Roberto Cemin

Evidence of parasympathetic impairment in some patients with cardiac syndrome X.

OBJECTIVESnCardiac syndrome X (SX) is a clinical condition characterised by angina, positive exercise stress test and negative coronary angiography; it has often been attributed to sympathetic hyperactivity. Here we tested the hypothesis that a parasympathetic, rather than a sympathetic, dysfunction could be the cause of the autonomic imbalance observed in SX.nnnMETHODSnIn 20 subjects with diagnosed SX and in 12 age-matched controls, we studied autonomic function by performing spectral analysis of RR interval and finger arterial pressure (SAP), in supine position and during head-up tilting. We also carried out a set of tests of parasympathetic function.nnnRESULTSnThe group of SX patients did not differ significantly from control subjects in any of the variables tested. In a subgroup of 13 SX, however, tilting increased the low-frequency power of SAP, but did not induce the expected increase in low-frequency and decrease in high-frequency power of RR. These patients, in supine position, had significantly lower sinus arrhythmia and a higher ratio of low to high frequency of RR, in comparison with control subjects. We interpreted these differences as signs of reduced parasympathetic, but essentially normal sympathetic, activity. The parasympathetic tests confirmed vagal impairment in the same SX subjects. On the other hand, all the tests indicated normal parasympathetic functions in the control subjects and in those SX patients who displayed the expected spectral changes in tilting.nnnCONCLUSIONSnIn about two thirds of the patients with SX, the pathophysiological mechanism causing the symptoms could be related to the reduced parasympathetic tone, rather than to an augmented sympathetic activity.

Reduced coronary flow reserve and parasympathetic dysfunction in patients with cardiovascular syndrome X.

ObjectiveAlthough cardiovascular syndrome X was described many years ago, its causes are still unclear. Many studies have addressed the autonomic function, whereas others have investigated the coronary reserve. The purpose of this study was to investigate the correlations between parasympathetic dysfunction and coronary flow reserve deficiency. Basic methodsEleven consecutive women suffering from cardiovascular syndrome X were enrolled in the study. All the patients underwent the analysis of heart rate and blood pressure variability, the cold face test and noninvasive evaluation of the coronary flow reserve by transthoracic echocardiography. Comparison was made with healthy volunteers. ResultsSeven patients (64%) showed vagal impairment in the analysis of heart rate and blood pressure variability and a pathological response to the cold face test, whereas four patients (36%) did not show significant differences from the control group. In these three groups, patients with and without vagal impairment and controls, there was a difference in the mean diastolic coronary velocity reserve (1.94±0.48; 3.73±0.95, 2.88±0.55, P=0.0005) and in maximal diastolic velocity reserve (2.00±0.48, 3.26±0.64, 2.65±0.57, P=0.0047). Post-hoc analysis demonstrated that the mean and maximal diastolic velocity reserves of the patients with vagal impairment seemed to be reduced compared with those of the other groups (P<0.05), which were similar. ConclusionsThis study confirmed that syndrome X patients represent a heterogeneous group. More than half of the patients exhibited vagal dysfunction. In these patients, coronary flow reserve was abnormal compared with controls and other syndrome X patients without vagal impairment.

Intravenous contrast echocardiography after myocardial infarction: relationship among residual myocardial perfusion, contractile reserve and long-term remodelling.

Objective Previous studies have shown the potential role played by intracoronary myocardial contrast echocardiography (MCE) in predicting long-term remodelling and function after myocardial infarction (MI). Scanty data, however, are available on the role of intravenous MCE in this regard. The aim of this study was to assess the role of residual myocardial blood volume in the asynergic region in modulating ventricular volume changes over time post-MI. Methods Thirty-two consecutive patients with anterior MI were studied predischarge using low-dose dobutamine echocardiography (Dob) and intravenous triggered MCE. Videointensity plots were generated from the apical approach and fitted exponentially. Volumes were assessed at baseline, during Dob and at 8 months. Results Baseline volumes, which appeared related to the extent of the asynergic region (P < 0.01) but showed no relation with videointensity in that area, did not change at follow-up, although Dob had elicited significant contractile reserve. However, videointensity in the asynergic region showed a significant interaction (P = 0.044) with the change in diastolic volume over time, with patients with the highest videointensity reverting remodelling (n = 11, from 69 ± 16 to 65 ± 16 ml/m2) as compared with the remaining population (n = 21, from 68 ± 16 to 73 ± 21 ml/m2). This was not seen when Dob-derived parameters were used. Multivariate analysis ranked videointensity second (P = 0.066), after baseline stroke volume (P = 0.005), in predicting changes in volumes over time. Conclusions Unlike inotropic reserve, residual myocardial blood volume in the dysfunctioning muscle, as assessed by predischarge quantitative intravenous MCE, has the potential to modulate remodelling in patients who suffered an anterior MI.

Coronary artery vasomotion and post-stenotic coronary artery blood flow after intracoronary lacidipine in patients with ischaemic heart disease a pilot study

AbstractBackground: The calcium antagonist lacidipine has been shown to be highly vasoselective and to improve myocardial perfusion in hypertensive patients. However, its effects on coronary artery vasomotility and on post-stenotic coronary flow reserve in patients with atherosclerotic heart disease are unknown.n Objectives: This study was designed to investigate the acute direct effects of repeated infusions of lacidipine on epicardial coronary artery vasomotion and on post-stenotic coronary artery blood flow in patients with stable angina pectoris and angiographic evidence of coronary heart disease.n Methods: In 8 patients with stable angina and moderate to severe stenosis of the left coronary artery, measurements of epicardial dimensions (quantitative angiography) and of coronary blood flow (Doppler guidewire) distal to a stenosis were performed at baseline and after 3 repeated intracoronary boluses of 12μg of lacidipine. Results were compared with those obtained after 10mg of intracoronary papaverine.n Results: The intracoronary administration of lacidipine was well tolerated, without any adverse effects. Lacidipine significantly increased the minimal luminal diameter of the lesion (peak relative increase of 43.7%), without significant changes in heart rate and systolic aortic pressure. Intracoronary lacidipine caused a dose-dependent increase in coronary flow reserve. Maximal vasodilatory effects were equivalent to those obtained with intracoronary papaverine.n Conclusions: These results suggest that lacidipine acts directly as a potent vasodilator in stenotic epicardial vessels and improves myocardial perfusion distal to a moderately severe stenosis in patients with stable angina.

Pre-analytic variability in cardiovascular biomarker testing

The impact of laboratory medicine on clinical cardiology has dramatically increased over the years and a lot of cardiovascular biomarkers have been recently proposed. In order to avoid clinical mistakes, physicians should be well aware of all the aspects, which could affect the quality of laboratory results, remembering that pre-analytic variability is an often overlooked significant source of bias, determining the vast majority of laboratory errors. This review addresses the determinants of pre-analitycal variability in cardiovascular biomarker testing, focusing on the most widespread biomarkers, which are cardiac troponins and natriuretic peptides.

Fully-automated, chemiluminescence IgA and IgG anti-tissue transglutaminase (tTG) antibodies serum assays for the screening of celiac disease.

AIMnCeliac disease (CD) is a systemic immune-mediated enteropathy sustained by gluten ingestion in genetically susceptible subjects. The European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) has recently revised the diagnostic criteria, emphasizing the crucial role of serological testing in the diagnosis of this condition. This study was hence aimed to evaluate a new chemiluminescence assay for measuring anti-transglutaminase (tTG) and anti-endomysium (EMA) antibodies in a general population of unselected outpatients.nnnMATERIALS AND METHODSnThe IgA and IgG anti-tissue transglutaminase (tTG) antibodies (Quanta Flash® IgA and Quanta Flash® IgG tTG, Inova Diagnostics, San Diego, CA, USA) were measured with the fully-automated BIO-FLASH® analyzer (Inova Diagnostics) in serum samples of 727 consecutive patients without a diagnosis of CD. Data were compared with those of anti-endomysium antibody (EmA) obtained in the same population.nnnRESULTSnA total of 96.4% samples display a negative concordance (anti-tTG negative and EMA negative), O% were positive for EMA and negative for anti-tTG IgA and IgG, 3.6% were both positive for tTG IgA and EMA, whereas 0.6% displayed discordant results (positive for anti-tTG and negative for EMA). The concordance (99%) and inter-rater agreement (Kappa Statistics, 0.943; p<0.001) between anti-tTG IgA and EmA antibodies were excellent, with sensitivity and specificity of 99% and 100%, respectively.nnnCONCLUSIONnThe results of this study show that Quanta Flash® IgA assay alone may be regarded as a reliable approach for screening of CD, with no need to perform EMA detection.

Syncope induced by transient total occlusion of the mitral valve orifice by a giant free-floating left atrial thrombus.

Left atrial ball thrombus is a rare disorder with potential fatal systemic embolism or mitral valve orifice occlusion that may result in sudden death. Its treatment is still controversial and is often associated with poor prognosis. We report the case of a 95-year-old woman with a history of permanent atrial fibrillation who was admitted to our hospital for syncope. A two-dimensional echocardiogram showed an enormous left atrial thrombus protruding through the mitral valve orifice. Cardiac surgeons declined to operate on the patient because of her very advanced age. Therefore, she was put on heparin but unfortunately died on day 17, secondary to a sudden cardiovascular arrest.

Praticare l’appropriatezza: il caso della troponina

RiassuntoGli esami di laboratorio contribuiscono in maniera considerevole al processo decisionale clinico e il numero di test che un moderno Laboratorio clinico esegue è oggi considerevole. L’impatto della Medicina di Laboratorio in Cardiologia è aumentato considerevolmente nel corso degli ultimi anni. Le troponine cardiache T e I (cTnT e cTnI) sono universalmente ritenute i biomarcatori di riferimento per la rilevazione di danno miocardico, e quindi anche per la diagnosi di infarto del miocardio. Recentemente sono stati introdotti nuovi metodi di determinazione delle cTn, caratterizzati da un considerevole miglioramento della sensibilità analitica e dell’imprecisione alle basse concentrazioni. Questi dosaggi, definiti di “ultima generazione”, consentono infatti di rilevare concentrazioni di cTn che non erano quantificabili con i metodi precedenti. Se da un lato ciò ha portato a un presunto aumento della sensibilità diagnostica per infarto miocardico, la controparte è stata una perdita di specificità. Per ovviare a tale problematica sono stati proposti algoritmi diagnostici basati su valutazioni seriali del biomarcatore, anche se il punto focale rimane comunque l’appropriatezza della richiesta. In conclusione, come spesso è accaduto in Medicina di Laboratorio, la sfida maggiore nell’utilizzo dei metodi ad alta sensibilità per la determinazione delle cTn è rappresenta dalla richiesta inappropriata e dall’inappropriata interpretazione del risultato, e non dal biomarcatore per sé.SummaryLaboratory testing significantly contributes to the clinical decision making, and the number of tests that a modern clinical laboratory can now perform is considerable. The impact of Laboratory Medicine in Cardiology has substantially evolved and increased over the past years. The cardiac troponin I and T (cTnI and cTnT) are universally regarded as the reference biomarkers for detection of myocardial injury and, understandably, for the diagnosis of myocardial infarction. Novel immunoassays for measurement of cTns have been recently introduced, which are characterized by a considerable improvement of analytical sensitivity and lower imprecision at low concentrations of the proteins. This assays, defined as last generation or high-sensitivity, allow to detect cTn concentrations that were virtually undetectable with the previous methods. On the one hand this has remarkably improved the diagnostic sensitivity for diagnosing myocardial infarction but, on the other, this has reduced the diagnostic specificity. A potential solution of this problem entails diagnostic algorithm based on the serial evaluation of these biomarkers, although the crucial issue still remains the appropriateness of the request. In conclusion, as often occurred in Laboratory Medicine, the leading problem with the use of highly-sensitivity cTn assays is the inappropriateness of ordering and interpretation of test results, and not the biomarker in itself.

Inoue balloon valvuloplasty for rheumatic tricuspid valve stenosis: an excellent technique with some intrinsic difficulties.

The Inoue catheter has a dumb-bell shaped configuration and is usually preferred due to its self-positioning configuration, size adjustability and technical ease performance. The structure of this catheter is designed in order to obtain different compliance characteristics. The balloon offers a rapid inflation-deflation sequence and its sizeadjustable nature makes step-wise dilatation possible to achieve optimal haemodynamic results, reducing complication risk from oversized inflations.

Acute chest pain with paraplegia.

To the Editor Aortic intramural haematoma is an acute disorder with potentially catastrophic consequences, which could be considered as a variant of aortic dissection and is detected in 5–20% of patients with acute aortic syndromes. Even if an universal definition is still under debate, it has been defined as the presence of a maximal crescent or circular thickening of the aortic wall of more than 7 mm without dissection flap, intimal tear or penetrating atherosclerotic ulcer. It may have presentation and symptoms similar to those of classic aortic dissection, such as acute onset of lancinating chest or back pain. With aortic dissection it shares also the same complications and similar prognosis. Treatment depends on its localization and is suggested to be surgical for a haematoma of the aortic root, ascending aorta or aortic arch, and medical for patients with uncomplicated intramural haematoma involving only the descending aorta. As for the other acute aortic syndromes, the diagnosis is usually made using a combination of transoesophageal echocardiography, magnetic resonance and computed tomography (black and white and contrast enhanced). Sometimes doubts are not cleared even after all the diagnostic images, and diagnosis remains a presumption.