A more-Comers populAtion trEated with an ultrathin struts polimer-free Sirolimus stent: an Italian post-maRketing study (the CAESAR registry)

Introduction

The use of contemporary drug-eluting stents (DES) has significantly improved outcomes of patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). However, concerns exist regarding the long-term proinflammatory effects of durable polymer coatings used in most DES, potentially leading to long-term adverse events. First-generation polymer-free stent technologies, such as sirolimus- and probucol-eluting stents (PF-SES), have shown an excellent safety and efficacy profile. The aim of this study was to evaluate the safety and efficacy of the new ultrathin Coroflex ISAR NEO PF-SES, in a more-comers PCI population.

Methods

The CAESAR (a more-Comers populAtion trEated with an ultrathin struts polimer-free Sirolimus stent: An Italian post-maRketing study) registry is a multicenter, prospective study conducted in Italy, enrolling more-comers CAD patients undergoing PCI with the Coroflex ISAR NEO stent. Patients with left main (LM) disease, cardiogenic shock (CS), or severely reduced left-ventricular ejection fraction (LVEF) were excluded. The primary endpoint was target-lesion revascularization (TLR) at 1 year.

Results

A total of 425 patients were enrolled at 13 centers (mean age 66.9 ± 11.6 years, Diabetes mellitus 29%, acute coronary syndrome 67%, chronic total occlusion 9%). Of these, 40.9% had multivessel disease (MVD) and in 3.3% cases, the target lesion was in-stent restenosis (ISR). Clinical device success was reached in 422 (99.6%) cases. At 1 year, only two (0.5%) subjects presented ischemia-driven TLR. The 1-year rates of target vessel revascularization and MACE were 0.5% and 5.1%, respectively. Major bleeding was observed in four (1.0%) patients.

Conclusion

In this multicenter, prospective registry, the use of a new ultrathin Coroflex ISAR NEO PF-SES in a more-comers PCI population showed good safety and efficacy at 1 year.

Interplay between COVID-19, pollution, and weather features on changes in the incidence of acute coronary syndromes in early 2020

Background

Coronavirus disease 2019 (COVID-19) has caused an unprecedented change in the apparent epidemiology of acute coronary syndromes (ACS). However, the interplay between this disease, changes in pollution, climate, and aversion to activation of emergency medical services represents a challenging conundrum. We aimed at appraising the impact of COVID-19, weather, and environment features on the occurrence of ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) in a large Italian region and metropolitan area.

Methods and results

Italy was hit early on by COVID-19, such that state of emergency was declared on January 31, 2020, and national lockdown implemented on March 9, 2020, mainly because the accrual of cases in Northern Italy. In order to appraise the independent contribution on changes in STEMI and NSTEMI daily rates of COVID-19, climate and pollution, we collected data on these clinical events from tertiary care cardiovascular centers in the Lazio region and Rome metropolitan area. Multilevel Poisson modeling was used to appraise unadjusted and adjusted effect estimates for the daily incidence of STEMI and NSTEMI cases.

The sample included 1448 STEMI and 2040 NSTEMI, with a total of 2882 PCI spanning 6 months. Significant reductions in STEMI and NSTEMI were evident already in early February 2020 (all p<0.05), concomitantly with COVID-19 spread and institution of national countermeasures. Changes in STEMI and NSTEMI were inversely associated with daily COVID-19 tests, cases, and/or death (p<0.05). In addition, STEMI and NSTEMI incidences were associated with daily NO2, PM10, and O3 concentrations, as well as temperature (p<0.05). Multi-stage and multiply adjusted models highlighted that reductions in STEMI were significantly associated with COVID-19 data (p<0.001), whereas changes in NSTEMI were significantly associated with both NO2 and COVID-19 data (both p<0.001).

Conclusions

Reductions in STEMI and NSTEMI in the COVID-19 pandemic may depend on different concomitant epidemiologic and pathophysiologic mechanisms. In particular, recent changes in STEMI may depend on COVID-19 scare, leading to excess all-cause mortality, or effective reduced incidence, whereas reductions in NSTEMI may also be due to beneficial reductions in NO2 emissions in the lockdown phase.

339 Interplay between COVID-19, pollution, and weather features on changes in the incidence of acute coronary syndromes in early 2020

Aims

Coronavirus disease 2019 (COVID-19) has caused an unprecedented change in the apparent epidemiology of acute coronary syndromes (ACS). However, the interplay between this disease, changes in pollution, climate, and aversion to activation of emergency medical services represents a challenging conundrum. We aimed at appraising the impact of COVID-19, weather, and environment features on the occurrence of ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) in a large Italian region and metropolitan area.

Methods and results

Italy was hit early on by COVID-19, such that state of emergency was declared on January 31, 2020, and national lockdown implemented on March 9, 2020, mainly because the accrual of cases in Northern Italy. In order to appraise the independent contribution on changes in STEMI and NSTEMI daily rates of COVID-19, climate and pollution, we collected data on these clinical events from tertiary care cardiovascular centers in the Lazio region and Rome metropolitan area. Multilevel Poisson modeling was used to appraise unadjusted and adjusted effect estimates for the daily incidence of STEMI and NSTEMI. The sample included 1448 STEMI and 2040 NSTEMI, with a total of 2882 PCI spanning 6 months. Significant reductions in STEMI and NSTEMI were evident already in early February 2020 (all P < 0.05), concomitantly with COVID-19 spread and institution of national countermeasures. Changes in STEMI and NSTEMI were inversely associated with daily COVID-19 tests, cases, and/or death (P < 0.05). In addition, STEMI and NSTEMI incidences were associated with daily NO2, PM10, and O3 concentrations, as well as temperature (P < 0.05). Multi-stage and multiply adjusted models highlighted that reductions in STEMI were significantly associated with COVID-19 data (P < 0.001), whereas changes in NSTEMI were significantly associated with both NO2 and COVID-19 data (both P < 0.001).

Conclusion

Reductions in STEMI and NSTEMI in the COVID-19 pandemic may depend on different concomitant epidemiologic and pathophysiologic mechanisms. In particular, recent changes in STEMI may depend on COVID-19 scare, leading to excess all-cause mortality, or effective reduced incidence, whereas reductions in NSTEMI may also be due to beneficial reductions in NO2 emissions in the lockdown phase.

Impact of temporary traffic bans on the risk of acute coronary syndromes in a large metropolitan area

BACKGROUND

Strong epidemiologic evidence has highlighted the role of pollution, on top of adverse climate features, as a novel cardiovascular risk factor. However, mechanistic proof that reducing pollution may be beneficial to prevent atherothrombotic events is limited. We aimed at appraising the impact of temporary traffic bans in a large metropolitan area on the risk of acute coronary syndromes.

METHODS

Aggregate and anonymized data from 15 tertiary cardiac care centers were obtained detailing precoronavirus disease 2019 (COVID-19) daily cases of ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), including those treated with percutaneous coronary intervention (PCI). Data on pollutants and climate were sought for the same days. Mixed level regression was used to compare the week before vs after the traffic ban (Fortnight analysis), the 3 days before vs. after (Weekly analysis) and the Sunday before vs. after (Sunday analysis).

RESULTS

A total of 8 days of temporary traffic bans were included, occurring between 2017 and 2020, totaling 802 STEMI and 1196 NSTEMI in the Fortnight analysis, 382 STEMI and 585 in the Weekly analysis, and 148 STEMI and 210 NSTEMI in the Sunday analysis.Fortnight and Sunday analyses did not disclose a significant impact of traffic ban on STEMI or NSTEMI (all P>0.05). Conversely, Weekly analysis showed non-significant changes for STEMI, but a significant decrease in daily NSTEMI when comparing the 3 days before the traffic ban with the ban day (P=0.043), as well as the 3 days before vs. the 3 days after the ban (P=0.025). No statistically significant effect of traffic ban was found at Fortnight, Weekly or Sunday analyses for daily mean concentrations of benzene, carbon monoxide, nitric oxide, nitrogen dioxide, ozone, sulfur dioxide, particulate matter (PM) <2.5 µm or PM <10 µm (all P>0.05). However, minimum daily concentrations showed a significant reduction of ozone during the ban in comparison to the week preceding it (P=0.034), nitric oxide during the ban in comparison to the 3 days preceding it (P=0.046), and an increase in benzene during the ban in comparison to the Sunday before (P=0.039).

CONCLUSIONS

Temporary traffic ban may favorably reduce coronary atherothrombotic events, and in particular NSTEMI, even if not globally and immediately impacting on environmental pollution. Further controlled studies are required to confirm and expand this hypothesis-generating results.

Posttransplant Lymphoproliferative Disorders in Neuronal Xenotransplanted Macaques

Posttransplant lymphoproliferative disorders (PTLDs) are a heterogeneous group of lymphoid proliferations that occur in the setting of depressed T-cell function due to immunosuppressive therapy used following solid organ transplantation, hematopoietic stem cell transplantation, and also xenotransplantation. In the present study, 28 immunosuppressed parkinsonian Macaca fascicularis were intracerebrally injected with wild-type or CTLA4-Ig transgenic porcine xenografts to identify a suitable strategy to enable long-term cell survival, maturation, and differentiation. Nine of 28 (32%) immunosuppressed primates developed masses compatible with PTLD, located mainly in the gastrointestinal tract and/or nasal cavity. The masses were classified as monomorphic PTLD according to the World Health Organization classification. Immunohistochemistry and polymerase chain reaction (PCR) analyses revealed that the PTLDs were associated with macaca lymphocryptovirus as confirmed by double-labeling immunohistochemistry for CD20 and Epstein-Barr nuclear antigen 2 (EBNA-2), where the viral protein was located within the CD20+ neoplastic B cells. In sera from 3 distinct phases of the experimental life of the primates, testing by quantitative PCR revealed a progression of the viral load that paralleled the PTLD progression and no evidence of zoonotic transmission of porcine lymphotropic herpesvirus through xenoneuronal grafts. These data suggest that monitoring the variation of macaca lymphocryptovirus DNA in primates could be used as a possible early diagnostic tool for PTLD progression, allowing preemptive treatment such as immunosuppression therapy reduction.

Angiographic and clinical outcome of invasively managed patients with thrombosed coronary bare metal or drug-eluting stents: the OPTIMIST study

AIMS

Stent thrombosis (ST) is a major complication of percutaneous coronary interventions (PCIs). An invasive management by re-PCI is the commonly adopted treatment for ST, but data on outcome are limited.

METHODS AND RESULTS

We performed a 2-year multicentre registry enrolling consecutive patients with angiographically confirmed ST undergoing PCI. The primary angiographic endpoint was optimal angiographic reperfusion (TIMI 3 + blush grade 2 or 3). The primary clinical endpoints were death and major adverse coronary and cerebrovascular events (MACCEs) at 6 months. A total of 110 patients underwent 117 urgent PCI during the study. Patients with drug-eluting stent (DES) thrombosis, compared with those with bare metal stent (BMS) thrombosis, exhibited a higher rate of late or very late presentation and of anti-platelet therapy withdrawal. Optimal angiographic reperfusion was obtained in 64% of the patients. Death and MACCE rates at 6 months were 17 and 30%, respectively. Clinical outcome was similar for BMS and DES thrombosis. Very late ST, implantation of stent during PCI for ST, and failure to achieve optimal angiographic reperfusion were the independent predictors of 6-month mortality.

CONCLUSION

DES and BMS thromboses have different clinical features, but a similar poor outcome. Indeed, PCI for ST is associated with a low rate of reperfusion and to a high rate of death and MACCE, calling for action in order to prevent its occurrence and to improve its management.

The Outcome of PCI for stent-ThrombosIs MultIcentre Study (OPTIMIST): rationale and design of a multicenter registry

BACKGROUND

Stent thrombosis (ST) is a recognized complication limiting the clinical efficacy of percutaneous coronary interventions (PCI). Because of the increasing number of stent-based PCI, the absolute number of patients experiencing ST is expected to expand. Re-PCI is the commonly adopted treatment for patients with ST; however, the prognostic variables as well as the angiographic and clinical results have not been systematically assessed. Moreover, the possible benefit associated with the use of adjunctive devices (AD) with theoretical antiembolic property has not been systematically analyzed in this high-risk population.

METHODS

We present the design of a prospective and retrospective multicenter registry to assess the contemporary angiographic and clinical outcome of PCI in patients with ST. Moreover, we sought to assess if the use of thrombectomy or distal protection AD is associated with any improvement in the PCI's angiographic results. All patients with angiographically confirmed ST undergoing attempt of PCI in the enrolling centers during a fixed 2-year study period will enter the study. Clinical outcome during hospitalization, at 30 days and 6 months will be assessed. Percutaneous coronary intervention with or without AD will be performed according to physician's discretion. All PCI cine-film will undergo blind core laboratory analysis to assess a series of key angiographic data (TIMI flow, TIMI frame count, thrombus score, myocardial blush grade, distal embolization).

CONCLUSIONS

The OPTIMIST study is designed to provide a detailed description of the angiographic and clinical outcome achieved in the real world with contemporary PCI for ST. Moreover, it will provide observational data regarding the role of AD in this high-risk scenario.

[Non-ST-elevation myocardial infarction with normal coronary arteries, clinical features and coronary artery flow]

BACKGROUND

No assessment has been made up today concerning clinical features, coronary artery flow and mid-term prognosis between acute non-ST-elevation myocardial infarction (NSTEMI) patients without epicardial coronary disease and those with epicardial coronary artery stenosis > 50% of at least one vessel.

METHODS

We evaluated consecutive NSTEMI patients who had undergone coronary angiography within the first 48 hours of infarction. We examined their age, sex, smoking habits, the incidence of diabetes, dyslipidemia, hypertension, and left ventricular ejection fraction. The coronary blood flow was assessed according to the conventional TIMI flow grade and with the TIMI frame count (TFC).

RESULTS

From October 1, 2001 to December 31, 2003, 50 patients out of 996 with NSTEMI (20 males, 30 females, mean age 60 +/- 13 years), showed normal coronary arteries (5%). This subset of patients was compared with 50 NSTEMI patients with coronary stenosis. Patients of the first group were younger and more frequently female with respect to NSTEMI patients with coronary stenosis. The differences between the two groups with respect to diabetes, hypertension, dyslipidemia incidence and ejection fraction (52 vs 47%) were not statistically significant. With the corrected TFC (cTFC) method we found a slow flow in at least one coronary vessel in a high percentage of NSTEMI patients with normal coronary arteries. When we compared normal vessels between the two groups, we found a higher cTFC in NSTEMI patients with normal coronary arteries than in NSTEMI patients with coronary stenosis. After a 16 +/- 8 months of follow-up we observed 8 events in the normal vessel group and 10 in the coronary stenosis group (p = NS).

CONCLUSIONS

The possible hypothesis of microvessel dysfunction as a pathogenesis of a slow flow in NSTEMI patients with normal coronary arteries is strong. Further studies are warranted to investigate microvessel disease and characteristics and possible causes of abnormalities. A larger perspective study with a longer follow-up is needed as well to evaluate the prognosis in this subset of patients.

Monochromatic excimer light (308 nm): an immunohistochemical study of cutaneous T cells and apoptosis-related molecules in psoriasis

BACKGROUND

Various types of UVB radiation source (290-320 nm) are used in treating psoriasis and their therapeutic mechanism has been attributed to immunosuppressive properties. Recently, a new UVB source generated by a 308-nm excimer laser has been introduced for the treatment of psoriasis.

OBJECTIVE

In this study we investigated the immunohistochemical evaluation of T cells and the expression of various apoptosis-related molecules in the psoriatic hyperproliferative skin before and after treatment with 308-nm monochromatic excimer light (MEL).

METHODS

Ten patients (three women and seven men), ranging in age from 29 to 79 years, affected by plaque-type psoriasis vulgaris, were treated with MEL. Biopsies from psoriatic lesions of MEL-treated sites were taken before, 24 h and/or 48 h after the first irradiation and analysed by the immunophosphatase alkaline technique (APAAP).

RESULTS

MEL treatment was found to cause a significant decrease in the rate of proliferation of keratinocytes and a relevant depletion of T cells in all psoriatic lesions, 48 h after the first irradiation: 308 nm light eliminated T cells from the psoriatic epidermis and also from the dermis, highlighting the ability of this UVB source to penetrate the skin compared with normal UVB and establish direct cytotoxic action on T cells infiltrating skin lesions. Rapid clearing of psoriatic lesions involves potential molecular targets of UVB in T cells including p53, which is upregulated after direct irradiation with 308-nm UVB. Moreover, Bcl-2 expression in healing psoriasis epidermis after MEL treatment is significantly decreased compared with untreated skin and the TUNEL (TdT-mediated dUTP-biotin nick end labelling) technique revealed the presence of relevant apoptotic keratinocytes in the irradiated epidermis.

CONCLUSIONS

These results indicate that psoriatic skin after monochromatic excimer light therapy is associated with significant T-cell depletion and alterations of apoptosis-related molecules accompanied by a decreased proliferation index and clinical remission.

Electrophysiological instability in the acute phase: prognostic significance of early ventricular fibrillation in acute myocardial infarction

BACKGROUND

In the prognostic stratification of patients affected by AMI is important to evaluate, besides the assessment of left ventricular function and residual ischemia, the presence of electrophysiological instability.

METHODS

We have analysed 15 patients all affected by AMI complicated by early ventricular fibrillation. During the hospital phase we evaluated the E.F.% (ECHO) and the presence of late ventricular potentials (SAECG). After hospital discharge we followed up the patients for 6 months.

RESULTS

None of the patients died during the hospital phase while the posthospital cardiac mortality was 20%. The three patients dead during the follow-up had an AMI localized in the anterolateral wall of the left ventricle, an E.F.% less than 40% and LVP positive in the hospital phase. Besides the clinical course was complicated by cardiac failure.

CONCLUSIONS

We conclude that these three patients are a "high risk profile subgroup" and should be submitted to extensive evaluation with cardiac catheterization, coronary arteriography and programmed ventricular stimulation.

Effects of K(ATP) channel blockade by glibenclamide on the warm-up phenomenon

AIMS

The increased tolerance to myocardial ischaemia observed during the second of two sequential exercise tests, i.e. the warm-up phenomenon, has been proposed as a clinical model of ischaemic preconditioning. As ATP-sensitive K+ channels appear to be a mediator of ischaemic preconditioning in both experimental and clinical studies, the aim of this study was to investigate the role of K(ATP) channels in the warm-up phenomenon.

METHODS AND RESULTS

Twenty-six patients with coronary artery disease were randomized to receive 10 mg oral glibenclamide, a selective ATP-sensitive K+ channel blocker, or placebo. Sixty minutes after glibenclamide or placebo administration, patients were given an infusion of 10% dextrose (8 ml x min(-1)) to correct glucose plasma levels or, respectively, an infusion of saline at the same infusion rate. Thirty minutes after the beginning of the infusions, both patient groups underwent two consecutive treadmill exercise tests, with a recovery period of 15 min to re-establish baseline conditions. Before exercise tests, blood glucose levels were similar in placebo and glibenclamide groups (96 +/- 10 vs 105 +/- 22 mg x 100 ml(-1), P=ns). After placebo administration, rate-pressure product at 1.5 mm ST-segment depression significantly increased during the second exercise test compared to the first (220 +/- 41 vs 186 +/- 29 beats x min(-1) x mmHg x 10(2), P<0.01), but it did not change after glibenclamide (191 +/- 34 vs 187 +/- 42 beats x min(-1) x mmHg x 10(2), P=ns), with a significant drug-test interaction (P=0.0091, at two-way ANOVA).

CONCLUSIONS

Glibenclamide, at a dose previously shown to abolish ischaemic preconditioning during coronary angioplasty, prevents the increase of ischaemic threshold observed during the second of two sequential exercise tests. These findings confirm that ischaemic preconditioning plays a key role in the warm-up phenomenon and that in this setting is, at least partially, mediated by activation of ATP-sensitive K+ channels.

Characterization of [3H]substance P binding sites in human skin

Radioligand binding experiments were performed with crude homogenates from normal human skin in order to investigate substance P receptor density. Binding of [3H]substance P ([3H]SP) reached equilibrium after 20 min and was saturable analysis of saturation curves gave a significantly better fit using two-site binding compared to the single-site model. Competition studies employing some selective agonists for NK1, NK2 and NK3 receptors have demonstrated that only the NK1 selective agonist, [Sar9, Met(O2)11]-SP, was a competitor for [3H]SP binding. In addition, the non-hydrolyzable guanosine 5'-0-(3-thiotriphosphate) altered the dissociation of SP from NK1 receptors by increasing the number of low-affinity sites. These data show that in the skin [3H]SP binds to a single population of substance P high-affinity sites, which represent NK1-type receptors.

Effects of A1 adenosine receptor blockade on the warm-up phenomenon

The increased tolerance to myocardial ischemia observed during the second of two sequential exercise tests, i.e. the warm-up phenomenon, has been proposed as a clinical model of ischemic preconditioning. Adenosine appears to be a mediator of ischemic preconditioning in both experimental and clinical settings. The purpose of this study was to investigate the role of A1 adenosine receptors in the warm-up phenomenon. A double-blind, placebo-controlled, cross-over design was used. Twelve patients with coronary artery disease and positive exercise test were randomized to receive either bamiphylline, a selective A1 adenosine receptor antagonist, or placebo, immediately prior to two consecutive treadmill exercise tests carried out on day 1. Then, on day 2 all patients underwent two consecutive exercise tests immediately after administration of the remaining treatment. During the first exercise test, bamiphylline, compared to placebo, increased the time to and rate-pressure product at 1.5 mm ST-segment depression (from 317 +/- 118 to 423 +/- 127 s, p < 0.05 and from 199 +/- 38 to 230 +/- 36 b/min.mmHg.10(2), p < 0.05, respectively). After both placebo and bamiphylline infusions, time to 1.5 mm ST-segment depression during the second exercise test was greater than that during the first test (445 +/- 121 vs 317 +/- 118 s, p < 0.001 and 483 +/- 128 vs 423 +/- 127 s, p < 0.05, respectively), as was rate-pressure product at 1.5 mm ST-segment depression (228 +/- 40 vs 199 +/- 38 b/min.mmHg.10(2), p < 0.01 and 253 +/- 42 vs 230 +/- 36 b/min.mmHg.10(2), p < 0.05, respectively). In conclusion, bamiphylline, at a dose able to increase ischemic threshold and exercise tolerance compared to placebo, does not prevent the warm-up phenomenon. These findings suggest that, in the setting of the warm-up phenomenon, A1 adenosine receptor blockade is insufficient to prevent ischemic preconditioning.

Mechanisms of the warm-up phenomenon

The warm-up phenomenon, described in patients with coronary artery disease, refers to the improved performance following a first exercise test. The aim of this study was to investigate the causes of the warm-up phenomenon. Fifteen patients with coronary artery disease and positive exercise test were enrolled. Patients were off treatment throughout the study. They underwent two consecutive treadmill exercise tests according to the Bruce protocol, with a recovery period of 10 min to re-establish baseline conditions. A third exercise test was then performed 2 h later. Before the onset of ischaemia, the rate-pressure product for a similar degree of workload was similar during the first and second exercise test, while it was lower during the third test (P < 0.05). Time to 1.5 mm ST-segment depression during the second and third exercise test was greater than during the first test (454 +/- 133 and 410 +/- 161 vs 354 +/- 127 s, P < 0.01, respectively). Similarly, the time to anginal pain onset was increased during the second and third exercise tests, compared to the first test (356 +/- 208 and 310 +/- 203 vs 257 +/- 204 s, P < 0.01, respectively). In contrast, rate-pressure product at 1.5 mm ST-segment depression during the second test was higher than that during the first test (232 +/- 47 vs 210 +/- 39 beats.min-1.mmHg.10(2), P < 0.01), while in the third test it was similar to that during the first (209 +/- 43 beats.min-1.mmHg.10(2), P = ns). The warm-up phenomenon observed a few minutes after exercise is characterized by an increase of both time to ischaemia and ischaemic threshold; this adaptation to ischaemia may be due to an improvement of myocardial perfusion or to preconditioning. Conversely, the warm-up phenomenon observed a few hours after repeated exercise is characterized by an increase of time to ischaemia but not of ischaemic threshold and is caused by a slower increase of cardiac workload. Thus, the mechanisms of the warm-up phenomenon may be different, time dependent and related to previous training.

Hemodynamic and clinical effects of captopril in patients with severe congestive heart failure

In a group of 10 patients (9 male, 1 female, aged 16 to 56, mean 43 years) with severe congestive heart failure (CHF), due to ischemic heart disease (8 cases) or dilatative cardiomyopathy (2 cases), the acute hemodynamic response to captopril (CPT) (90 min after 50 mg po) was evaluated. CPT was then given starting with 15 mg q 8 hr, gradually increased within 2 or 3 days to 50 or 75 mg q 8 hr. A hemodynamic re-evaluation was performed after 20 days, and, in 5 patients, after 1 year of CPT treatment. The clinical follow-up done every 3 months in the outpatient clinic. CPT acutely produced a decrease in mean pulmonary wedge pressure: 23.8 +/- 8.9 to 18.6 +/- 8.6 mmHg, p less than 0.01, and an increase in cardiac index: 2.43 +/- 0.73 to 2.91 +/- 0.85 l/min/m2, p less than 0.01; systemic and pulmonary resistances decreased significantly, with no significant changes in heart rate and in mean brachial artery pressure. This favourable hemodynamic response persisted after 20 days of CPT treatment. In the group of 5 patients, who underwent a third hemodynamic evaluation, no statistically significant differences were demonstrated in respect to the previous control values. All patients on chronic CPT treatment experienced a gradual clinical improvement, reaching a steady state after 2 to 3 weeks; the surviving patients remained stable in the improved functional class for at least 6 months. The mortality rate was 30% in the first year, increasing to 50% in the second and to 60% in the third year of treatment. After a mean follow-up 35.7 months (range 33 to 39) the 4 surviving patients remained in the same functional class as after the first year for therapy. In our CHF patients CPT improved the quality of life, with the best clinical and hemodynamic results the first few months of treatment; life expectancy probably was not affected.

[Reliability of the ejection fraction determined with the nuclear stethoscope. Comparison with angiocardiography]

The purpose of this investigation was to compare the Ejection Fraction values simultaneously obtained with the Nuclear Stethoscope and with Cineangiography, in 25 patients (17M-8W) subjected to diagnostic cardiac catheterization. In all patients the determination of Ejection Fraction with the Nuclear Stethoscope always preceded the Cineangiography. Ejection Fraction values obtained with Nuclear Stethoscope change from 32 to 75%; those calculated with Cineangiography, between 18 and 88%. The average Ejection Fraction values obtained with Nuclear Stethoscope (59 +/- 13%) doesn't differ significantly from Cineangiography (59 +/- 21%). There was a direct relationship between Ejection Fraction determined by the Nuclear Stethoscope and Cineangiography (r = 0.93; p less than 0.001). In the obtained results the Authors point out that the Ejection Fraction with Nuclear Stethoscope gives assurance in most patients, although in some particular conditions Nuclear Stethoscope provides Ejection Fraction values which differ from those obtained with Cineangiography. They conclude that Nuclear Stethoscope, for its safe, repeating and simple application, is a methodology of useful employment for Ejection Fraction determination in the single patient, which allows a correct definition of the prognosis and a conforming therapeutic strategy.

Nomogram for calculation of stenotic cardiac valve areas from cardiac output and mean transvalvular gradient

In 15 patients (group 1) with isolated mitral stenosis and in 14 patients (group 2) with isolated aortic stenosis the stenotic valve areas were calculated according to: A) Gorlin's formula; B) Hakki's simplified formula, using mean mitral gradient by planimetry or peak-to-peak aortic gradient; C) the three-point simplified formula, using mean gradient calculated by the three-point method for both mitral and aortic valve. The three-point method is definitely easier to use than planimetry. The values (mean +/- SD) of mitral valve areas in group 1 patients were, respectively: 1.56 +/- 0.63 cm2; 1.56 +/- 0.55; 1.51 +/- 0.53. The values of aortic valve areas in group 2 patients were: 0.91 +/- 0.63; 0.77 +/- 0.41; 0.88 +/- 0.52. An excellent correlation was shown between the valve area calculated by Gorlin's formula and both Hakki's simplified formula and the three-point simplified formula. For aortic valve area the correlation is even better if the mean gradient by the three-point method is used instead of the peak-to-peak gradient. On the basis of the simplified formula, a nomogram was constructed which allows an immediate calculation of valve areas from cardiac output and transvalvular gradient.