Pier Luigi Pellegrino

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.

Left Atrial Appendage Closure Guided by 3D Printed Cardiac Reconstruction: Emerging Directions and Future Trends.

Percutaneous left atrial appendage (LAA) occlusion has emerged as an alternative therapeutic approach to medical therapy for stroke prevention in patients with atrial fibrillation. 3D printing is a novel technology able to create a patient specific model of any given anatomical portion of the heart.

Combined exogenous and endogenous catecholamine release associated with Tako-Tsubo like syndrome in a patient with atrio-ventricular block undergoing pace-maker implantation.

We report the case of a 65-year-old woman with complete atrio-ventricular block who underwent orciprenaline administration and pacemaker implantation. The intervention was complicated by pneumothorax and acute left ventricular systolic dysfunction with typical apical ballooning (Tako-Tsubo like syndrome). The patient was treated with diuretics and calcium-sensitizers and completely recovered. We speculate that both external and internal catecholamine triggered an acute left ventricular impairment with typical Tako-Tsubo features.

Cardiovascular sequelae of radiation therapy

Radiotherapy (RT) is one of the main therapeutic options for malignancy treatment; nevertheless, RT is not free from side effects, including an increased risk for secondary neoplasms and other organs injury. Cardiovascular complications are the second most frequent fatal post-RT sequelae, which physicians should be aware of and ready to diagnose early and cure. This review therefore aims to examine epidemiology, pathogenesis and clinical dose-correlated manifestations of RT-induced cardiovascular disease. Future perspectives on screening, prevention and treatment are also provided.

Systemic inflammation in nonischemic dilated cardiomyopathy

We investigated links between inflammatory systemic activation and clinical presentation of nonischemic dilated cardiomyopathy (NIDC). Thirty-one consecutive patients with NIDC (age 57 ± 10 years, left ventricular ejection fraction 32% ± 7%) were enrolled in the study: subjects with ischemic heart disease, valvular heart disease, congenital malformations, pulmonary, renal, inflammatory, or metabolic diseases were excluded. All patients underwent physical examination, electrocardiography, chest radiology, echocardiography, and coronary angiography. Plasma levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and fibrinogen were ascertained. New York Heart Association (NYHA) functional class was significantly correlated with concentrations of fibrinogen (r = 0.42, P < 0.05) and CRP (r = 0.52, P < 0.01), and with ESR (r = 0.46, P < 0.05). Left ventricular ejection fraction was inversely related to fibrinogen (r = −0.41, P < 0.05) and ln CRP (r = −0.46, P < 0.05). Correlations between NYHA class and markers of inflammation remained significant also after correction for age, sex, and cardiovascular risk factors. Ongoing treatment with statins was associated with reduced CRP levels. Inflammatory markers are increased in patients with NIDC proportionally with severity of symptoms and systolic impairment. Systemic inflammation might be related to deterioration of NYHA class.

Acute phase proteins activation in subjects with coronary atherosclerosis and micro-vessel coronary circulation impairment

Aim To investigate possible correlations between acute phase proteins (APPs) activation and coronary flow in subjects with coronary artery disease (CAD) undergoing coronary angiography. Methods Fifty-nine consecutive patients with CAD who underwent coronary angiography were enrolled in the study: blood samples were taken in order to evaluate plasmatic concentrations of C-reactive protein (CRP) and APPs such as alpha-1-anti-trypsin (A1AT), alpha-1-glyco-protein (A1GP) and haptoglobin (HG). Coronary flow on left anterior descending (LAD) was assessed with TIMI frame count (TFC). Patients with TIMI flow 0–1 were excluded from the study. Results Coronary atherosclerosis expressed in terms of number of coronary vessels with severe (>70%) lumen narrowing was related to serum concentrations of all considered APPs (A1GP: r 0.282, P < 0.05; A1AT: r 0.256, P 0.055; HG: r 0.335, P < 0.01). TFC on LAD was related to all considered APPs (A1GP: r 0.24, P 0.06; A1AT: r 0.28, P < 0.05; HG: r 0.43, P < 0.01; log CRP: r 0.57, P < 0.001); correlations remained significant even after correction for age, gender, risk factors, diagnosis and treatment. Among 12 patients who were previously treated with coronary angioplasty, those implanted with a drug eluting stent showed a significantly slower coronary flow on LAD (19.6 ± 2.07 vs. 16.71 ± 2.06, P < 0.05) if compared with those implanted with a bare metal stent. Conclusions An increased inflammatory systemic activation featured by plasmatic concentrations of CRP and APPs might be associated with both coronary atherosclerosis and an impaired coronary micro-circulation.

Carbohydrate antigen-125: additional accuracy in identifying patients at risk of acute heart failure in acute coronary syndrome.

ObjectivesTo evaluate levels of carbohydrate antigen-125 (CA-125) in patients with acute coronary syndrome (ACS), with regard to incidence of acute heart failure (AHF) and levels of brain natriuretic peptide (BNP). MethodsIn 47 consecutive patients with ACS, circulating levels of CA-125 and BNP were ascertained in the first 24 h and after 3 days of hospitalization. Left ventricular function and in-hospital incidence of AHF were also evaluated. ResultsBNP and CA-125 levels were significantly higher in patients with pulmonary oedema (PO) (564.25±500.50 vs. 258.57±284.81 pg/ml, P<0.05; 51.78±54.71 vs. 13.78±12.01 UI/ml, P<0.001) proportionally to Killip class (r=0.44, r=0.47; P<0.01) and were related to LV end-diastolic dimension (r=0.47, P<0.01; r=0.66, P<0.001) and LV ejection fraction (r=−0.63, P<0.001; r=−0.37, P<0.01). CA-125 levels identified patients with PO with higher specificity (97.1 vs. 31.4%), positive predictive value (83.3 vs. 33.3%) and accuracy (83.0 vs. 48.9%) when compared with BNP. ConclusionCA-125 levels are increased in patients with ACS and systolic dysfunction or AHF. Patients with PO are better identified by combined BNP and CA-125 assay rather than by only BNP.

Dynamic changes of QTc interval and prognostic significance in takotsubo (stress) cardiomyopathy

Prolonged QT corrected (QTc) intervals are associated with adverse cardiovascular outcomes both in healthy and high‐risk populations. Our objective was to evaluate the QTc intervals during a takotsubo cardiomyopathy (TTC) episodes and their potential prognostic role.