Salvatore Caponnetto

Insulin-like growth factor-1 and angiographically documented coronary artery disease☆

In conclusion, we have reported an association between low IGF-I concentrations and CAD in relatively young men. This observation raises the possibility that IGF-I deficiency could be part of the polymetabolic syndrome. Whether a subnormal IGF-I production is due to growth hormone secretory abnormalities or to other metabolic reasons (e.g., insulin resistance or fat distribution, or both) is still unknown.

MRI in Hypertrophic Cardiomyopathy: A Morphofunctional Study

Objective We compared MRI with two-dimensional echocardiography (2dE) and Doppler echocardiography to determine the diagnostic role of MRI in hypertrophic cardiomyopathy (HCM). Materials and Methods Twenty-three patients with 2dE diagnosis of HCM were examined with MRI; 12 of 23 patients were also studied by color (cDE) and continuous wave (cwDE) Doppler echocardiography. Morphologic information and diastolic heart wall thickness were obtained by SE sequences; functional study was performed by gradient echo sequences (cine MR). Results The correlation between MR, SE sequences and 2dE was better for septal (r = 0.930, p < 0.01) than for posterolateral (r = 0.739, p < 0.01) wall thickness. The assessment of the distribution of the hypertrophy was changed by MR in five cases. Cine MR functional study showed a systolic subaortic signal void (dynamic obstruction) in 12 of 22 patients and a systolic left atrial signal void (mitral regurgitation) in 17 of 22. Systolic wall thickening was studied by cine MR and 2dE in 11 patients: A good correlation was found for septum (0.01 < p < 0.05) and a poor one for posterolateral wall (p > 0.05). The cine MR and cDE turbulence duration in the left ventricle and atrium showed excellent correlation (p < 0.01). Good agreement was found between the duration of subaortic turbulence (cine MR or cDE) and the pressure gradient (cwDE) (p < 0.01 and 0.01 < p < 0.05, respectively) and between cine MR and cDE semiquantitative estimate of the mitral regurgitation (p < 0.01). In all patients with subaortic MR signal void studied with cwDE, a pressure gradient was present. Conclusion Magnetic resonance imaging can play an important role in the diagnosis of HCM after 2dE-DE.

Recognition and treatment of unstable angina

SummaryDespite the growing number of patients discharged from hospital with a diagnosis of unstable angina, the diagnostic procedures and treatment of unstable angina are still greatly debated, as they have been for patients with myocardial infarction. In recent years the definition and classification of the clinical syndrome of unstable angina has been subjected to numerous proposals by distinguished cardiologists.An attempt to clarify and redefine practical guidelines for different subgroups of patients has been developed and carried out by the US Agency for Health Care Policy and Research (AHCPR).The current medical approach to treatment of patients with unstable angina is discussed in detail, analysing the role of antiplatelet medications, β-blockers, nitrates, heparin and calcium antagonists. The small subgroup of patients with refractory unstable angina should undergo urgent coronary angiography and revascularisation. Previous and current research on medical treatment with thrombolytic therapy, GPIIb/IIIa platelet receptor blockers and direct thrombin inhibitors is outlined, keeping in mind one of the main aspects of pathophysiology of the disease, that is ongoing thrombus formation.In the future, a more aggressive strategy aimed at normalising the atherogenic lipid profile in this very high risk group of patients should be carried out, based on the positive results of lipid-lowering drug trials both in primary and secondary prevention.

Association between plasma insulin and angiographically documented significant coronary artery disease

Abstract The positive association we found between plasma insulin levels and angiographically documented significant CAD strengthens the epidemiologic view that hyperinsulinemia may be associated with an increased risk for CAD mortality and nonfatal myocardial infarction.

Magnetic resonance imaging in Bland-White-Garland syndrome

postoperative course was uneventful. The patient was discharged on the twelfth postoperative day and remained well3 months later. This case of ventricular septal defect is unique in that no direct perforation of the interventricular septum occurred. I t can be speculated that incomplete rupture originating from the left ventricular side of the posterior septum led to the dissection, with consecutive perforations toward the right ventricular side. This is supported by the finding that the sites of the perforations do not lay adjacent to each other as would otherwise be expected. It is surprising that the extent of the defect did not correlate with the severity of the symptoms and the only moderately elevated right ventricula~ pressures. Three-dimensional echo CT provided a better appreciation of the pathomorphologic mechanism (Fig. 1, right) and helped to explain this phenomenon by documenting only a small defect toward the right ventricle (Fig. 2), thus permitting only moderate left-toright shunting. The third chamber, which showed systolic enlargement, therefore acted as a pressure and volume reservoir. In conclusion, this case report documents for the first time a postischemic dissection of the interventricular septum with the development of a third chamber that communicates with both ventricles. The use of echo CT allowed complete three-dimensional representation of this defect.and provided both morphologic and functional clues that were not available by conventional echocardiographic imaging techniques. Further studies are necessary to delineate other potential implications of three-dimensional echocardiography.

Perfusional and metabolic effects of nisoldipine as shown by positron emission tomography after acute myocardial infarction

After myocardial infarction, regional dysfunction can occur in viable myocardial regions because of the presence of baseline hypoperfusion. Recent evidence suggests that these areas may maintain a residual perfusion reserve. The aim of the present study was to evaluate whether oral nisoldipine can increase regional myocardial blood flow (MBF) in dyssynergic but viable myocardium after myocardial infarction. Patients with isolated left anterior descending coronary stenosis were studied 1 month after the first myocardial infarction. Patients underwent [18F]fluorodeoxyglucose imaging, and MBF was measured, using positron emission tomography and [13N]ammonia, at baseline and following dobutamine administration (10 micrograms/kg/min over 5 minutes). MBF measurements were repeated 24 hours after nisoldipine (10 mg twice daily). Preliminary results suggest that necrotic areas showed the largest reduction in baseline MBF. Dyssynergic-viable regions showed a reduced resting MBF but maintained a residual perfusion reserve in response to inotropic stimulation. Thus, nisoldipine selectively improved basal perfusion in dyssynergic-viable myocardium.

Effectiveness and safety of a single intravenous bolus injection of tissue-type plasminogen activator in acute myocardial infarction

Abstract The efficacy of multiple intravenous bolus injections of tissue-type plasminogen activator (t-PA) in inducing rapid coronary recanalization in patients with acute myocardial infarction was previously demonstrated. In this Bolus Dose-Escalation Study of Tissue-Type Plasminogen Activator (BEST), the efficacy of 3 different doses of a single rapid intravenous bolus injection of t-PA (duteplase, Wellcome Foundation, London) in inducing coronary patency (Thrombolysis In Myocardial Infarction perfusion grade 2 or 3) in 64 patients with acute myocardial infarction presenting

Thrombolysis in refractory unstable angina.

Multiple drug therapy, including nitrates, beta blockers, calcium antagonists, aspirin, and heparin, has been advocated as effective in the treatment of unstable angina, a syndrome with a multifactorial pathogenesis. Recently, plaque rupture and thrombosis have been demonstrated as the most important pathogenetic mechanisms. Nevertheless, clear-cut results on the effects of thrombolytic treatment in unstable angina are still lacking. Some possible explanations why the medical treatment of unstable angina has still not yet been standardized, whereas that of myocardial infarction has, are suggested. A review of randomized and nonrandomized studies published on this topic evaluating the role of different thrombolytic agents in unstable angina is presented. In addition the role of coronary angiography is discussed. In view of the disappointing results of coronary artery bypass surgery performed in the acute phase of the disease, one of the goals of clinical research is to identify subsets of patients at high and low risk and who undergo different types of therapeutic interventions. To support published data suggesting that total myocardial ischemia has a significant impact on prognosis, we present our results of a study carried out on patients with refractory unstable angina treated with thrombolytic therapy and evaluated with continuous electrocardiographic monitoring in the attempt to correlate total myocardial ischemia with short-term prognosis. Data in favor of the prognostic role of continuous electrocardiographic monitoring in unstable angina are also reviewed. Finally, we propose some suggestions that might be useful for future studies.

Hemodynamic and metabolic effect of propionyl-L-carnitine in patients with heart failure

Congestive heart failure (CHF) is an insidious disease process associated with profound symptoms and a poor long-term prognosis. Today the increasing geriatric population may in part explain the high prevalence, and mortality rate, of the syndrome, despite improved therapeutic strategies in the treatment of hypertension, coronary artery disease, severe arrhythmias and sudden death. According to the Framingham study, five-year mortality for CHF is 60% in men and 45% in women; if we consider patients in NYHA class IV, one year mortality reaches almost 50% [1].

Actual Costs Versus Diagnostic-Related Group Reimbursements for Unstable Angina: An Important Distinction for Effective Disease Management

ObjectivePatients with unstable angina fall within a wide therapeutic and prognostic spectrum, and, in general, have access to specialty care and invasive procedures. Today, when hospital admissions for unstable angina outnumber those for myocardial infarction worldwide, and growing economic pressures are being placed on healthcare systems, cardiologists should re-examine clinical strategies for treating unstable angina in light of healthcare cost accounting. This study examines the number of patients with unstable angina hospitalised in our centre and the services supplied to them to determine the ‘real’ cost regarding diagnostic and therapeutic procedures for these patients compared with the reimbursement rates established by the diagnosis-related group (DRG) system.Design and SettingApatient schedule was drawn up to prospectively register the number and types of cardiac processes carried out during hospitalisation for all patients with unstable angina in the period between 1 March and 30 May 1996. The time (in minutes) actually spent by both physicians and nurses for each process was carefully recorded in order to calculate the ‘activity budget’. An ‘economic budget’ was calculated for each cardiac process, taking into account salaries, materials, equipment maintenance, depreciation and indirect medical and nonmedical costs for hospitalisation in the coronary care unit and ward.Results53 out of 318 patients (16%) were discharged with a diagnosis of unstable angina. According to the DRG system, patients were allocated to 4 DRGs: DRG 140 (medically treated unstable angina; 18 patients); DRG 124 (unstable angina with angiography; 16 patients); DRG 122 (unstable angina evolving into myocardial infarction; 6 patients); DRG 112 (unstable angina with angioplasty; 13 patients). The mean cost for a hospitalised patient with unstable angina was 2911 euro (EUR): (DRG 140 = EUR1403.4; DRG 124 = EUR1462.2; DRG 122 = EUR3178.1; DRG 112 = EUR6658.3). The differences in costs were essentially related to the procedures involved in medical care; DRGs involving expensive cardiac processes had higher costs. Furthermore, these data show a marked discrepancy between ‘real’ costs and current DRG reimbursements.ConclusionsThe data show the standard management of unstable angina in our centre. Calculating the true costs of unstable angina is the first step towards maximising resources and optimising benefits. Our experience suggests that the use of this system is an essential means of creating an efficient management system for a cardiology unit. It should also be used to gather all the information necessary to establish whether reimbursement rates are covering real costs and to initiate the reduction of deficits or the utilisation of surpluses.