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Background: Tissue Doppler Imaging (TDI) is a sensible and feasible method to detect longitudinal left ventricular (LV) systolic dysfunction (LVSD) in patients with diabetes mellitus, hypertension or ischemic heart disease. In this study, we hypothesized that longitudinal LVSD assessed by TDI predicted inducible myocardial ischemia independently of other echocardiographic variables (assessed as coexisting potential markers) in patients at increased cardiovascular (CV) risk., Methods: Two hundred one patients at high CV risk defined according to the ESC Guidelines 2012 underwent exercise stress echocardiography (ExSEcho) for primary prevention. Echocardiographic parameters were measured at rest and peak exercise., Results: ExSEcho classified 168 (83.6 %) patients as non-ischemic and 33 (16,4 %) as ischemic. Baseline clinical characteristics were similar between the groups, but ischemic had higher blood pressure, received more frequently beta-blockers and antiplatelet agents than non-ischemic patients. The former had greater LV size, lower relative wall thickness and higher left atrial systolic force (LASF) than the latter. LV systolic longitudinal function (measure as peak S') was significantly lower in ischemic than non-ischemic patients (8.7 ± 2.1 vs 9.7 ± 2.7 cm/sec, p = 0.001). The factors independently related to myocardial ischemia at multivariate logistic analysis were: lower peak S', higher LV circumferential end-systolic stress and LASF., Conclusions: In asymptomatic patients at increased risk for adverse CV events baseline longitudinal LVSD together with higher LV circumferential end-systolic stress and LASF were the factors associated with myocardial ischemia induced by ExSEcho. The assessment of these factors at standard echocardiography might help the physicians for improving the risk stratification among these patients for ExSEcho.

Background: Cardiovascular diseases are the first cause of death worldwide. In the last decades, therapeutic advances have determined an increase in survival rates, with a subsequent rise in the number of elderly people suffering from chronic cardiovascular diseases and associated comorbidities requiring comprehensive, team-based multidisciplinary care. The aim of this study is to describe the organization, purposes and activities of a nurse-led cardiology clinic., Methods: Between November 1, 2009 and October 31, 2014, the nurse-led clinics located within our Cardiology Outpatient Center provided care to 2081 out of 26 057 patients (8%) with complex healthcare needs, high cardiovascular risk and/or specific therapeutic indications or needs for reassessment; 1875 of these patients received nurse-led interventions: 451 (21.7%) in Chronic Heart Disease (CHD) care; 402 (19.3%) in Heart Failure (HF) care; 1022 (49.1%) at the Oral Anticoagulant Therapy (OAT) care, while 206 patients (9.9%) underwent Nurse Triage. Nursing assessment includes a clinical multidimensional analysis, with identification of relevant health issues and planning of a nursing intervention (education, intensified monitoring, and support to therapy) shared with the cardiologist in a joint report., Results: The clinical characteristics and the social care needs of the patients who received nurse-led care were extremely heterogeneous. Patients with heart failure were the oldest (79 years), most severe (58.2% hospitalized last year), with Charlson index ≥3% (82.8 %); 72.4% were taking ≥7 drugs daily. The majority of them had medium-to-low education levels and more frequently lived alone, with disabilities, inadequate self-monitoring, and self-care behaviors. Patients on anticoagulant therapy were younger (71 years), in 75.9% of cases with atrial fibrillation, most frequently assisted by a caregiver and without functional limitations. The patients of these two nurse-led clinics (HF and OAT) were those who came most frequently after hospital discharge, presented mainly clinical instability and problems of adherence to the therapeutic programs, and needed in most cases a therapeutic intervention associated with an intensification of clinical/behavioral monitoring., Conclusions: Nursing assessment supports the specialist's intervention by intensifying clinical surveillance and therapeutic intervention in the most complex real-world patients. It provides information to complete the cardiological assessment and is essential to better understand patients' health and social care needs, and to suggest and coordinate a tailor-made plan.

Background and Aims: Patients who underwent a successful repair of the aortic coarctation show chronic hyperdynamic state and normal left ventricular (LV) geometry; however, there are few data regarding the LV systolic function in the long term. Accordingly, we assessed LV systolic mechanics and factors associated with LV systolic dysfunction (LVSD) in patients with repaired CoA., Methods: Clinical and echocardiographic data from 19 repaired CoA were analyzed 28 ± 13 years after surgery. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S') were analyzed as indexes of LV circumferential and longitudinal systolic function, respectively. Echocardiographic data of CoA patients were compared with 19 patients matched for age and hypertension and 38 healthy controls. Sc-MS was considered impaired if <89%, S' if <8.5 cm/s (10th percentiles of healthy controls, respectively)., Results: There were no statistical differences between study groups in LV volumes, mass and geometry. LV ejection fraction and Sc-MS were similar in all groups, however, CoA group had a significantly lower peak S' in comparison with matched and healthy controls (7.1 ± 1.3, 10.3 ± 1.9, and 11.1 ± 1.5, respectively; all P < 0.001). Prevalence of longitudinal LVSD defined as low S' was 84% in CoA, 13% in matched, and 5% in healthy control group (all P<0.05). Multivariate logistic regression analysis revealed that low peak S' was independently related to higher E/E' ratio and the presence of CoA., Conclusions: Patients who underwent a successful repair of CoA commonly show asymptomatic longitudinal LVSD associated with worse LV diastolic function in the long-term follow-up., (© 2015 Wiley Periodicals, Inc.)

Background: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) share a common organ failure trajectory marked by prognostic uncertainty, which is a barrier to appropriate provision of palliative care. We describe in a prospective cohort from specialist hospital services the epidemiology and late clinical course of these chronic diseases to trace criteria for transition to palliative care in the community., Methods and Results: Seven centers enrolled 267 patients with advanced HF (n=174) or COPD (n=93) using common (multiple hospitalizations or severely impaired functional status or cachexia) and disease-specific (HF: systolic dysfunction, NYHA classes III-IV, end-organ hypoperfusion; COPD: very severe airflow obstruction, hypoxemia, hypercapnia, or long-term oxygen therapy) entry criteria. These patients represented 7.2% and 13% respectively of the overall HF and COPD population hospitalized during one year. They showed similar symptom burden, functional and quality of life impairment, recurrent hospitalizations, and 6-month mortality (39% and 37%, respectively). Organ failure progression was the cause of death in >75%. In-hospital overall stay during the previous year was the main mortality predictor in both. Disease-specific predictors included anemia, hyponatremia, no beta-blockers in HF; older age, hypercapnia in COPD., Conclusions: Patients with advanced HF/COPD represent almost 10% of subjects hospitalized yearly with a primary diagnosis of HF or COPD, have similarly impaired functional status, disabling symptoms and reduced survival. Overall days spent in-hospital during the previous year, a "red flag" in the late clinical course of both diseases, might be used as a simple, reliable screening tool for appropriate transition to palliative care in the community., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

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: Monitoring patients on oral anticoagulation is essential to prevent haemorrhage and recurrent thrombosis, but it is still difficult. We studied a group of 348 patients with mechanical heart valve prostheses to verify whether the use of a new portable prothrombin time device might improve the management of oral anticoagulant therapy., Methods and Material: We used a new portable prothrombin time device to check the anticoagulation therapy in a group of 348 patients with mechanical heart valve prostheses to validate its results by comparing to routine I.N.R. determinations (28 pts) and verify its user-friendliness by a face-to-face interview. Furthermore, the incidence of haemorrhagic and thromboembolic events has been studied by a two-year follow-up., Results: Pearson correlation indicated an R2 = 0.9 between I.N.R. values determined by routine or by a new portable prothrombin time device. All patients agreed to replace the routine I.N.R. determinations with those by the new procedure, particularly female, young and those with usually difficult blood collections. During the two-year follow-up period, 21 haemorrhagic (2.6/100/patients/year) and 5 thromboembolic events (0.6/100/patients/year) occurred; but neither replaced valves' thrombi nor fatal events were found out., Conclusions: I.N.R.s determined using a new portable prothrombin time device are convincing as routine determinations. Such new procedure improves the quality of life, and the therapeutical range of anticoagulation is maintained safer and longer than by routine determinations. These results suggest that the control of anticoagulation in patients to a set I.N.R. therapeutic range is improved by using portable prothrombin time device in expert anticoagulation clinics, such improvement may result in reducing mortality as well as morbidity in patients treated with oral anticoagulants.

Background: Chronic atrial fibrillation unassociated with rheumatic valvular heart disease (NRAF) considerably increases the risk of thromboembolism. Recent studies have provided new evidence concerning the risk-benefit ratio of anticoagulant therapies in patients with AF., Objective: To evaluate the incidence of primary end points (ischemic stroke, systemic embolism, bleeding complications to oral anticoagulant or antiplatelet therapy) and secondary end points (death, TIA) in patients with NRAF., Methods and Results: Between November 1992 and June 1993, 694 patients with chronic NRAF were enrolled in the Trieste Area Study on Nonrheumatic Atrial Fibrillation (TASAF), an ongoing prospective community study with a follow-up period of 2 years. The preliminary results of the enrolled study population show: an elevated mean age (71 +/- 9 years), the prevalence of males (383/694), high prevalence of overt or previous heart failure (23%), of mitral regurgitation confirmed at echocardiography (30%) and of previous myocardial infarction (11%). Many of the enrolled patients had a history of hypertension (58%). With regard to the etiology of the underlying heart disease, the following should be emphasized: a high incidence of cardiac hypertrophy (with or without history of hypertension) (28%) and of degenerative cardiopathy (20%); unclassifiable cardiopathy (14%); and lone AF (13%). Echocardiographic findings: left ventricular dysfunction (17%); mitral annular calcification (27%); and good mean left ventricular function (EF 0.50 +/- 0.15). Retrospectively there were 96 clinically documented embolic events in 78 subjects while in 34 patients there were 38 episodes suspected for embolism or TIA. Nine patients suffered 1 recurrence of embolism; three patients suffered 2 recurrences; one patient had 3 recurrences; and 4 patients had one suspected recurrence of TIA. In 35 cases the embolic events clustered around the time of the onset of the arrhythmia. In the other 99 subjects the embolic complication appeared after the onset of AF: range 1-266 months. The group of patients with true embolic events in comparison with patients without embolism or with suspected embolism or TIA had same variables predictive of thromboembolic complications: arrhythmia duration (p = 0.09) and previous myocardial infarction (p = 0.03); in contrast mitral annular calcification (p = 0.06), history of hypertension (p = 0.09) and cardiac hypertrophy (with or without hypertension) (p = 0.07) demonstrated only a slight trend of statistical significance. Comparing the clinical characteristics and echocardiographic findings of patients without embolism with those of patients with tru embolism, or suspected embolism, or TIA the variables predictive of thromboembolic events were: arrhythmia duration (p = 0.007), history of hypertension (p = 0.01), cardiac hypertrophy (with or without hypertension (p = 0.02) and mitral annular calcification (p = 0.01), at the same time, age showed only a trend of statistical significance (p = 0.06). Among the 616 patients without a history of embolism only 3% were treated with oral anticoagulant agents and 28% with antiplatelet therapy, while among the 78 subjects with documented embolism only 28% were receiving anticoagulant therapy and 58% were receiving antiplatelet agents., Conclusions: NRAF is an important risk factor for thromboembolism. Some clinical characteristics and echocardiographic findings increase the risk. Physicians still hesitate to use oral anticoagulants and antiplatelet agents in their patients for the prevention of embolic complications.

To clarify the clinical and prognostic value of the ECG, an ECG review was undertaken in 45 consecutive patients with a histologic diagnosis of active myocarditis (29 men and boys and 16 women and girls; age, 36.8 +/- 15 years; idiopathic myocarditis, 39 cases). In patients (21) with symptoms of recent onset (less than or equal to 1 month) AV block and repolarization abnormalities were the prevailing ECG features at the time of admission, and a pseudoinfarction pattern (Q waves plus ST-segment elevation) frequently heralded a rapidly fatal course ("fulminant myocarditis"). Left atrial enlargement and atrial fibrillation, left ventricular hypertrophy and LBBB, which prevailed in patients who had symptoms for longer periods, corresponded to the most severe degree of left ventricular dysfunction during the initial hemodynamic and echocardiographic evaluation. The overall mortality rate after 58 +/- 24 months from the time of diagnosis was 29%. Abnormal QRS complexes and LBBB were markers of poor survival, independently of initial indexes of left and right ventricular function, both of which indicate an increased propensity for sudden cardiac death.

In order to assess the development of tolerance we analyzed in a placebo-controlled study the effect of monotherapy with isosorbide-5-mononitrate (IS-5-MN) 60 mg in a controlled release formulation (Durules) once-a-day. The IS-5-MN was evaluated after the first dose and after once-a-day therapy for three days in 11 ambulatory patients (10 males, 1 female, aged 54 +/- 9 years) with stable exercise-induced silent myocardial ischaemia and significant coronary stenoses. The drug was given at 8 o'clock in the morning, and a bicycle ergometer exercise test was performed after 4 hours. The ST segment depression was evaluated by a computer-assisted system. Standing blood pressure decreased during all three periods of active treatment with IS-5-MN, (in comparison with placebo p < 0.001 and p < 0.01, p < 0.01 respectively). Heart rate did not change significantly. Compared with placebo baseline values, ischaemic threshold increased during the first day of treatment (188 sec, p < 0.0001 at 4 hours), and to a lesser extent both in second (103 sec, p < 0.003) and third day (116 sec, p < 0.003). The total exercise time increased during all three days of active therapy but significantly so only during the first day. The exercise stress test performed in the 5th day during placebo demonstrated a high reproducibility of ischaemic-threshold (235 vs 241 sec, p: ns), implying that the improvement during the active treatment with IS-5-MN was not due to a "training effect". Headache in 2 patients was the only significant side-effect.(ABSTRACT TRUNCATED AT 250 WORDS)

To assess heart rate variability in chronic atrial fibrillation, 60 patients (20 men, 40 women: mean age 63 +/- 8 years: NYHA 2.0 +/- 0.5) with various cardiac conditions were investigated with 24-hour Holter monitoring during daily life. Twenty-five healthy subjects (5 men, 20 women: mean age 55 +/- 9) were considered as the control group. All patients had "controlled" heart rate (50-90 bpm) on basal ECG, normal hematological and thyroid hormone values, and took digoxin alone (mean dosage 0.22 +/- 0.05 mg). Mean digoxin plasma levels were 0.88 +/- 0.48 ng/ml. Maximum, minimum and average heart rate were quite good during the night but too high during the daytime and far higher than those observed in healthy subjects. In fact, up to 82% of patients (at 9 a.m.) had a maximum heart rate higher than 115 bpm. Pauses between 2.0 and 3.0 sec occurred in 40 out of 60 patients (66%). No patients had pauses longer than 4.0 sec. In our experience, patients in chronic atrial fibrillation "controlled" with digoxin alone showed a daytime heart rate which was often too high. We suggest 24-hour Holter monitoring to detect subgroups that may be treated successfully with digoxin associated with calcium-antagonists or beta-blockers.

Ibopamine (SB-7505), the orally active 3,4-diisobutyryl ester of N-methyldopamine, was investigated at doses ranging from 1.09 to 2.34 mg/kg in 12 patients suffering from refractory congestive heart failure. In 7 patients ibopamine produced favorable effects, increasing cardiac index (+35%), stroke volume index (+27%), stroke work index (+30%) and decreasing systemic vascular resistances (-15%), total pulmonary resistances (-20%), pulmonary arteriolar resistances (-28%), whereas in 5 patients it was ineffective. Transient adverse reactions occurred in 3 patients.

Acute and chronic effects of captopril (C) were studied in 14 patients (12 males, 2 females; mean age 56 +/- 15 years) with chronic congestive heart failure (CCHF) refractory to digitalis and diuretics. All patients underwent hemodynamic evaluation before and after increasing doses of C (6.25-100 mg). Nine patients were evaluated during long term therapy by means of clinical examination, exercise testing, chest-X-ray and echocardiography. After C the following acute haemodynamic changes were observed. Mean right atrial pressure: -25% (p less than 0.01), left ventricular filling pressure: -22% (p less than 0.01), mean systemic arterial pressure: -15% (p less than 0.01), systemic vascular resistance: -31% (p less than 0.01), cardiac index: +36% (p less than 0.01). Of the 9 patients who were evaluated during long term C treatment, 7 (group A, mean follow up 6.4 +/- 4.2 months) improved in 1 or 2 NYHA functional classes and showed an increased exercise tolerance during the first 3-6 months of therapy. In this period, however, two sudden deaths and one drop-out were observed. Moreover, after the seventh month two patients of this group deteriorated clinically. Two patients (group B) developed a progressively weight gain during the first 15 days of C treatment. In the majority of our patients with refractory CCHF, captopril improves cardiac performance in the acute phase and in the first 3-6 months of therapy. Controlled studies and longer follow up are needed to understand better the long term effects of C in CCHF patients.

Acute haemodynamic effects of molsidomine, antianginal drug with vasodilator properties, were evaluated in 12 male patients with chronic congestive heart failure in New York Heart Association functional class 3 or 4 (mean age 56 +/- 7 years; ischemic heart disease in 8 cases, dilated cardiomyopathy in 3 cases, heart disease of combined aetiology in 1 case). After sublingual molsidomine (4 mg: 6 cases; 8 mg: 6 cases) the following haemodynamic changes were observed: mean right atrial pressure - 35% (p less than 0.01), left ventricular filling pressure -30% (p less than 0.01), total pulmonary resistance -33% (p less than 0.01), pulmonary arteriolar resistance -32% (p less than 0.01), cardiac index -6% (p less than 0.05), stroke volume index -12% (p less than 0.05), stroke work index +18% (p less than 0.01), heart rate -6% (p less than 0.01), double product -10% (p less than 0.01) (Fig. 3). Peak haemodynamic effect was reached between 30 and 90 minutes, lasting till 180 minutes. Molsidomine acutely reduced preload, did not show side effects and was well tolerated. These results suggest that molsidomine might be used in the treatment of chronic congestive heart failure, especially if characterized by an increased right and left ventricular filling pressure.