Antonio Varveri

Chlamydia pneumoniae infection and atherosclerotic coronary disease

BACKGROUND Previous works have suggested an association between Chlamydia pneumoniae infection and coronary heart disease. We evaluated the prevalence of C. pneumoniae infection in patients with acute myocardial infarction (AMI) and coronary heart disease (CHD). METHODS AND RESULTS Ninety-eight patients with AMI, 80 patients with CHD, and 50 control subjects matched for age and sex were investigated. Immunoglobulin (Ig)M, IgG, and IgA antibodies to C pneumoniae were measured by the microimmunofluorescence test. IgM antibodies were not found; IgG positivity was found in 58.2% of the AMI group, 60.0% of the CHD group, and 38% of the control group, whereas for IgA, positivity was found in 33.7%, 43.7%, and 22% of cases in AMI, CHD, and control groups, respectively. Titers indicating reinfection were found in AMI and CHD groups in 6.1% and 10%, respectively, whereas titers indicating chronic infection were found in 14% of the AMI group and 25% of the CHD group. A significant correlation was found between chronic C pneumoniae infection and dyslipidemias in the AMI and CHD groups (P =.003; P =. 0006). CONCLUSIONS The results suggest that chronic C pneumoniae infection may be associated with the development of atherosclerotic coronary disease. In our next step, we will test whether antichlamydial antibiotics may help to reduce the risk of atherosclerotic disease.

Usefulness of echocardiography in the prognostic evaluation of non-Q-wave myocardial infarction.

Patients with non-Q-wave myocardial infarction (MI) are a heterogeneous population with a wide range of coronary disease severity and extent of myocardial necrosis, showing, therefore, different electrocardiographic findings and different outcomes. To evaluate the role of echocardiography in the management of non-Q-wave MI patients, 192 consecutive patients without previous MI were studied (78 with ST segment elevation, 56 with ST depression and 58 without ST modifications). All patients underwent 2-dimensional echocardiography (16-segment model) within 24 hours of admission to the coronary care unit. Wall-motion abnormalities, wall-motion score index, ejection fraction, and end-diastolic and end-systolic volumes were evaluated. In 35 patients, death, reinfarction, recurrent angina, or severe heart failure occurred during the in-hospital phase, whereas the remaining 157 patients had a good outcome. Patients with a poor prognosis were older (68 +/- 6 vs 59 +/- 5 years, p < 0.01), had a worse left-ventricular function (wall-motion score index 1.4 +/- 0.4 vs 1.25 +/- 0.3, p < 0.05; end-systolic volume 54 +/- 25 vs 38 +/- 12 mL/m2, p < 0.01; ejection fraction 50 +/- 10 vs 58 +/- 8%, p < 0.01), and presented more frequently with ST segment depression (49 vs 25%, p < 0.01). The positive and negative predictive values for early clinical events were, respectively: ST segment depression 0.30 and 0.87; wall-motion abnormalities in > 3 segments 0.28 and 0.86; wall-motion score index > 1.33 = 0.28 and 0.87; end-diastolic volume > 46 mL/m2 = 0.49 and 0.91; ST segment depression and wall-motion abnormalities in > 3 segments 0.60 and 0.88. These results underline the usefulness of echocardiography in the early risk stratification of non-Q-wave MI patients, together with electrocardiographic data. Patients with ST segment depression and more extensive wall-motion abnormalities are at higher risk and their management needs a more aggressive approach.

Optimization of the atrioventricular delay in sequential and biventricular pacing: physiological bases, critical review, and new purposes

Atrioventricular (AV) delay optimization in sequential and biventricular (BiV) pacing, although widely recommended, is often poorly performed in clinical practice as an improper setting can reduce the success of the stimulation. Despite the several methods proposed, the AV delay is frequently programmed in an empirical way or left to a predefined value (usually the manufacturers setting), without considering the different variables involved in this context, concerning the intra- and interindividual variability of the electromechanical events, the peculiarities of the several cardiopathies, the spontaneous interatrial and AV conduction, the pharmacological therapy, and the pacing mode. The manuscript illustrates the physiological bases of the optimization, describes why and how to programme the best AV delay at rest and during daily activities and discusses critically all methods proposed, divided into three groups: predefined formulas, iterative attempts, and automatic settings. The manuscript is not only a review because it tries to clarify this complex topic, stating the fundamental concept in BiV pacing; the optimal AV delay should be short enough to have always a pre-exitated stimulation and contemporary an optimal left ventricular filling. The paper suggests new purposes and new solutions for this goal, it shows the limits of the actual guidelines and the disappointing results obtained in several studies by automatic methods, goading to find new algorithms.

Safety of drug eluting stents in patients on chronic anticoagulation using long‐term single antiplatelet treatment with clopidogrel

Background: Use of triple therapy with aspirin, clopidogrel, and anticoagulants significantly increases bleeding, thus drug eluting stents (DES) are usually avoided in patients requiring anticoagulation. We tested use of DES vs. BMS using a long‐term therapy with clopidogrel only and anticoagulants in this group of patients. Methods: We enrolled 165 consecutive patients, 79 receiving DES (age 67 ± 9 years, 84% with atrial fibrillation) and 86 receiving bare metal stents (BMS) (age 70 ± 11 years, 71% with atrial fibrillation). All patients received aspirin + clopidogrel + oral anticoagulants for 4 weeks, then aspirin was stopped and clopidogrel was continued during the 12‐month follow‐up. Primary end point was the combined incidence of major adverse coronary events and major bleedings. Results: Incidence of the primary endpoint was 10.1% in patients with DES and 26.7% in patients with BMS (P = 0.01). There was a large difference in incidence of target vessel revascularization (8.1% for DES, 23.3% for BMS, P = 0.01), whereas incidence of myocardial infarction (3.8% in DES vs. 8.1% in BMS) and major bleeding (1.3% vs. 2.3%, respectively) were not significantly different. There were no cases of stent thrombosis. On multivariate Cox regression analysis, the only factor associated with a reduced risk of the primary endpoint was use of DES (hazard ratio 0.35 with 95% confidence interval 0.14–0.85, P = 0.02). Conclusions: Results of our cohort study suggest that use of DES associated with a treatment with clopidogrel only may be safe and significantly reduce the need for new revascularization in patients requiring chronic anticoagulation.© 2009 Wiley‐Liss, Inc.

Clinical effects of routine postdilatation of drug‐eluting stents

To assess the clinical effects of postdilatation of drug‐eluting stents (DES).

A Prognostic Index Relating 24‐Hour Ambulatory Blood Pressure to Cardiac Events in Ischemic Cardiomyopathy Following Defibrillator Implantation

Background: We assessed the role of left ventricular ejection fraction and of ambulatory blood pressure monitoring (ABPM) to predict cardiac death and heart failure in patients with defibrillator fulfilling MADIT II criteria. ABPM variables assessed included: mean 24 hours diastolic and systolic blood pressure, mean 24 hours heart rate, and pulse pressure.

Echocardiography in the coronary care unit: diagnostic and prognostic impact in comparison with clinical and other indicators.

The clinical arena in which we must consider the role of echocardiography is characterized by 2 fundamental findings: (1) most patients with chest pain and suspected acute myocardial infarction (MI) do not present diagnostic electrocardiograms; and (2) an early and correct diagnosis is necessary to match the patient with the most adequate treatment. Echocardiography may be very useful in the coronary care unit, allowing a correct diagnosis of ischemic heart disease when electrocardiography is unclear, even before the rise of cardiac enzymes is detected. It may also play a role in decision-making for thrombolytic therapy. In addition, echocardiography provides useful information for early risk stratification. In fact, although high-risk patients are well identified by simple clinical or instrumental variables (i.e., Killip classification, enzymatic data, blood-gas analysis, electrocardiogram, etc.), most patients (>60%) are identified as low risk, and several subjects classified into the low-risk groups have a poor prognosis and are not detected using a single variable. In our experience, 2-dimensional echocardiography was able to further stratify between patients of low-risk classes. Therefore, echocardiography plays an important role in the early stratification of acute MI patients, especially in those without signs or symptoms of heart failure.

Treatment of left main disease with a new dedicated side-branch protection stent.

To the Editor Revascularization of unprotected left main coronary artery remains a challenging procedure in interventional cardiology. In the past left main stenting using baremetal stents (BMS) was associated with high restenosis rates (up to 20–30%); this unacceptable restenosis rate had significantly limited the indications for left main stenting. Recently, introduction of drug-eluting stents (DES) has strikingly reduced the restenosis rate and allowed for broader indications for left main stenting: however, treatment of the left main bifurcation is still associated with a higher rate of complications, including restenosis, revascularization and risk of myocardial infarction. The need for optimal results on both left anterior descending and circumflex arteries has led to the introduction of several two-stent techniques for left main interventions (including crush stenting, minicrush, T-stenting, V stenting, kissing stent, etc.). Yet, as shown by several large registries, risk of new events is still higher in patients treated with two stents compared with patients treated with a simple one-stent technique. This may limit the indications for left main stenting when the need for double stenting of both left anterior descending and circumflex can be predicted from baseline angiographic features. It has been proposed that the introduction of dedicated bifurcation stents may reduce restenosis and, at the same time, provide optimal acute results on both the two main vessels; however, experience with this new strategy is still very limited.