't well tolerated of the patients. Recently, the utility of multislice computed tomography in the evaluation of direction, location, and size of shunt flow in congenital heart disease has been demonstrated. Cardiac magnetic resonance imaging (MRI) is a recent imaging technique that permits with high spatial resolution and without ionising radiation an accurate identification of many cardiovascular diseases. We report an unusual detection of an atrial defect by phase-contrast cine MRI in a patient clinically suspected of arrhitmogenic right ventricular displasia.

Prostate-specific antigen (PSA) has been identified as a member of the human kallikrein family of serine proteases and it is an established marker for detection of prostate cancer. Apparently spurious result has been reported in a work about mean serum PSA concentration during acute myocardial infarction with mean serum PSA concentration significantly lower on day 2 than either day 1 or day 3 and it has been reported that these preliminary results could reflect several factors, such as antiinfarctual treatment, reduced physical activity or an acute-phase response. Elevation of prostate-specific antigen has also been reported during acute myocardial infarction in three patients and in another one also after transurethral resection of the prostate (TURP) and without histological diagnosis of prostate cancer. In our report we present three cases of diminution of serum PSA concentration during acute myocardial infarction. Our report extends the evaluation of PSA during acute myocardial infarction. It seems that when elevation of prostate-specific antigen occurs during acute myocardial infarction, coronary lesions are frequent and often more severe than when diminution of prostate-specific antigen occurs during acute myocardial infarction. It opens a possible new intriguing scenario of the role of the prostate-specific antigen in acute myocardial infarction.

Paroxysmal atrial fibrillation is considered a frequent complication of acute myocardial infarction.It has been rarely reported alternating right and left bundle branch block associated with atrial fibrillation. It has also been rarely reported changing axis deviation with left bundle branch block also during atrial fibrillation and acute myocardial infarction. We present a case of changing axis deviation with changing bundle branch block and new-onset of atrial fibrillation in a 96-year-old Italian man with acute myocardial infarction.

Left ventricular outflow tract obstruction can occur at the supravalvular, valvular, or subvalvular level. Each level of obstruction is associated with distinct symptomatology, natural history, and operative approach. We describe a case of asymptomatic double site of left ventricular outflow tract obstruction: subvalvular aortic stenosis associated with valvular aortic stenosis.

Revelation of a myocardial bridge has been described at coronary angiography. The pathophysiology of myocardial bridging is incompletely understood. It is sometimes associated with overt pathology, as well as it can just be an incidental finding without any significance. It has been also reported an acute myocardial infarction with normal coronary arteries associated with iatrogenic hyperthyroidism. We present a case of acute myocardial infarction in a 28-year-old Italian man with normal coronary arteries, iatrogenic elevated levels of free triiodothyronine and myocardial bridge.

Elevated troponin I in the absence of angiographically visible coronary lesions is seen in up to 10-15% of those undergoing angiography for suspected coronary artery disease. Serum troponin-I is a sensitive indicator of myocardial damage but abnormal troponin I levels have been also reported without acute coronary syndrome and without cardiac damage. Cardiac troponin I is released from myocytes in both reversible and irreversible myocardial injury. The changes in myocyte membrane permeability resulting from the injury could be enough for the release of cardiac troponins from the free cytosolic pool of myocytes without structural damage. It has been reported that the presence of tachycardia sufficient to warrant hospital admission also can raise troponin. We present a case of troponin I positive in a 49-year-old Italian woman admitted to the hospital with supraventricular tachycardia. Also this case focuses attention on the importance of a correct evaluation of abnormal troponin I levels.