Giovanni Bertini

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.

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.

Clinical course of lone atrial fibrillation since first symptomatic arrhythmic episode

Abstract This study indicates that arrhythmia recurs in ≈60% of patients during the first episode of lone AF diagnosed in the field; however, sustained AF rarely develops. A low risk of stroke was seen, particularly in patients aged

Intravenous nitrates in the prehospital management of acute pulmonary edema

STUDY OBJECTIVE We sought to assess the effect of nitrates on prehospital mortality among patients with acute pulmonary edema (APE). METHODS The study involved a retrospective evaluation of the records of prehospital outcome in 640 patients with APE rescued by the mobile CCU (MCCU) of Florence, Italy, between January 1980 and December 1991. The MCCU serves an urban environment with a population of 400,000 in a 102-sq km area. In the years 1980 through 1983, patients were treated with oxygen, morphine, furosemide, digoxin, nitrates, aminophylline, or dopamine, according to the attending physicians judgment. From 1984 through 1991, new guidelines for the use of intravenous nitrates, based on differential treatment according to blood pressure, were in use. RESULTS Overall prehospital mortality rate for APE in all patients was 7.8% (50 of of 640 patients). Mortality after 1984 was significantly lower than before (5.3% versus 13%, P < .01). Nitrates were effective in reducing mortality, even in hypotensive patients. Multivariate analysis showed that outcome was significantly affected by two clinical features (dyspnea and low blood pressure), treatment with nitrates, and calendar period effects (before/after 1984). CONCLUSION Our findings suggest that the use of intravenous nitrates improves short-term prognosis in APE.

Role of a prehospital medical system in reducing heroin-related deaths.

ObjectiveThe mortality rate from heroin overdose in Italy between 1977 and 1987 increased significantly. However, in the same period, a significant increase was not observed in Tuscany, an administrative region in Italy. This study was performed to determine if the prehospital emergency medical system of Florence, the capital of Tuscany (the only one operating in Italy during the study period), affected this lower mortality rate. DesignRetrospective study. SettingThe Florence system consists of 17 mobile ICUs, each of which is staffed by a physician and three paramedics. These units are able to carry out advanced cardiopulmonary resuscitation with equipment transported to the scene of an emergency. PatientsA total of 126 consecutive patients with heroin overdose, assisted by four mobile ICUs from January 1, 1984 through December 31, 1987. InterventionsCommon therapeutic protocol in the treatment of heroin overdose and of cardiac arrest. ResultsFifty-two (41.3%) patients were in respiratory arrest, and seven (5.6%) patients were in cardiorespiratory arrest. The prehospital mortality rate was 1.6%, the inhospital mortality rate was 0.8%, and the overall mortality rate was 2.4%. During the period considered, the number of heroin overdose-related interventions increased significantly, as did the number of heroin overdoses complicated by respiratory arrest or by cardiorespiratory arrest, but the mortality rate remained low. ConclusionWe suggest that an emergency medical system can play an important role in reducing the mortality rate from heroin overdose.

Neuropsychological outcome of survivors of out-of-hospital cardiac arrest

Thirty patients resuscitated from out-of-hospital cardiac arrest (15 with and 15 without postanoxic coma on admission) underwent a clinical examination and neuropsychological testing. In order to assess quality of life, they were compared to two matched control groups; 15 patients with previous myocardial infarction and 15 healthy subjects. None of the survivors showed severe neurologic impairment, and all had returned to self-sufficient physical activity. However, the behavior rating scale scores were significantly worse in patients with postanoxic coma. The processing ability linked to memory was significantly worse in the postanoxic coma group. Mood disorders were also observed in this group, but they did not have pathological significance. The remarkably low incidence of neurologic and psychological sequelae in these resuscitated patients, particularly in those with early clinical evidence of severe cerebral damage, is an encouraging result that supports the therapeutic systems development and efforts in the management of out-of-hospital cardiac arrest.

Left Atrial Size Changes in Patients with Paroxysmal Lone Atrial Fibrillation: An Echocardiographic Follow-up

Left atrial enlargement has been demonstrated to occur as a consequence of the arrhythmia in patients with chronic atrial fibrillation (AF) in the absence of organic heart disease, whereas contrasting results have been reported in patients with paroxysmal lone AF. In the present investigation the behavior of left atrial size was followed up for an average period of 30.3 months in 20 patients with paroxysmal lone AF since their first arrhythmic episode. No significant changes in left atrial size were found at the end of the follow-up period. In 65% of patients the arrhythmia recurred at least once yearly. Left atrial size at enrollment was not significantly different in these patients from those without recurrences and did not change in either group during follow-up. The results suggest that in patients with lone AF left atrial dilatation occurs only after the arrhythmia becomes chronic. Early restoration of sinus rhythm may interrupt the vicious circle leading to atrial enlargement.

Clinical, Controlled Trial of Somatostatin with Ranitidine and Placebo in the Control of Peptic Hemorrhage of the Upper Gastrointestinal Tract

There are many controversies concerning the treatment of hemorrhages of the upper gastrointestinal tract. In order to determine whether some currently used drugs, such as somatostatin (SST) and ranitidine, may be useful in the control of hemorrhages, we have conducted a controlled (not blind) study with alternate assignment in 220 accurately selected patients affected with hemorrhage secondary to acute peptic ulcer disease. We divided the patients into three groups on the basis of the severity of disease (moderate, serious, massive); a subgroup of each group underwent one of the three studied treatments (SST, ranitidine, placebo). After careful clinical and laboratory assessment, we followed the patients over a period of 72 h. The criteria to assess the efficacy of the treatment were: number of patients who had stopped bleeding; time needed to stop the hemorrhage, and the number of recurrences of bleeding in every group and subgroup. At the end of the study, SST and ranitidine were more effective in the control of hemorrhage than placebo. SST was more effective than ranitidine, especially in patients with moderate and serious hemorrhages; it achieved a recovery of nearly 100% in the group with moderate bleeding.

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.

Doppler echocardiography in suspected lone atrial fibrillation

Echocardiography is frequently required in patients with atrial fibrillation (AF) to exclude underlying heart disease. In the present investigation the authors evaluated 56 patients with paroxysmal AF (PAF) (27 men, 29 women, mean age 54 ±11.3 years) in whom lone AF was suspected on clinical grounds. M-mode, B-mode, and Doppler examination were performed and measurements taken according to American Society of Echo cardiography criteria. Left atrial diameter, left and right atrial volumes, left ventricular (LV) diameters, LV fractional shortening, and Doppler indexes of LV diastolic function were not different in patients with PAF in comparison with those of a control group of 56 age-matched subjects free from cardiovascular diseases. Echocardiographic examination results were entirely normal in 32/56 patients (57%) vs 39/56 of the control group (69%) . Mitral valve prolapse was found in five patients (9%), but only one showed mild mitral regurgitation. Doppler examination disclosed a mild (+/++) mitral regurgitation in eight patients and a small aortic or pulmonary diastolic flow in four and two patients, respectively, in the absence of significant morphologic valvular abnormalities. In these patients the sizes of heart chambers were entirely normal. Aneurysm of the interatrial septum was found in one patient and an increased thickness of the epipericardial junction in another two patients. Finally two patients had a small increase of right atrial volume without demonstrable causes. The results suggest that lone AF can be correctly suspected on the basis of clinical findings (history, physical examination, and ECG) and that in these patients echocardiography rarely discloses organic heart disease.