Gianfranco Antonelli

Telecardiology improves quality of diagnosis and reduces delay to treatment in elderly patients with acute myocardial infarction and atypical presentation.

Aim To assess whether telemedicine technology applied to public emergency healthcare system improves overall quality of home diagnosis in case of acute myocardial infarction among elderly patients, often characterized by higher rates of atypical presentation. Methods About 27 841 patients from Apulia (Italy) who called public emergency healthcare number ‘118’ underwent home ECG evaluation. Data were transmitted with a mobile telephone support to a telecardiology ‘hub’ active continuously (24/7). Data from elderly patients (>70 years) were compared with younger ones. Results Thirty-nine percent of patients complained of chest (or epigastric) pain; ST elevation acute myocardial infarction (STEMI) was diagnosed in 1.9% of patients enrolled; 50.2% of patients with STEMI were above 70 years of age. Among STEMI patients older than 70 years, atypical presentation was detected in 32% [95% confidence interval (CI): 26.8–38.1] of patients (vs. 11% 95% CI: 7.8–15.5, P<0.001). Rate of atypical STEMI presentation, immediately diagnosed, thanks to telecardiology, rose up from 9.2% (95% CI: 5–17%) in the class of age 60–69 years to 25.6% (95% CI: 20–35%) in the class of age 70–79 years, to 35.2% (95% CI: 26–45%) in the class 80–89, and to 46.1% (95% CI: 26–67%) in the class greater than 89 years of age (P<0.01 in all cases). Number needed to treat (to avoid a single missed STEMI diagnosis) was 9.4 (95% CI: 6.4–12.9) for patients younger than 70 years versus 3.1 (95% CI: 2.6–3.7) among those older than 70 years (P<0.001).

Telecardiology applied to a region-wide public emergency health-care service.

Aim To assess feasibility and reliability of telecardiology technologies applied to a region-wide public emergency health-care service. Methods About 27,841 patients from all over Apulia (19.362 km2, 4 million inhabitants) were referred from October 2004 until April 2006 to public emergency health-care number “118” and underwent ECG evaluation according to a previously fixed inclusion protocol. Data recorded were transmitted with mobile telephone support to a telecardiology “hub” active 24-h a day. Hospitalization or further examinations were arranged by emergency physicians on the basis of ECG diagnosis and consultation. Results Thirty-nine percent of patients complained of chest pain (CP) or epigastric pain, 26% loss of consciousness, 10% breathlessness, and 7% palpitations. Atrial fibrillation (AF) was diagnosed in 11.68% of patients and ST-elevation acute myocardial infarction (STEMI) in 1.91%. Among patients with CP, ECG showed STEMI in only 3.84% of cases, theoretically eligible for fibrinolysis or primary PCI; patients with STEMI complained of CP in 78.94% of cases. Of the patients, 65.28% with STEMI were from small towns without coronary care units, thus benefiting from an immediate pre-hospital diagnosis. Among patients with palpitations, only 10.27% of subjects showed ECG signs of supra-ventricular tachycardia and 25.18% of AF; other subjects avoided further improper hospitalization or emergency department monitoring. Conclusions This first region-wide leading experience shows the feasibility and reliability of telecardiology applied to a public emergency health-care service. Telemedicine protocols would probably be useful in lowering the number of improper hospitalizations and shortening delay in the diagnosis process of some heart diseases.

Atrial fibrillation with symptoms other than palpitations: incremental diagnostic sensitivity with at-home tele-cardiology assessment for emergency medical service

Background: Clinical presentation of atrial fibrillation (AF) is usually represented by palpitations; nevertheless, atypical presentation of AF with symptoms other than palpitations may be not uncommon in elderly patients. This study therefore aimed to evaluate incremental diagnostic value of tele-medicine at-home assessment in patients who called emergency medical service (EMS). Methods: A total of 27,841 consecutive EMS patients referred for suspected heart disease underwent ECG assessment with a mobile ECG-recorder device. ECGs were transmitted with mobile-phone support to a tele-cardiology ‘hub’ active 24/7 where a cardiologist read the ECGs. Rate of prevalence of AF, age of patients, and symptoms were analysed. Results: AF was diagnosed in 11.67% of patients who underwent ECG examination. Typical symptoms were complained by 6.56% of whole patients, only 14.05% of patients with AF: rate of subjects with AF and typical symptoms significantly decreased with age (<65 years 29.58%, 65–75 years 17.06%, >75 years 10.35%, p < 0.001). Number needed to diagnose an AF with atypical presentation (number needed to treat) decreased from 45 (<65 years) to 9 (65–75 years) and 5 (>75 years) (p < 0.001). Tele-cardiology support increased the rate of at-home diagnosis of AF from two-fold (in 40-year-olds) up to four-fold (60-year-olds) and seven-fold (70-year-olds). Conclusions: AF with symptoms other than palpitations is a common finding in elderly EMS patients. Tele-cardiology support improves the sensitivity of diagnosis of AF in elderly EMS patients and is useful in at-home identification of subjects with AF and atypical presentation.

Two-dimensional echocardiographic evaluation of aneurysms of the descending thoracic aorta.

To determine the ability of two-dimensional echocardiography (2-D echo) to detect aneurysms and dissections of the descending thoracic aorta (DTA), we studied 15 patients, five with proved DTA dissections (group A) and 10 with proved aneurysms without dissection (group B), using 2-D echo in three recording positions: precordial, suprasternal and a modified apical. The DTA was visualized in 14 of 15 patients (93%); in each patient in group A, an intimal flap was recognized (in two patients only by the apical approach and in one patient by all approaches). The DTAwas visualized in nine of 10 patients in group B; in each patient, the internal dimension of the DTA was enlarged (2543 mi/nm2). In one group B patient, aortic dissection was erroneously suspected because spurious echoes were present in the lumen; in another patient, 2-D echo failed to demonstrate a thrombotic stratification in the enlarged lumen. We conclude that 2-D echo using all available approaches appears to be a reliable technique for evaluating dissections and aneurysms of the DTA.

Integration between point-of-care cardiac markers in an emergency/cardiology department and the central laboratory: methodological and preliminary clinical evaluation

Abstract To achieve rapid assessment of chest pain in emergency/cardiology departments, a short turnaround time for cardiac marker testing is necessary. Nevertheless, Total Quality Management principles must be incorporated into the management of point-of-care testing (POCT); in this setting we implemented the Stratus CS ® assay as POCT for cardiac markers in our emergency/cardiology department. The analytical performance of the troponin I method was evaluated; information connectivity between the Stratus CS ® data management system and the laboratory information system was implemented and practical training of testing personnel was carried out at the POCT site. A total of 41 non-ST-segment elevation patients admitted to the hospital were followed to evaluate the appropriateness of hospital admission, formulated on the basis of the cardiac troponin-I level measured at the POCT site by clinical staff. Our preliminary clinical data suggest that the high sensitivity of the Stratus CS ® troponin method could play an important role in the early identification of patients with acute myocardial infarction in a low to intermediate-risk population for acute coronary syndrome. Our POCT model suggests that the central laboratory could ensure that the POCT program remains in compliance with quality requirements. Nevertheless, our comparison studies suggest that the implementation of POCT requires a high level of integration between cardiologists and pathologists to guarantee appropriate interpretation of the monitoring results for suspected ACS patients.

Clinical impact of the troponin 99th percentile cut-off and clinical utility of myoglobin measurement in the early management of chest pain patients admitted to the Emergency Cardiology Department.

ObjectiveTo verify the clinical impact of different low cut-offs for troponin I/cardiac troponin I (99th percentile to 10% CV) and for myoglobin, in early risk stratification of patients with suspected acute coronary syndrome. MethodsA total of 516 consecutive non-ST-elevation patients admitted to hospital were followed. The first measurement of cardiac markers was performed at the point-of-care in the Emergency Cardiology Department, using Stratus CS. The lowest cardiac troponin I concentration with a CV≤10% (cardiac troponin I concentration=0.07 μg/l) was used to perform an early diagnosis of cardiac damage and to admit non-ST-elevation patients to the Intensive Cardiac Unit. Final diagnosis of acute myocardial infarction was assessed according to European Society of Cardiology and American College of Cardiology diagnostic criteria: cardiac marker follow-up after hospital admission was performed in central laboratory. We retrospectively assessed how the diagnostic accuracy of an early diagnosis of myocardiac damage in the same population might have changed if different lower cardiac troponin I cut-offs had been used upon admitting patients in the Emergency Cardiology Department, independently from the analytical imprecision of the method. ResultsA diagnosis of acute myocardial infarction was performed on 110 (21.3%) of 516 non-ST-elevation-patients admitted to hospital. Seventy (13.6%) patients had cardiac troponin I >0.07 μg/l in the Emergency Cardiology Department (P>0.05). Using lowering cut-off values, the difference between the fraction of patients that was positive compared with the diagnosis according to European Society of Cardiology and American College of Cardiology criteria and had remained statistically significant (P<0.05) up to 0.03 μg/l (99th percentile upper reference limit) was considered (85 patients, 16.5%, n.s.). Relative operating characteristic analysis confirmed that the best clinical cut-off was related to the cardiac troponin I concentration that meets the 99th percentile upper reference limit. The diagnostic accuracy of myoglobin in detecting the minimum cardiac damage was significantly lower, independently from the cut-offs considered. ConclusionThe diagnostic accuracy in detecting myocardial damage early in the Emergency Cardiology Department improves when the 99th percentile is used as a decisional value of cardiac troponin I; the use of this cut-off makes the measurement of myoglobin unnecessary.

Comparative Effect of Lercanidipine, Felodipine, and Nifedipine GITS on Blood Pressure and Heart Rate in Patients With Mild to Moderate Arterial Hypertension: The Lercanidipine in Adults (LEAD) Study

This multicenter, double‐blind, parallel‐group study compared the effects of three dihydropyridine calcium channel blockers (lercanidipine, felodipine, and nifedipine gastrointestinal therapeutic system) on blood pressure and heart rate in 250 patients with mild to moderate hypertension (diastolic blood pressure 95 and 109 mm Hg). Patients were randomized to 4 weeks of treatment with once‐daily doses of lercanidipine 10 mg, felodipine 10 mg, or nifedipine gastrointestinal therapeutic system 30 mg. After 4 weeks of treatment, the dose was doubled in nonresponding patients. At 8 weeks, no significant differences in blood pressure were observed among the three groups. Increases in heart rate in all three groups induced by stressful conditions before and after treatment were not exacerbated during active treatment. The incidence of adverse drug reactions was lower in the lercanidipine and nifedipine groups than in the felodipine group (p<0.05); in particular, the incidence of edema for lercanidipine was 5.5% vs. 13% for felodipine and 6.6% for nifedipine.

Pre-hospital electrocardiogram triage with tele-cardiology support is associated with shorter time-to-balloon and higher rates of timely reperfusion even in rural areas: data from the Bari- Barletta/Andria/Trani public emergency medical service 118 registry on primary angioplasty in ST-elevation myocardial infarction

Background: We report the preliminary data from a regional registry on ST-elevation myocardial infarction (STEMI) patients treated with primary angioplasty in Apulia, Italy; the region is covered by a single public health-care service, a single public emergency medical service (EMS), and a single tele-medicine service provider. Methods: Two hundred and ninety-seven consecutive patients with STEMI transferred by regional free public EMS 1-1-8 for primary-PCI were enrolled in the study; 123 underwent pre-hospital electrocardiograms (ECGs) triage by tele-cardiology support and directly referred for primary-PCI, those remaining were just transferred by 1-1-8 ambulances for primary percutaneous coronary intervention (PCI) (diagnosis not based on tele-medicine ECG; already hospitalised patients, emergency-room without tele-medicine support). Time from first ECG diagnostic for STEMI to balloon was recorded; a time-to-balloon <1 h was considered as optimal and patients as timely treated. Results: Mean time-to-balloon with pre-hospital triage and tele-cardiology ECG was significantly shorter (0:41±0:17 vs 1:34±1:11 h, p<0.001, –0:53 h, –56%) and rates of patients timely treated higher (85% vs 35%, p<0.001, +141%), both in patients from the ‘inner’ zone closer to PCI catheterisation laboratories (0:34±0:13 vs 0:54±0:30 h, p<0.001; 96% vs 77%, p<0.01, +30%) and in the ‘outer’ zone (0:52±0:17 vs 1:41±1:14 h, p<0.001; 69% vs 29%, p<0.001, +138%). Results remained significant even after multivariable analysis (odds ratio for time-to-balloon 0.71, 95% confidence interval (CI) 0.63–0.80, p<0.001; 1.39, 95% CI 1.25–1.55, p<0.001, for timely primary-PCI). Conclusions: Pre-hospital triage with tele-cardiology ECG in an EMS registry from an area with more than one and a half million inhabitants was associated with shorter time-to-balloon and higher rates of timely treated patients, even in ‘rural’ areas.

Diastolic Dysfunction and Baroreflex Sensitivity in Hypertension

The determinants of diastolic dysfunction in patients with systemic hypertension are not completely known. To evaluate the possible role of age, arterial blood pressure, and baroreflex heart rate response impairment in causing diastolic dysfunction, we studied 61 patients (42 male; mean+/-SD age, 43.9+/-12 years) with newly recognized and therefore previously untreated systemic hypertension. Diastolic dysfunction was evaluated by means of Doppler echocardiography (and diagnosed as such when the early to atrial peak velocity ratio corrected to heart rate was <1), arterial blood pressure by 24-hour ambulatory monitoring, and baroreflex heart rate response by means of the spectral technique (alpha index) during paced (0.27 Hz) and spontaneous breathing (in a supine position and during tilt). Nineteen patients had diastolic dysfunction, the most powerful predictor of which was age (r=-0.63, P<0.001). The patients with diastolic dysfunction had significantly lower values for spectral baroreflex gain in the high-frequency band than those without (5.2+/-3 versus 8.4+/-5 ms/mm Hg during paced breathing, P<0.05; 7. 4+/-4 versus 13.3+/-7 ms/mm Hg in a supine position, P<0.05; 4.3+/-4 versus 5+/-2 ms/mm Hg during tilt, P<NS). Ambulatory blood pressure values were not significantly different in the patients with (137+/-14 and 89+/-9 mm Hg) and without (144+/-11 and 82+/-24 mm Hg) diastolic dysfunction. In conclusion, age and impaired baroreflex heart rate response (but not pressure overload) are determinants of left ventricular diastolic dysfunction in patients with newly recognized and untreated systemic hypertension.

Two-dimensional echocardiographic recognition of an atrial septal aneurysm

Abstract We report the detection by cross-sectional echocardiography of an atrial septal aneurysm in a 29-year-old woman with mitral and tricuspid valve prolapse.