Valentina Cospite

Optimal Duration of Treatment in Surgical Patients With Calf Venous Thrombosis Involving One or More Veins

The aim of this study was to evaluate different durations of treatment in patients with calf venous thrombosis (CVT) involving 1 or more deep veins. The authors studied 2 groups of patients with postsurgical CVT diagnosed by echo-color Doppler. The first group consisted of 68 patients with CVT involving a single vein, and the second group consisted of 124 patients with CVT involving 2 or more veins. Immediately after diagnosis, all patients were treated with nadroparin calcium and sodium warfarin. Heparin treatment was withdrawn after 5–6 days of treatment, when the international normalized ratio (INR) was stabilized between 2 and 3. Each group was divided into 2 subgroups receiving anticoagulation treatment for 6 or 12 weeks, respectively. The endpoint was proximal extension of the thrombotic lesion, defined as the extension of the thrombus to the popliteal and/or femoral vein. In patients with single-vessel CVT there was no significant difference between the 2 subgroups, whereas in patients with CVT involving 2 or more vessels, a statistically significant difference was observed, the number of cases showing proximal extension of the thrombus being higher among patients treated for 6 weeks. Twelve weeks of anticoagulation treatment is better than 6 weeks only in patients with postsurgical CVT involving 2 or more veins.

Influence of preload and afterload on stroke volume response to low-dose dobutamine stress in patients with non-ischemic heart failure: A cardiac MR study

BACKGROUND Lack of increase in left ventricular (LV) stroke volume (SV) during low-dose dobutamine stress (LDD) is attributed to exhausted cardiac contractile reserve in failing heart. However, the role of the afterload and preload in SV changes is underestimated. The aim of the study was to investigate the effects of LDD on preload reserve and afterload in patients with non-ischemic heart failure. METHODS 58 patients (age 62 years) underwent LDD (up to 20μg/kg/min) using cardiac magnetic resonance. RESULTS LV-SV increased by 27% in 24 patients (p<0.001) (SV+), while decreased by 19% in 22 patients (p<0.001) (SV-). The LDD-to-rest reduction in preload, as defined by LV end-diastolic volume (EDV), was more pronounced in SV- than SV+ (24% and 8% respectively, p<0.05). The LLD-to-rest increase in systolic blood pressure to LV end systolic volume ratio, an index of LV contractility, was higher but not statistically different in SV+ in comparison to SV- (70% vs 48%, p=ns). Systemic vascular resistance during LDD tended to be higher in SV- (23%, p=ns), while it was significantly reduced in SV+ (9.5%, p<0.011), whereas arterial elastance (Ea) increased in SV- (30%, p<0.001) but decreased in SV+ (0.5%, p=0.04). At multivariable regression models LV-EF, LV-EDV and Ea significantly contributed to LV-SV changes in all patients. Also among SV+ and SV- LV-EDV and Ea revealed significant contribution to LV-SV change. CONCLUSIONS At similar contractile reserve response, the lack of LDD-induced increase in LV-SV, can be related to reduced preload reserve as well as to increased afterload.

Hypertension and Peripheral Arterial Disease: A Plethysmographic Study

Sixty patients suffering from arterial hypertension and/or obliterative arteriopathy of the lower limbs (20 hypertensive uncomplicated [H group], 20 normotensive affected by obliterative arteriopathy [A group], 20 suffering from both hypertension and peripheral arterial disease [HA group]) were studied, by strain gauge plethysmography, in compar ison with 20 healthy subjects (N group). The aims were to evaluate the arterial and venous hemodynamics of the lower limbs in such conditions and also to determine whether the vascular damage is primary or represents a consequence of the hypertensive pathology in the patients affected by both hypertension and peripheral arterial disease. The resting blood flow did not show significant differences in the mean values, even if lightly decreased in hypertensive patients (with or without peripheral arteriopathy). The peak flow was reduced significantly both in the H group and in the A and HA groups. The half-time (t½) and total time (tT), which indicate vascular reactivity, were signifi cantly decreased in the H group, but they were increased in the A and HA groups. Finally, the venous compliance was decreased in the H group, did not vary significantly in the A group, and showed an intermediate behavior in the HA group. These results suggest that hypertensive and arteriopathic patients develop similar arterial structural changes. However, they show a different behavior with regard to vascular reactivity and venous hemodynamics, as demonstrated by venous plethysmography.

The association between the 4G/5G polymorphism in the promoter of the plasminogen activator inhibitor-1 gene and extension of postsurgical calf vein thrombosis.

The objective of this study was to evaluate whether the presence of a plasminogen activator inhibitor type 1 (PAI-1) promoter polymorphism 4G/5G could significantly influence the proximal extension of vein thrombosis in spite of anticoagulant treatment in patients with calf vein thrombosis (CVT) following orthopaedic, urological and abdominal surgery. We studied 168 patients with CVT, who had undergone orthopaedic, urological and abdominal surgery, subdivided as follows: first, 50 patients with thrombosis progression; second, 118 patients without thrombosis progression. The 4G/5G polymorphism of the plasminogen activator inhibitor 1 was evaluated in all patients and in 70 healthy matched controls. We also studied PAI-1 activity in plasma. The presence of 4G/5G genotype was significantly increased in the group of patients with the extension of thrombotic lesions and was associated with an increase in CVT extension risk (odds ratio adjusted for sex 2.692; 95% confidence interval 1.302–4.702). Moreover, we observed a significant increase of PAI-1 plasma activity in patients with extension of thrombotic lesion vs. patients without extension (P = 0.0001). Patients with 4G/5G genotype in the promoter of the plasminogen activator inhibitor – 1 gene present a higher risk of extension of thrombotic lesions.

Hypertension and Peripheral Arterial Hemodynamics

Sixty uncomplicated hypertensive patients (30 stable and 30 borderline) were studied, by strain gauge plethysmography, in comparison with 25 normotensive subjects, in order to evaluate the arterial hemodynamics of the lower limbs in essential hypertension and to verify the different pattern in borderline and in stable hypertensives. Resting blood flow, even if slightly decreased in hypertensive groups, did not show significant differences in its mean values; peak flow, instead, was reduced proportionally to the severity of hypertension in all the hypertensive patients, but only in the stable hypertensives was it statistically significant. Minimal vascular resistance showed a similar behavior: it was significantly increased only in the stable hypertensives, whereas basal vascular resistance was raised in all hypertensive patients and also in the borderline group. Finally, the half-time and the total hyperemic response time, which indicate vascular reactivity, were significantly decreased in all the hypertensives. These results suggest that the stable hypertensive patients develop principally arterial structural changes, while the borderline hypertensive patients have only functional modi fications, such as a reduced compliance and a hyperdynamic condition.

A case of Takotsubo syndrome.

Takotsubo syndrome, first reported by Satoh et al in 1990, is a reversible cardiomyopathy frequently precipitated by a stressful event with a clinical presentation that mimics an acute coronary syndrome (1). The syndrome was initially reported in the Japanese literature but in recent years it has also been reported in North American and European populations (2).The clinical presentation is similar to that of acute myocar-dial infarction in the absence of any obstructive epicardial coronary artery lesion. This type of left ventricular dysfunction is characterized by preserved basal function, moderate-to-severe dysfunction in the mid-ventricle, and apical akinesis (3).We report a case of that syndrome presented to our emer -gency department in July 2007 with a history of central chest pain after a stressful event.The patient was a 66-year-old-woman with a family his-tory of cardiovascular disease. Remote pathological anamne-sis highlighted a history of depression-anxiety syndrome, gastro-oesophageal reflux disease and dyspeptic disorders.She was referred to our emergency department on July 2007, 2 hours and 30 minutes after the onset of chest pain. The patient underwent two stressful events (2 family mem-bers of the patient had passed away recently).At admission blood pressure was 110/60 mmHg, ECG revealed sinus rhythm, ST elevation of approximately 2 mm from V4 to V6 and the second ECG showed T wave inversion and QTc at the upper limits of reference, myocardial necrosis markers were elevated (peak serum mass CK-MB was 4,35 ng/mL, and the peak level of troponin T was 4,35 ng/mL). Transthoracic echocardiography revealed akinesis of theapex and distal segment of the left anterior wall, pre -served systolic function with ejection fraction of 65%, normal diameters and parietal thickness. Emergency cardiac catheterization was performed and showed normal coronary arteries; left ventriculography revealed apical dyskinesia (Figure 1).4 days later a cardio-MRI was performed. It revealed apex dyskinesia and hypokinesis of the distal segments of the anterior, inferior and lateral wall and ipokinesis of the inter-ventricular septum in the distal segment. After gadolinium-DTPA injection, no late hyperenhancement was observed (Figure 2). On discharge she remained asymptomatic. She was dismissed on medical therapy with ramipril, ASA, spironolac-tone, omeprazol.Serial ECGs and echocardiograms performed after dis-charge showed that the ECG and left ventricular contraction gradually returned to normal over a 12-week period.Follow-up MRI was performed after 3 months. It revealed no ventricular wall motion abnormalities, no myocardial per-fusion defects or late hyperenhancement.Takotsubo cardiomyopathy is an increasingly recognized diagnosis. Its clinical presentation mimics the presentation of acute ST elevation myocardial infarction without con-comitant epicardial coronary artery disease. Despite the ini-tial dramatic presentation of this disease the prognosis is quite favourable. Takotsubo cardiomyopathy could be more common than previously thought and although under-reported it is an important diagnosis to make, with an excellent prognosis.

Diseases of the arteries of the upper limb

In 1961 Reivich et al [1] described for the first time a syndrome caused by stenooccluding pathological processes involving the subclavian artery proximal to the emergence of the ipsilateral vertebral artery, and characterized by the activation of specific collateral pathways of the ascending aorta; that same year Fisher et al [2] named it ‘subclavian steal syndrome’. In this case the subclavian artery, stenosed or occluded at the origin, is supplied with blood from the ipsilateral vertebral artery with a reverse flow direction [3]. This allows valid compensation for hemodynamic disorders in the brachial area, at the expense, however, of the encephalic region from which blood diverted to the subclavian artery is subtracted. This phenomenon was first noted in 1886 [4], after a subclavian artery ligation for a traumatic aneurysm: the vertebral artery was ligated and the patient survived ten years. Later contributions on this subject have not only shown that subclavian steal syndrome is a reliable indicator of severe subclavian artery stenosis, though the syndrome itself is relatively benign, but have also provided a more detailed etiological framework showing that alongside arteritic, traumatic, congenital and iatrogenic forms exist others — which occur more frequently — of atherosclerotic origin [5] (Table 17.1).