Alberto Conti

Propafenone versus amiodarone in field treatment of primary atrial tachydysrhythmias

Thirty-nine patients with paroxysmal atrial fibrillation or supraventricular tachycardia randomly received amiodarone or propafenone intravenously at home. Fifteen patients received amiodarone and 24 received propafenone; 87.5% of the patients who received propafenone and 40% of the patients who received amiodarone were converted at home to sinus rhythm (P less than .005). The median time of conversion was 10 minutes (range 5 to 35) for propafenone and 60 minutes (range 20 to 130) for amiodarone (P less than 0.005). When either drug failed to terminate atrial tachydysrhythmias at home, the same drug always restored sinus rhythm with subsequent oral treatment during hospitalization. No major side effects were observed after the infusion of either drug. The incidence of minor side effects was not significantly different between the two drugs. Both the drugs are efficacious and safe in the acute management of primary supraventricular tachydysrhythmias. Propafenone showed a greater rapidity of action.

Hemodynamic and electrocardiographic effects of fructose-1,6-diphosphate in acute myocardial infarction

Acute hemodynamic and electrocardiographic effects of fructose-1,6-diphosphate (FDP), an agent that is supposed to restore anaerobic glycolytic flux in the ischemic myocardium, were studied in 40 patients with acute myocardial infarction who were grouped into 4 subsets: subset 1, normal (15 mm Hg or less) pulmonary artery (PA) wedge pressure and normal (35 g-m/m2 or greater) left ventricular (LV) stroke work index; subset 2, elevated (more than 15 mm Hg) PA wedge pressure and normal LV stroke work index; subset 3, normal PA wedge pressure and reduced (less than 35 g-m/m2) LV stroke work index; subset 4, elevated PA wedge pressure and LV stroke work index moderately reduced to a range between 16 and 34 g-m/m2. Patients were randomized into an FDP (250 mg/kg body weight in isotonic saline solution intravenously in 20 minutes) and into a placebo group. Each subset contained 5 FDP- and 5 placebo-treated patients. After basal measurements, hemodynamic measurements were reassessed at 60, 90 and 120 minutes from the infusions, while a standard 12-lead electrocardiogram was recorded in the basal state and 120 minutes after infusion. Nonsignificant hemodynamic change was observed in the placebo subsets, and FDP failed to exert any effect in subsets 1, 2 and 3. A 24% (p less than 0.02) increase in cardiac index occurred 60 minutes after FDP in subset 4. LV stroke work index also increased, while PA wedge pressure remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic scores for early stratification of septic patients admitted to an emergency department-high dependency unit.

Objectives The aim of this study was to identify a reliable tool for the early prognostic stratification of septic patients admitted to the emergency department-high dependency unit (ED-HDU), a clinical setting providing a subintensive level of care; we also estimated the cost saving associated with HDU stay compared with ICU stay. Materials and methods Mortality in Emergency Department Sepsis (MEDS), Acute Physiology Age Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA) score (SOFA-T0) and the Charlson index were calculated at ED admission. SOFA score was also calculated after 24 h (SOFA-T1). The primary outcome was 28 days mortality. Results We admitted 140 patients with severe sepsis or septic shock in our ED-HDU from June 2008 to December 2010; 135 were included in the study. One month’s mortality was 29%. SOFA-T1 was significantly higher in patients who needed an ICU admission (7.5±3.8 vs. 5.3±3.0, P=0.048); it also showed the best mortality prediction ability (area under the curve 0.80, 95% confidence interval 0.70–0.91), compared with MEDS, SAPS, and APACHE score. Troponin and procalcitonin evaluated at ED admission and after 24 h did not show significant differences according to prognosis; patients with lactate more than 2 showed a higher mortality (40 vs. 22%, P=0.034). In a regression analysis adjusted for age, lactate value, and the Charlson index, SOFA-T1 (RR 1.551, 95% confidence interval 1.204–1.998, P<0.001) maintained an independent prognostic value for 28 days mortality. During the 267 days of stay at the ED-HDU, the total saving was &OV0556;460 041, compared with the cost of the same period in the ICU. Conclusion SOFA score is a feasible and accurate tool for an early risk stratification of septic patients admitted to the ED-HDU.

A new simple risk score in patients with acute chest pain without existing known coronary disease

OBJECTIVE To derive and validate a prediction rule in patients with acute chest pain (CP) without existing known coronary disease. METHODS Cohort study including 2233 patients with CP. Based on clinical judgment, 1435 were discharged as very low risk and the remaining 798 underwent exercise tolerance test (ETT). END POINT 6-month composite of cardiovascular death, nonfatal myocardial infarction, and revascularization. The prediction rule was derived from a randomly selected test cohort (n = 1106) summing factors of variables selected by multivariate regression analysis: CP score higher than 6 (factor of 3), male gender, age older than 50 years, metabolic syndrome, and diabetes mellitus (factor of 1, for each). The prediction rule was validated in the remaining cohort (n = 1127). All patients with CP were categorized into 3 groups: group A (prediction rule 0-1), B (2-4), or C (5-6). Outcomes and prognostic yield of ETT were compared among each group. RESULTS In the test cohort, 55 patients (5%) reached the composite end point. Event rate increased as the prediction rule increased: 1% for group A, 6% for B, and 25% for C (P < .001). This pattern was confirmed in the validation cohort (P < .001). A normal ETT did not significantly improve the high (99%) negative predictive value in group A and did not succeed in excluding the composite end point (17%) in group C. CONCLUSIONS In patients with acute CP without existing coronary disease, a prediction rule based on clinical characteristics provided a useful method for prognostication with possible implication in decision making.

Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED

BACKGROUND: Acute dyspnea is a common symptom in the ED. The standard approach to dyspnea often relies on radiologic and laboratory results, causing excessive delay before adequate therapy is started. Use of an integrated point‐of‐care ultrasonography (PoCUS) approach can shorten the time needed to formulate a diagnosis, while maintaining an acceptable safety profile. METHODS: Consecutive adult patients presenting with dyspnea and admitted after ED evaluation were prospectively enrolled. The gold standard was the final diagnosis assessed by two expert reviewers. Two physicians independently evaluated the patient; a sonographer performed an ultrasound evaluation of the lung, heart, and inferior vena cava, while the treating physician requested traditional tests as needed. Time needed to formulate the ultrasound and the ED diagnoses was recorded and compared. Accuracy and concordance of the ultrasound and the ED diagnoses were calculated. RESULTS: A total of 2,683 patients were enrolled. The average time needed to formulate the ultrasound diagnosis was significantly lower than that required for ED diagnosis (24 ± 10 min vs 186 ± 72 min; P = .025). The ultrasound and the ED diagnoses showed good overall concordance (&kgr; = 0.71). There were no statistically significant differences in the accuracy of PoCUS and the standard ED evaluation for the diagnosis of acute coronary syndrome, pneumonia, pleural effusion, pericardial effusion, pneumothorax, and dyspnea from other causes. PoCUS was significantly more sensitive for the diagnosis of heart failure, whereas a standard ED evaluation performed better in the diagnosis of COPD/asthma and pulmonary embolism. CONCLUSIONS: PoCUS represents a feasible and reliable diagnostic approach to the patient with dyspnea, allowing a reduction in time to diagnosis. This protocol could help to stratify patients who should undergo a more detailed evaluation.

Abnormal troponin level as short-term predictor of poor outcome in acute atrial fibrillation

BACKGROUND The link between minor troponin (cardiac troponin I [cTnI]) elevations and atrial fibrillation (AF) is still debated. METHODS A total of 948 patients with AF lasting less than 48 hours participated in the study and were required to undergo 1-month and 12-month follow-up. The exclusion criteria were represented by younger than 18 years, the presence of hemodynamic instability, or severe comorbidity. Primary end point was the composite of ischemic vascular events inclusive of stroke, acute coronary syndrome, revascularization, and death. RESULTS In the short term, 4 patients (5%) of 78 with abnormal cTnI reached the primary end point (P = .001 vs others). Conversely, in the long term, 13 patients (17%) with abnormal cTnI, 21 (10%) with known ischemic vascular disease, and 50 (5%) aged patients (75 ± 10 years) reached the primary end point (P < .001, P < .001, and P = .002, respectively). At multivariate analysis, abnormal cTnI (hazard ratio [HR], 2.84; 95% confidence interval, 1.38-5.84; P = .005), known ischemic vascular disease (HR, 2.03; 95% confidence interval, 1.11-3.70; P = .021), and age (HR, 1.05; 95 confidence interval, 1.02-1.08; P = .002) were predictors of the primary end point. Minimal or minor cTnI elevation (<0.45 or ≥ 0.45 ng/mL, respectively) showed no differences when associated with the primary end point. The C-statistic demonstrated the significant prognostic value of older age and known ischemic vascular disease, beyond troponin. Clinical parameters inclusive of heart rate, blood pressure, and risk factors for arteriosclerosis showed no relationship with adverse events. Readmission rate did not differ between groups. CONCLUSIONS In patients with acute AF, minor cTnI elevations link to short-term adverse events. Known ischemic vascular disease and older age showed prognostic value only in the long term.

Clinical management of atrial fibrillation: early interventions, observation, and structured follow-up reduce hospitalizations

BACKGROUND Novel facilities such as an intensive observation unit and an outpatient clinic could result in improving management of patients presenting with atrial fibrillation (AF). METHODS This observational study enrolled 3475 patients. Group 1 (1120 patients; years 2004-2005) was managed with standard approach; group 2 (992 patients; years 2006-2007) was managed with additional intensive observation; group 3 (1363 patients; years 2008-2009) was managed with additional intensive observation and outpatient clinic. Primary end point was admission to hospital. Secondary end points included modalities of rhythm conversion and administration of class IC vs class III antiarrhythmic drugs in patients with AF lasting less than 48 hours. RESULTS Lack of rhythm control, comorbidities, diabetes, and age were independent predictors of hospitalization. Admissions significantly decreased from group 1 (50%) to 2 (38%) and to 3 (24%) (P < .001). Interestingly, more than a quarter of patients in group 3 were referred to the outpatient clinic for short-term follow-up, eventually avoiding admission. Patients with AF lasting less than 48 hours (n = 2189) and without structural heart disease (n = 1685) achieved sinus rhythm in 89% of cases and were discharged. In these patients, early administration of antiarrhythmic drugs of class IC and III gained sinus rhythm in 80% and 20%, respectively (P < .001). Spontaneous conversion occurred in 26%; electrical, 17%; and pharmacological, 57%. CONCLUSIONS In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations. Patients without structural heart disease treated with antiarrhythmic drugs achieved sinus rhythm in 89% of cases, mostly with class IC drugs.

Hemodynamic effects of digoxin in acute myocardial infarction in man: a randomized controlled trial

Hemodynamic effects of digoxin in acute myocardial infarction (AMI) have been acknowledged to depend on the basal cardiocirculatory state. In the present study, the effects of digoxin in patients with AMI were evaluated in four hemodynamic subsets, based on the relationship between mean pulmonary capillary wedge pressure (PCWP, in mm Hg) and left ventricular stroke work index (LVSWI, in g-m/m2): subset 1: normal (less than or equal to 15 mm Hg) PCWP and normal (greater than or equal to 35 g-m/m2) LVSWI; subset 2: elevated (greater than 15 mm Hg) PCWP and normal LVSWI; subset 3: reduced (less than 35 g-m/m2) LVSWI and normal PCWP; and subset 4: elevated PCWP and LVSWI moderately reduced to a range between 16 and 34 g-m/m2. Forty patients were admitted to the study and were randomly assigned to one of two groups in each subset: control group (19 patients) and treated group (21 patients). Five patients were randomized into each of the subsets 2, 3, and 4 in both the control and treated groups, while in subset 1 there were four control and six digoxin-treated patients. Control patients were administered a placebo saline solution and digoxin-treated patients received 0.50 mg of the drug intravenously in 20 minutes. The effects of the placebo and of the drug were evaluated at 30, 60, and 90 minutes from the end of the infusion. Hemodynamic data did not vary in the control group, and digoxin did not exert any relevant effect in subsets 1 and 2. After drug infusion, cardiac index (Cl, in L/min/m2) significantly increased in subset 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Yield of nuclear scan strategy in chest pain unit evaluation of special populations.

BackgroundPatients with chest pain (CP) and nondiagnostic ECG represent heterogeneous population in whom the evaluation of coronary risk factors including metabolic syndrome (MetS) and diabetes mellitus (DM) might improve risk stratification. MethodsWe enrolled 798 consecutive CP patients; 14% presented with MetS and 10% with DM; the remaining 76% presented with other coronary risk profiles (others). All patients underwent maximal exercise tolerance test (ETT) and myocardial perfusion imaging (exercise-MPI). Those with positive testing underwent angiography, whereas the remaining patients were discharged and later followed up. Primary end-point was a composite of coronary stenoses greater than or equal to 50% documented by angiography or coronary events at follow-up. ResultsPatients with MetS or DM had significantly lower survival free from end-point than those patients without (P<0.001). Exercise-MPI showed high negative predictive value in MetS, DM, and others (>96%); however, positive predictive value was 69, 74, and 52%, respectively (P<0.05). ETT alone showed negative predictive value (88%) which was significantly lower than exercise-MPI (98%), (MetS vs. others: P<0.001, and DM vs. others: P=0.05). The area under the receiver-operating characteristic curves obtained from the multivariate model includes clinical data alone, clinical data and ETT results, or clinical data and exercise-MPI results increase progressively. ConclusionA nuclear scan strategy in special populations, including CP patients with MetS or DM, is a valuable tool for risk stratification and adds incremental prognostic value over clinical and ETT values.

An atypical case of inverted Tako-Tsubo syndrome: case report and review of the literature

Dr. Vicidomini, Dr. Zanobetti, Dr. Innocenti: A 69-yearold Caucasian woman was admitted to our emergency department (ED) for an acute and initial episode of substernal chest pain radiating to the left arm, which had lasted about 1 h, associated with dyspnea and diaphoresis. She had a past medical history of depression and first stage primary biliary cirrhosis. She was taking chronic low-dose sotalol therapy (80 mg PO bid) for a prior episode of supraventricular tachycardia. She had an otherwise normal heart, and was without cardiovascular risk factors. At admission, she denied any recent emotional or stressful event. The first EKG recorded 10 min after the ED admission showed mild ST-segment depression in the precordial leads V5 and V6 (Fig. 1), without significant changes in the inferior, posterior and right precordial leads. The first blood sample analysis exhibited normal values of Troponin-I (cTn-I: 0.10 lg/L, normal range: 0–0.15 lg/L) and CK-MB (1.1 ng/ml, normal range: 0.5–3.6 ng/ml). The patient, fully asymptomatic, was admitted to our intensive observation unit. Based on our protocol, a second blood chemistry control was performed 6 h after the initial results. An elevated cTn-I value of 3.31 lg/L with normal CK-MB value (1.0 ng/ml) was observed. The EKG registered at the same time as the laboratory blood tests showed T-wave inversion in the precordial leads from V1 to V4 (Fig. 2), not present in the first tracing,and a small QT dispersion with a QT interval a bit longer than previous EKG. Trans-thoracic echocardiography showed normal left ventricular internal dimensions; the segmental wall motion analysis revealed akinesis of the basal anterior wall and the entire interventricular septum associated with hypokinesis of the inferior wall basal segments. Posterolateral basal segments and all mid-ventricular and apical segments appeared hyperkinetic.