Barbara Paladini

The onset of symptomatic atrial fibrillation and paroxysmal supraventricular tachycardia is characterized by different circadian rhythms

Abstract Circadian patterns have been demonstrated for several biologic phenomena including cardiovascular diseases such as acute myocardial infarction and sudden death.1 Diurnal distribution of paroxysmal supraventricular arrhythmias has been less extensively investigated,2,3 but only data on hospitalized patients are available. The aim of this study was to find if a diurnal distribution could be identified in the occurrence of the different types of symptomatic supraventricular arrhythmias in patients rescued at home by the Florence Mobile Coronary Care Unit.

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.

Chest pain unit management of patients at low and not low-risk for coronary artery disease in the emergency department. A 5-year experience in the Florence area.

In this study, we screened a total of 6723 consecutive patients with chest pain and ECG non-diagnostic for acute myocardial infarction (AMI) on presentation to the emergency department (ED). The aim of the study was to avoid missed AMI, improve safe early discharge and reduce inappropriate coronary care unit (CCU) admission. Chest pain patients were triaged using a clinical chest pain score and managed in a chest pain unit (CPU). Patients with a low clinical chest pain score were considered at very ‘low-risk’ for cardiovascular events and discharged from the ED; patients with a high chest pain score were submitted to CPU management. Observation and titration of serum markers of myocardial injury were obtained up to 6 hours. Rest or stress myocardial scintigraphy (SPECT) was performed in patients >40 years or with ≥2 major coronary risk factors. Exercise Tolerance Test (ETT) or Stress-Echocardiogram (stress-Echo) were performed in younger patients or with <2 coronary risk factor, or unable to exercise, respectively. We discharged directly from the ED the majority of patients (4454; 66%): in this group there was only a 0.2% final diagnosis of coronary artery disease (CAD) at follow-up. The remaining 34% of patients, with non-diagnostic or normal ECG, were managed in the CPU. In this group, 1487 patients (representing 22% of the overall study group) were found positive for CAD, two-thirds because of delayed ECG or serum markers of myocardial injury, and one-third by Echo, SPECT or ETT. In conclusion, CPU based management allowed 22% early detection of myocardial ischaemia and 78% early discharge from the ED avoiding inappropriate CCU admission and optimizing the use of urgent angiography.

Early out-of-hospital lidocaine administration decreases the incidence of primary ventricular fibrillation in acute myocardial infarction

This study was designed to assess the effectiveness of early prehospital intravenous administration of lidocaine in preventing primary ventricular fibrillation (PVF) in patients with suspected acute myocardial infarction (AMI). Sixty patients with suspected AMI, seen by the Mobile Coronary Care Unit (MCCU) of Florence, were randomly allocated at home to treatment with lidocaine (bolus i.v. of 1 mg/kg, followed by an infusion of 4 mg/min) or placebo (infusion of saline at a rate of 1 mL/min), respectively. The lidocaine group (27 patients) and the control group (33 patients) were not significantly different in age, clinical condition, or time of randomization. The diagnosis of AMI was confirmed in all 60 patients during the hospital stay. Ventricular fibrillation (VF) occurred in 5 patients in the control group in comparison to none in the lidocaine group (P < 0.05). Three patients experienced VF at home and were successfully resuscitated by an MCCU cardiologist. In another two patients, VF occurred during the first 4 hours after onset of symptoms. No major side effects were observed after the infusion of lidocaine. Our findings support the effectiveness of the prophylactic administration of lidocaine in preventing PVF in the prehospital phase of AMI and suggest that the drug can be safely administered in this setting by prehospital personnel.

Feasibility of out-of-hospital treatment of supraventricular tachycardias

Abstract Despite the overall good prognosis, most patients with supraventricular tachyarrhythmias require hospitalization for the restoration of sinus rhythm. In the last decade, Mobile Coronary Care Units (MCCU) were instituted in several towns for the treatment of out-of-hospital cardiac arrest and to decrease prehospital times in acute myocardial infarction. 1 Cardiologist-staffed MCCUs can successfully attempt at-home cardioversion in patients with supraventricular arrhythmias, thus decreasing the number and cost of most hospitalizations. The present study reviews the results of 10 years of activity by Florences MCCU in the out-of-hospital treatment of recent onset (

Aggressive approach and outcome in patients presenting atrial fibrillation and hypertension

AIM Aggressive approach in patients presenting atrial fibrillation (AF) and hypertension could result in improving rhythm control and reducing admission. METHODS Out of 3475 patients presenting AF, those with hypertension (n=1739, 52%) underwent standard (n=591, group 1, years 2004-2005) or aggressive pharmacological and electrical approach (n=1148, group 2, years 2006-2009). Overall, in 1071 patients AF duration was less than 48 h. Primary endpoint was rhythm conversion; secondary endpoints were modalities of rhythm conversion and reduction of admissions. RESULTS At univariate and multivariate analyses, AF lasting less than 48 h, absence of comorbidities and younger age were independent predictors of sinus rhythm; conversely, lack of sinus rhythm, older age, AF lasting more than 48 h and comorbidities were independent predictors of hospitalization. Overall, 55% of patients achieved sinus rhythm in group 1 versus 62% in group 2 (p=0.018). Interestingly, in patients with AF lasting less than 48 h, 89% achieved sinus rhythm, more likely by class 1C than by class III antiarrhythmic drugs (p<0.001). Overall reduction of admission accounts for 60%; 50% of patients need admission in group 1 versus 29% in group 2 (p<0.001). CONCLUSIONS Aggressive pharmacological and electrical approach in patients presenting AF and hypertension significantly improved rhythm conversion overall up to 62%. Patients with AF lasting less than 48 h eventually achieved sinus rhythm up to 89%, mostly by class IC antiarrhythmic drugs. Admissions eventually reduced up to 60%.