Raimondo Pirisi

Detection of coronary restenosis aftercoronary angioplasty by contrast-enhanced transthoracic echocardiographic Doppler assessment of coronary flow velocity reserve

OBJECTIVES This study sought to evaluate the diagnostic potential of contrast-enhanced transthoracic echocardiography (CE-TTE) during adenosine infusion, a noninvasive method for evaluating coronary flow reserve (CFR), in detecting restenosis after successful percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND Restenosis is the most important limitation of PTCA, and CFR can be impaired in patients with angiographically documented significant coronary stenosis. METHODS We performed 6 +/- 2 months of follow-up of 53 patients after successful elective PTCA in the left anterior descending coronary artery (LAD). Coronary angiography was performed at the end of the planned follow-up period or even before, if clinically indicated. Thus, of the 53 patients, a total of 63 angiographic studies were performed; CE-TTE assessment of CFR was achieved before each of the 63 angiographic studies. RESULTS Coronary angiography revealed the presence of restenosis (defined as >50% stenosis at a previous PTCA site) in 32 angiographic examinations (group A) and no coronary restenosis in the remaining 31 examinations (group B). Coronary flow reserve was significantly reduced in group A compared with group B (1.65 +/- 0.5 vs. 3.17 +/- 0.8, p < or = 0.001). A noninvasive CFR value < or = 2 was 93% specific and 78% sensitive for detecting significant restenosis, with positive and negative diagnostic accuracies of 92% and 80%, respectively. CONCLUSIONS Noninvasive CFR assessment by CE-TTE is an accurate method of monitoring significant restenosis in the LAD when following up patients submitted to elective PTCA.

Propionyl carnitine in stable effort angina.

SummaryThe aim of this study was to investigate the antiischemic activity of propionyl carnitine (PC) in 18 informed, volunteer male patients, aged 37–70, suffering from a typical stable effort angina. The study design was randomized, balanced, crossover, and double blinded. The study lasted 75 days. In the first 15 days of washout the patients performed two maximal symptom-limited bicycle tests to verify the repeatability of the parameters examined. Then one group received PC for 30 days 500 mg three times a day, and the other group received placebo (PL) three times a day. At the end of 30 days the groups exchanged treatments. At the end of each period, 2 hours after the last oral administration, the patients performed a maximal symptom-limited bicycle exercise test with increased loads of 10 watts/min. No significant differences were observed between the two tests performed during the wash-out period, for a 1mm ST-segment depression time, for the time to the end of exercise, and for the rate x pressure product at the same experimental time. The oral administration of PC in coronary patients increased both the 1 mm ST-segment depression time and the time to the end of exercise. Furthermore, the drug reduced the ischemic depression of ST at maximal common work and at maximal work. After PC, the rate x pressure product was not significantly different in relation to placebo at submaximal and maximal exercise. Thus PC seems to have an antiischemiclike effect, probably related to its metabolic activity.

Echocardiographic accidental finding of asymptomatic cardiac and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty

Percutaneous vertebroplasty (PVP) is a therapeutic, interventional radiological procedure involving bone cement injection into a vertebral body. Although PVP is considered a minimally invasive procedure, cement leakage into the perivertebral venous system can occur with its migration towards the right heart and the pulmonary circulation. We report a case of accidental finding of asymptomatic cardiac and pulmonary embolism caused by cement leakage after PVP.

Early Noninvasive Evaluation of Coronary Flow Reserve after Angioplasty in the Left Anterior Descending Coronary Artery Identifies Patients at High Risk of Restenosis at Follow-Up

BACKGROUND Coronary restenosis is the most important clinical limitation after percutaneous coronary intervention (PCI), and coronary flow reserve (CFR) is reduced in the presence of significant coronary stenosis. This study evaluated whether detection of early reduction of Doppler echocardiographically derived CFR in the left anterior descending coronary artery can identify patients at high risk for developing restenosis after successful PCI. METHODS Doppler echocardiographically derived CFR was studied in 124 consecutive patients at 1-month and 6-month follow-up after PCI in the left anterior descending coronary artery, together with coronary angiography. RESULTS Restenosis was detected in 39 angiographic examinations (group A) and no coronary restenosis in the remaining 85 (group B) at 6 months. At 1 month, CFR was reduced in group A compared with group B (P < .0001), and a significant reduction of CFR in group A (P < .0001) but not in group B (P = .89) was detected at 6 months. CFR ≤ 2.5 at 1 month was 67% sensitive and 87% specific for predicting significant restenosis, with positive and negative predictive values of 67% and 87%, respectively. CONCLUSIONS CFR ≤ 2.5 detected 1 month after PCI in the left anterior descending coronary artery has the potential to identify patients at higher risk for developing coronary restenosis and indicates the need for close clinical follow-up.

Felodipine Improves the Anti-Ischaemic Effect of Metoprolol in Stable Effort-Induced Angina

SummaryThe anti-ischaemic effects of sustained release felodipine 10 mg/day, metoprolol 200 mg/day and both drugs together were assessed in 16 male patients with stable effort-induced angina pectoris in a randomised double-blind crossover study. At the end of each 7-day treatment period, patients performed a maximum symptom-limited cycloergometer exercise test. All 3 active regimens significantly (p < 0.05) increased the ischaemic threshold (time to 1mm ST-segment depression) and exercise capacity (time to angina pain or exhaustion), and decreased ST-segment depression at maximum common workload vs placebo. The combination regimen produced a significantly greater effect on ischaemic threshold and ST-segment depression at maximum workload and maximum common workload than felodipine alone, and a greater effect on ST-segment depression at maximum common workload than metoprolol alone. Rate-pressure product at ischaemic threshold and maximum workload was increased by felodipine and decreased by metoprolol or the combination regimen. Thus, the combination of felodipine with metoprolol resulted in greater anti-ischaemic activity than that observed with either drug alone, reflecting their different, but complementary, mechanisms of action.

Antianginal and Anti-Ischaemic Activity of Nebivolol in Stable Angina of Effort

SummaryNebivolol is a racemic adrenergic β-blocker, with β-blocking activity that is essentially due to its d-enantiomer.The anti-ischaemic activity of nebivolol was investigated in 16 patients with stable angina of effort, with a fixed ischaemic threshold (variations < ± 15%).After a 10-day washout period, patients were randomised to treatment with either nebivolol 5mg daily or placebo for 14 days. Patients underwent maximal symptom-limited exercise tests (10 W/min on a bicycle) during washout (twice), and after the completion of each treatment period. Patients were studied by ECG and systolic blood pressure measurement (cuff method). After nebivolol treatment, ischaemic and anginal thresholds were increased for at least 8 hours compared with placebo (ischaemic threshold: nebivolol 637.5 ± 47sec; placebo 534.3 ± 38sec; p < 0.01; anginal threshold: nebivolol 754.6 ± 59sec; placebo 674 ± 41 sec; p < 0.05). Rate pressure product was significantly decreased at rest and during exercise.In conclusion, nebivolol possesses an anti-ischaemic and antianginal activity lasting at least 8 hours. This activity is mainly due to the reduction in myocardial oxygen consumption.

[The network for acute coronary syndromes in the metropolitan area of Cagliari (Italy): management of ST-elevation myocardial infarction, reperfusion time, and adherence to guidelines].

BACKGROUND An integrated network for the management of acute ST-elevation myocardial infarction (STEMI) allows a pre-hospital diagnosis and facilitates the best strategy to provide the most effective reperfusion therapy. This study aims to assess the network impact on timing and mode of reperfusion in the metropolitan area of Cagliari. METHODS From January 1, 2008 to December 31, 2010 all patients affected by STEMI with symptom onset <12h were enrolled. We evaluated modality of hospital access, reperfusion therapies, and time for avoidable delay. The first medical contact-to-balloon time (FMC-to-balloon) was compared between patients without ECG transmission (No-ECG group) and those with ECG transmission and direct transport to the cath-lab (Cath-Lab-ECG group) or the emergency room/intensive cardiac care unit (ER/ICCU-ECG group). RESULTS Out of 622 patients enrolled, 324 (52.1%) arrived to hospital by emergency medical systems. In this group a pre-hospital diagnosis was made in 79.3% of cases (n = 257); among them, 138 patients (53.7%) had a direct access to cath-lab, 99 to ICCU (38.5%), and 20 (7.8%) to ER. In the whole study population an urgent coronary angiography was performed in 612 patients (98.4%) and a primary percutaneous coronary intervention (p-PCI) in 589 (96.2%). In the Cath-Lab-ECG group the FMC-to-balloon was 89 ± 29 min (median 87 min, interquartile range 72-100), significantly lower than in the ER/ICCU-ECG group [122 ± 39 min (115 min)] and the No-ECG group [150 ± 54 min (139 min)] (p<0.01). A FMC-to-balloon ≤90 min was achieved in 66.4% of Cath-Lab-ECG patients, 22.1% of ER/ICCU-ECG patients, and 8.3% of No-ECG patients (Cath-Lab-ECG vs ER/ICCU-ECG, p<0.01). CONCLUSIONS Our results show that an integrated network provides a pre-hospital diagnosis in the majority of STEMI. However, only a direct transport to the cath-lab allows to achieve a FMC-to-balloon ≤90 min in a large proportion of patients. Out of this condition, adherence to guideline-recommended time of ≤90 min is significantly lower.

IMPACT OF AN EMERGENCY STEMI NETWORK IN OCTOGENARIAN PATIENTS

early myocardial reperfusion is the target therapy to salvage ischemic myocardium in patients with ST elevation myocardial infarction (STEMI). In this perspective, it is recommended the establishment of a STEMI network that allows an early diagnosis and early reperfusion therapy. Octogenarians