Natale Daniele Brunetti

Lack of Efficacy of Drug Therapy in Preventing Takotsubo Cardiomyopathy Recurrence: A Meta‐analysis

Efficacy of chronic drug therapy in prevention of stress‐induced cardiomyopathy recurrences is not well established. We therefore aimed to evaluate in this meta‐analysis whether pharmacological treatment can effectively prevent takotsubo cardiomyopathy (TTC) recurrences, according to available studies.

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).

Incremental value and safety of oral ivabradine for heart rate reduction in computed tomography coronary angiography

BACKGROUND Heart rate (HR) reduction is essential to achieve optimal image quality and diagnostic accuracy with computed tomography coronary angiography (CTCA). Administration of ivabradine could be an attractive alternative to beta-blockade to reduce HR. METHODS One-hundred-twenty-three patients referred for CTCA were prospectively enrolled. Patients were divided in two groups depending on the absence or presence of chronic beta-blockade treatment. Within the two groups patients were randomized to either no additional premedication or oral ivabradine for 5 days prior to CTCA. In presence of chronic beta-blockade therapy it was shifted to atenolol 50mg twice a day for 5 days prior to CTCA. HR and blood pressure were assessed at admission (T0), immediately before CTCA (T1) and during CTCA (T2). The target HR was <65 bpm. RESULTS Ivabradine significantly reduced HR during CTCA. Mean relative HR reduction was 15% for controls, 12% for chronic beta-blockade, 19% for ivabradine and 24% for both chronic beta-blockade and ivabradine at T2 (p for trend <0.001). The rate of patients who reached the target HR at T2 was 83% in controls, 71% with chronic beta-blockade, 97% with ivabradine and 97% with both (p for trend <0.05). The percentage of patients that needed additional IV beta-blockade at T1 decreased from 69% to 40% with ivabradine and 30% with both (p for trend <0.05). CONCLUSIONS Ivabradine is safe and effective in increasing the rate of patients at target HR and in reducing the need for additional IV beta-blockade in patients referred for CTCA.

Increased Troponin Levels in Nonischemic Cardiac Conditions and Noncardiac Diseases

Elevated cardiac troponin levels often lead to a diagnosis of acute coronary syndrome (ACS). However, this finding may occur also in other conditions, both nonischemic and noncardiovascular, leading to an incorrect diagnosis of ACS and, sometimes, invasive tests. We describe various cardiovascular diseases other than ACS (heart failure, pulmonary embolism, etc.) and noncardiovascular diseases (renal failure, etc.) that may cause elevated troponin levels and give possible explanations and prognostic relevance for this rise.

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.

Acute Phase Proteins In Atherosclerosis (Acute Coronary Syndrome)

Investigation of the mechanisms of atherosclerosis has determined that inflammation plays a central role in the development, progression, and outcome of acute coronary syndrome (ACS). C-reactive protein (CRP) plasma levels increase in patients with ACS. CPR is an important prognostic marker in ACS, following angioplasty, and in the long-term management of post-infarction patients. Although CRP will remain over time a useful marker, the role and implications of increased plasma concentrations of other acute phase proteins (APPs), such as alpha-1-antitrypsin (A1AT), alpha-1 glycoprotein (A1GP), haptoglobin (HG), ceruloplasmin (CP), and C3c and C4 complement fraction, in patients with ACS are still not completely defined. This short review summarizes the experimental and clinical evidence regarding the role, and the biological and clinical significance of these other APPs in ACS.

Hyper-acute precipitating mechanism of Tako-Tsubo cardiomyopathy: In the beginning was basal hyperkinesis?

Tako-Tsubo cardiomyopathy (TTC), also known as stress inducedcardiomyopathy or apical ballooning syndrome, was first describedby Dote in 1991 [1].Itisdefined as a fully reversible acutedeterioration of left-ventricular function, which is mainly found inwomen after an episode of emotional or physical stress (e.g. psycho-social stress, sepsis, surgery) [2]. The underlying mechanisms remainunclear, although increased catecholamine levels were thought asmain responsible [3,4]. Even less known are the mechanismsunderlying the hyper-acute phase of TTC, which precede apicalballooning and are usually missed because they occur during thepre-hospital phase of the disease. We describe in this case thehyper-acute phase of TTC observed during early in-hospital recur-rence of TTC.A 74-year-old woman, with amyotrophic lateral sclerosis (ALS),referred for pneumonia, after a stressful event during hospitalization,complained of chest pain, with evidence at electrocardiogram of STelevation, negative T-waves in anterior leads, intra-ventricular

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.

Prehospital telemedicine electrocardiogram triage for a regional public emergency medical service: is it worth it? A preliminary cost analysis.

Telemedicine has been shown to improve quality of health‐care delivery in several fields of medicine; its cost‐effectiveness, however, is still a matter of debate.

Time intervals and myocardial performance index by tissue Doppler imaging

The application of tissue Doppler imaging (TDI) has shown remarkable growth in clinical practice during the past few years, especially, in risk stratification of patients with coronary heart disease or heart failure (systolic and diastolic). Myocardial performance index (MPI) is a Doppler echocardiographic parameter defined as the sum of the isovolemic contraction and relaxation times divided by the ejection time. It is considered as a reliable parameter to assess global left ventricular function. Cardiac time intervals and MPI have also been found as new applications in diagnosing cardiotoxicity from chemotherapy, COPD, valvular heart disease, pulmonary hypertension and endocrinopathies.