[Evaluation of a public health programme: direct Clopidogrel administration by cardiology units in acute myocardial infarction]

OBJECTIVES

to compare the benefit of a personalised outpatient therapy prescribed upon discharge by the cardiology unit to the patients undergoing a percutaneous coronary intervention with drug-eluting stent or bare-metal stent vs. the usual practice.

DESIGN

controlled, multicentre, non-randomized study that enrolled patients who underwent coronary stent implantation and treated in the year after stent implantation with two protocols: the treatment group received Clopidogrel directly from the cardiology unit at each monitoring visit; the control group received a prescription for outpatient treatment through the standard retail pharmacy channel.

SETTING AND PARTICIPANTS

the recruited centres adopting the new treatment protocol are Magenta, Legnano, and Rho (ASL Milano1, Magenta - Lombardy Region, Northern Italy), with 477 patients included; the recruited centres following for the standard protocol are Niguarda and San Carlo (ASL Milano), with 307 patients included. We identified all patients aged ≥40 years, discharged after coronary stent implantation between January 1st, 2010 and March 31st, 2011, and followed for 1 year.

MAIN OUTCOME MEASURES

all coronary events, second coronary interventions or deaths in the year after hospital discharge.

RESULTS

we found differences between the two treatments in relation with coronary events: hazard ratio (HR) for the control group in patients with ST-elevation myocardial infarction (STEMI) is 3.32 (95%CI 1.67- 6.62), HR in patients with non-ST elevation myocardial infarction (NSTEMI) is 2.44 (95%CI 1.07-5.57). The compliance at 1 year is 80% in the treated group vs. 70% in the control group, respectively (p-value <0.01).

CONCLUSIONS

the application of the therapeutic plan, governed by the interventional cardiology, increases treatment adherence and reduces the risk of cardiovascular events subsequent to the insertion of a stent. It is crucial, therefore, to improve the adherence to dual antiplatelet therapy by using high levels of integration between inpatient and outpatient care to reduce adverse health outcomes during post-surgery phase and to ensure the taking in charge of the patient.

[Remote monitoring of implantable cardiac devices: health technology assessment ]

Clinical follow-up of patients with cardiac implantable electronic devices is challenging because of the increasing technical complexity of devices and clinical complexity of patients. Remote monitoring (RM) offers the opportunity to optimize clinic workflow and to improve device monitoring and patient management by reducing in-hospital visits, physician and nurse time required for patient follow-up, and hospital and social costs. Continuous RM may lead to early detection of device malfunctions and clinical events, such as arrhythmias and heart failure. Early reaction may improve patient outcome. RM is easy to use and patients show a high level of acceptance and satisfaction. Implementing RM in daily practice may require changes in clinical workflow. Primary nursing-based models have demonstrated the best results. In spite of a favorable cost-benefit ratio, RM reimbursement still represents an issue in several European countries, including Italy, which limits widespread RM utilization. The fee-for-service payment approach, the global budget for device patient follow-up and/or integrated care packages for heart failure management represent the keys to introduce reimbursement and to improve patient care, while reducing healthcare costs.

[Upstream administration of oral antiplatelet agents in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention]

Current guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) recommend the administration of dual antiplatelet therapy with aspirin and an ADP receptor blocker "as early as possible" before angiography (upstream), though this suggestion is not based on the results of randomized clinical trials designed to investigate pre-hospital rather than in-hospital drug administration. The present review analyzed randomized clinical trials, registries and observational studies that assessed clopidogrel, prasugrel and ticagrelor administration in STEMI patients undergoing primary PCI to evaluate if their upstream use may be justified in clinical practice. A significant difference favoring early clopidogrel administration has been demonstrated in observational studies. No evidence is available for prasugrel and ticagrelor; however, the initial delay of their antiplatelet effect in STEMI patients could support an upstream strategy to obtain complete platelet inhibition in the first hours after PCI and prevent major adverse events (e.g., stent thrombosis) despite an increased risk of major bleeding, particularly in case of urgent bypass surgery. Data from specifically designed randomized clinical trials are warranted to establish whether early administration of prasugrel and ticagrelor may favor reperfusion and improve clinical outcome with an acceptable risk-benefit ratio.

Cost-utility analysis of the EVOLVO study on remote monitoring for heart failure patients with implantable defibrillators: randomized controlled trial

BACKGROUND

Heart failure patients with implantable defibrillators place a significant burden on health care systems. Remote monitoring allows assessment of device function and heart failure parameters, and may represent a safe, effective, and cost-saving method compared to conventional in-office follow-up.

OBJECTIVE

We hypothesized that remote device monitoring represents a cost-effective approach. This paper summarizes the economic evaluation of the Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators (EVOLVO) study, a multicenter clinical trial aimed at measuring the benefits of remote monitoring for heart failure patients with implantable defibrillators.

METHODS

Two hundred patients implanted with a wireless transmission-enabled implantable defibrillator were randomized to receive either remote monitoring or the conventional method of in-person evaluations. Patients were followed for 16 months with a protocol of scheduled in-office and remote follow-ups. The economic evaluation of the intervention was conducted from the perspectives of the health care system and the patient. A cost-utility analysis was performed to measure whether the intervention was cost-effective in terms of cost per quality-adjusted life year (QALY) gained.

RESULTS

Overall, remote monitoring did not show significant annual cost savings for the health care system (€1962.78 versus €2130.01; P=.80). There was a significant reduction of the annual cost for the patients in the remote arm in comparison to the standard arm (€291.36 versus €381.34; P=.01). Cost-utility analysis was performed for 180 patients for whom QALYs were available. The patients in the remote arm gained 0.065 QALYs more than those in the standard arm over 16 months, with a cost savings of €888.10 per patient. Results from the cost-utility analysis of the EVOLVO study show that remote monitoring is a cost-effective and dominant solution.

CONCLUSIONS

Remote management of heart failure patients with implantable defibrillators appears to be cost-effective compared to the conventional method of in-person evaluations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00873899; http://clinicaltrials.gov/show/NCT00873899 (Archived by WebCite at http://www.webcitation.org/6H0BOA29f).

Mortality and ST resolution in patients admitted with STEMI: the MOMI survey of emergency service experience in a complex urban area

BACKGROUND

Since 2001, the urban area of Milan has been operating a network among 23 cardiac care units, the 118 dispatch centre (national free number for medical emergencies), and the county government health agency called Group for Prehospital Cardiac Emergency.

METHODS AND RESULTS

In order to monitor the network activity, time to treatment, and clinical outcome, a periodic survey, called MOMI(2), was repeated two or three times a year. Each survey lasted 30 days and was repeated in comparable periods. Data were stratified for hospital admission mode. We collected data concerning 708 consecutive ST-elevation myocardial infarction (STEMI) patients (male 72.6%; mean age 64.4 years). In these six surveys, we observed a high rate of primary percutaneous coronary intervention (73.2%) and a mortality rate of 6.3%. Using advanced statistical models, we identified age, Killip class, and the symptom onset-to-balloon time as most relevant prognostic factors. Nonparametric test showed that the modality of hospital admittance was the most critical determinant of door-to-balloon time. 12-lead ECG tele-transmission and activation of a fast track directly to the catheterization laboratory are easy action to reduce time to treatment.

CONCLUSIONS

The experience of the Milan network for cardiac emergency shows how a network coordinating the community, rescue units, and hospitals in a complex urban area and making use of medical technology contributes to the health care of patients with STEMI.

Remote monitoring reduces healthcare use and improves quality of care in heart failure patients with implantable defibrillators: the evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study

BACKGROUND

Heart failure patients with implantable cardioverter-defibrillators (ICDs) or an ICD for resynchronization therapy often visit the hospital for unscheduled examinations, placing a great burden on healthcare providers. We hypothesized that Internet-based remote interrogation systems could reduce emergency healthcare visits.

METHODS AND RESULTS

This multicenter randomized trial involving 200 patients compared remote monitoring with standard patient management consisting of scheduled visits and patient response to audible ICD alerts. The primary end point was the rate of emergency department or urgent in-office visits for heart failure, arrhythmias, or ICD-related events. Over 16 months, such visits were 35% less frequent in the remote arm (75 versus 117; incidence density, 0.59 versus 0.93 events per year; P=0.005). A 21% difference was observed in the rates of total healthcare visits for heart failure, arrhythmias, or ICD-related events (4.40 versus 5.74 events per year; P<0.001). The time from an ICD alert condition to review of the data was reduced from 24.8 days in the standard arm to 1.4 days in the remote arm (P<0.001). The patients' clinical status, as measured by the Clinical Composite Score, was similar in the 2 groups, whereas a more favorable change in quality of life (Minnesota Living With Heart Failure Questionnaire) was observed from the baseline to the 16th month in the remote arm (P=0.026).

CONCLUSIONS

Remote monitoring reduces emergency department/urgent in-office visits and, in general, total healthcare use in patients with ICD or defibrillators for resynchronization therapy. Compared with standard follow-up through in-office visits and audible ICD alerts, remote monitoring results in increased efficiency for healthcare providers and improved quality of care for patients.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00873899.

Abstract 252: In-hospital and Discharge quality of pharmacological care among Acute Myocardial Infarction patients in Northern Italy

Aim . We aim to evaluate the adherence to ACC/AHA guidelines for secondary prevention in a representative population of 35-79 years old living in Northern Italy, in 2007-2008.

Methods . The study population comprises the 35-79 years old residents in the Varese Province. From the regional Hospital Discharge Record database we identified n=1917 hospitalizations with a main discharge code ICD-IX 410.xx occurring in the 17 surveyed hospitals. Clinical information was available for n=1908 events; according to the ACC/AHA 2008 performance measures, data collection included ASA administration at arrival, in-hospital assessment of left ventricular systolic function and LDL-cholesterol, prescription of ASA, beta-blockers and statin at discharge, as well as smoking cessation advice. Data on documented contraindications were also carefully collected. N=87 non acute events were excluded, leaving a final number of n=1821 records. The main performance measure is the proportion of patients treated according to guidelines among those without documented contraindications (eligible patients). We further considered a sex- and age at admission-adjusted analysis, by means of a logistic model.

Results . Mean age at admission was 64.6±10.5 years, 72.8% were men. Data availability was above 90% for all the indicators. Almost 95% of patients received ASA at arrival; 91% had evaluation of left ventricular systolic function, and 69% had an evaluation of LDL-cholesterol during the hospitalization. ASA, beta-blockers and statin at discharge were prescribed to 94.9%; 74.3%; and 91.0% of eligible patients, respectively. Smoking cessation advice in clinical records was present in 1 smoker out of 4. Women were less likely to receive a prescription for beta-blockers, and the elderly (75-79 years old) less likely to have prescription for ASA and beta-blockers at discharge.

Conclusions . Overall, a high proportion of eligible patients receives the recommended drug prescription at discharge; however, gender- and age-related disparities in secondary prevention care are present. A less than expected proportion of eligible patients had in-hospital LDL assessment, reducing the number of eligible patients for statin prescription.

Healthcare continuity from hospital to territory in Lombardy: TELEMACO project

OBJECTIVES

To verify implementation and use of TELEMACO (TELEMedicina Ai piccoli COmunilombardi; http://www.telemaco.regione.lombardia.it/), which provides specialized continuity of care with innovative healthcare services in remote areas of the Lombardy region of Italy; to design a network in the territory for sharing of continuityof- care programs; and to allow the relevant health authorities to collect cost data to establish a model for sustainable pricing for implementing these services.

METHODS

TELEMACO provides home-based telemanagement services for patients with chronic heart failure and chronic obstructive pulmonary disease (COPD), as well as second-opinion teleconsultations in cardiology, dermatology, diabetology, and pulmonology for general practitioners and second-opinion teleconsultations on digital images in cases of traumatic brain injury and stroke. A total of 2 service centers, 10 cardiology and pneumology departments, 30 specialists, 176 general practitioners, 40 nurses, 2 emergency departments, and 2 consultant hospitals were involved.

RESULTS

A total of 166 patients with chronic heart failure and 474 patients with COPD were enrolled. There were 4830, 51, and 44 second-opinion teleconsultations for cardiologic, dermatologic, and diabetic conditions, respectively. There were 147 second-opinion teleconsultations on digital images, 68 for stroke, and 79 for traumatic brain injury. Implementation of TELEMACO introduced innovations in working methods and provided evidence to the health authorities for allocating funds for such services.

CONCLUSIONS

TELEMACO provided evidence that there is a growing need for home management of patients using telemedicine, a common and efficacious approach that can ensure care continuity, especially in chronic diseases.

Design of the evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study to assess the ability of remote monitoring to treat and triage patients more effectively

Background

Heart failure patients with implantable defibrillators (ICD) frequently visit the clinic for routine device monitoring. Moreover, in the case of clinical events, such as ICD shocks or alert notifications for changes in cardiac status or safety issues, they often visit the emergency department or the clinic for an unscheduled visit. These planned and unplanned visits place a great burden on healthcare providers.

Internet-based remote device interrogation systems, which give physicians remote access to patients' data, are being proposed in order to reduce routine and interim visits and to detect and notify alert conditions earlier.

Methods

The EVOLVO study is a prospective, randomized, parallel, unblinded, multicenter clinical trial designed to compare remote ICD management with the current standard of care, in order to assess its ability to treat and triage patients more effectively.

Two-hundred patients implanted with wireless-transmission-enabled ICD will be enrolled and randomized to receive either the Medtronic CareLink^® monitor for remote transmission or the conventional method of in-person evaluations. The purpose of this manuscript is to describe the design of the trial. The results, which are to be presented separately, will characterize healthcare utilizations as a result of ICD follow-up by means of remote monitoring instead of conventional in-person evaluations.

Trial registration

ClinicalTrials.gov: NCT00873899

Remote monitoring of CRT-ICD: the multicenter Italian CareLink evaluation--ease of use, acceptance, and organizational implications

PURPOSE

The Medtronic CareLink allows remote implantable device follow-up. In this first European experience with CareLink, we assessed the ease of use of the system, the acceptance, and satisfaction of patients and clinicians.

METHODS

Patients implanted with biventricular defibrillators for more than 6 months received the CareLink monitor and were trained to perform home device interrogation and transmission. Patient and clinician experience and preference were evaluated through specific questionnaires.

RESULTS

Sixty-seven patients were enrolled and were able to perform data transmissions during the 3-month study duration. The overall duration of interrogation procedure was 7 +/- 5 minutes, and frequently the procedure did not require the assistance of a caregiver. Patients reported a general preference for remote versus in-clinic follow-up and described a sense of reassurance created by the remote monitoring capability.In the centers, the review procedure was successful; its mean duration was 5 +/- 2 minutes per transmission and the users indicated that the access and navigation of the review website were easy. At the end of the evaluation, the data available for remote review were judged complete and adequate to provide almost the same standard of care as that offered in traditional in-clinic visit. In general, the remote monitoring was seen as a potential tool to improve the clinical management of patients with device.

CONCLUSIONS

The ease of use, satisfaction, and acceptance of the CareLink Network in European clinical practice appears elevated both for patients and for clinicians.

[Cardiological emergency network in Lombardy]

AIMS

To achieve a reduction of time to reperfusion through the organization of an interhospital network and the involvement of the Regional Health Authority.

METHODS

Four major endpoints were identified: institutional governance action, clinical management of acute ST-elevation myocardial infarction (STEMI), priority actions for cardiac arrest and early defibrillation, actions to avoid the delay related to decision-making, and logistic factors. Since 2001 in the urban area of Milan a network has been operating among 23 coronary care units, the 118 Dispatch Center (national free number for medical emergencies) and the Health Country Government Agency named Group for Prehospital Cardiac Emergency. In order to monitor the network activity and time to treatment and clinical outcomes a periodic monthly survey, called MOMI (One Month Monitoring Myocardial Infarction), was undertaken and repeated twice yearly. Data were evaluated according to hospital admission modality.

RESULTS

Global times are: symptom onset to first medical contact 116 min (interquartile range [IQR] 189), time to first ECG 7 min (IQR 12), door-to-balloon time 77 min (IQR 81.7). Non-parametric test showed that the modality of hospital admittance was the most critical determinant of door-to-balloon time. The shortest one (49.5 min) was that of patients transported by means of advanced rescue units with 12-lead ECG teletransmission and activation of a fast track directly to the cath lab.

CONCLUSIONS

Our data show how in a complex urban area the organization of an interhospital network and the availability of ECG teletransmission are effective in reducing time to reperfusion, in the treatment of major arrhythmias and in pre-alert of coronary care units and cath labs in case of confirmed STEMI. This experience also stimulated an improvement in technological equipment of rescue units with extension of 12-lead teletransmission to basic life support units. Through the Health Country Government Agency and the Scientific Societies we carry on with our job to create a regional network for cardiac emergency involving all the hospitals.

[The network for the management of acute coronary syndromes in Milan: results of a four-year experience and perspectives of the prehospital and interhospital cardiological network]

In patients with acute ST-elevation myocardial infarction (STEMI), in order to shorten the time to definitive treatment, it is essential to coordinate the intervention between the local healthcare system and the hospitals. In 1999, a Working Group for Prehospital Emergency in Cardiology was established in Milan, and a network for 12-lead ECG transmission between advances life support (ALS) ambulances, the headquarter of 118 Rescue Service and the Coronary Care Units (CCU) or Divisions of Cardiology was developed: between February 1, 2001 and May 1, 2005, 6821 patients with suspected heart attack were rescued and their ECG recorded and transmitted (177 patients/month, 20% of them with an ST-segment shift, 11% ST-segment elevation, 9% non-ST-segment elevation, 24% with normal ECG). The rate of false positive automatic diagnosis of acute myocardial infarction was 0.3%, the rate of false negative was 0.8%. Forty-six patients with ventricular fibrillation underwent DC-shock. After May 1, 2004, clinical data of patients with STEMI transferred to the hospitals by ALS ambulances were reported in a database: 82% of the 89 patients were treated with primary angioplasty. The time (median, interquartile ranges) between ECG arrival to the CCU and the ECG report was 2 min (1-5), between ECG arrival to the CCU and patient arrival to the hospital was 34 min (24-42), between ECG arrival to the CCU and primary angioplasty was 69 min (50-93); the door-to-balloon time was 33 min (22-60). The telephone ECG transmission has been demonstrated to be a useful and rapid tool, easy to use; the automatic ECG diagnosis was accurate. In patients with STEMI the telephone ECG transmission shortened the time of delivery of therapy, helped to recover arrhythmic complications, allowed both the coordination between the 118 System and the Divisions of Cardiology and the implementation of the triage for primary angioplasty. Increasing the technological level of the service will be the next step of the program: the protocol will be upgraded in order to increase the number of patients rescued, to shorten the time of operation and to administer prehospital fibrinolytic therapy in selected patients.

[The early management of ST-elevation acute myocardial infarction in the Lombardy Region (GestIMA)]

BACKGROUND

Recent international and national surveys on the management of ST-elevation myocardial infarction have described a number of crucial issues regarding the prehospital phase, the criteria to address patients to primary angioplasty, the organization of interhospital transfers. GestIMA is a perspective survey organized by the Lombardy Sections of the Italian Cardiology Societies (ANMCO and SIC) aimed to investigate the management of the acute phase of myocardial infarction in the Lombardy Region.

METHODS

Between October 15 and November 14, 2003, consecutive patients hospitalized for ST-elevation myocardial infarction in the coronary care units of 60 hospitals in Lombardy were enrolled into the study.

RESULTS

Among 612 patients (median age 67 years, interquartile range 56-76 years, 68% males, 43% with acute anterior myocardial infarction), 43% reached the hospital using the 118 emergency medical service, in 20% an ECG was recorded before arrival (reported in 47%), 1.5% were treated with thrombolysis and 1.0% with glycoprotein IIb/IIIa inhibitors before hospital admission. Sixty-eight percent of patients underwent a reperfusion treatment: 43% with primary angioplasty (6% facilitated), 25% with thrombolysis (18% of them had rescue angioplasty). Primary angioplasty was mainly performed in younger patients and in those directly admitted to centers equipped with interventional facilities. During the acute phase of myocardial infarction, 10% of patients arrived to the coronary care units from 39 peripheral hospitals without coronary care unit; 21% of patients had a secondary transport between hospitals with coronary care unit (47% for primary angioplasty).

CONCLUSIONS

In the Lombardy Region, where a high rate of patients with ST-elevation myocardial infarction was treated with primary angioplasty in 2003, the 118 emergency medical service and the transmission of ECG by telephone are still underutilized. Moreover, the prehospital pharmacological treatment, the prehospital triage of patients to address to primary angioplasty and the organization of secondary transfer need to be improved.

Service level web monitoring in the field management of emergencies

Cardiologic Emergency Project is based on a hospital network in Milan, Italy, in order to provide patients with more efficient first aid immediately after the occurrence of an Acute Coronary Syndrome. The Project includes ECG transmission from running ambulances to the 118 telephone central help desk, and from there to the suitable hospital. Since the maximum total transfer time should stay within a few tens of minutes, and given that a number of different factors may cause very dangerous delays, the effective coordination of several healthcare systems, devices and organizations is critical. Monitoring of the activities on each component is a must. Cardiologic Emergency Project uses a Web application devoted to the monitoring and evaluation of the service levels. Web applications allow the quantitative monitoring of the durations of extra-hospital operations. Several types of tables and graphics are automatically filled for the best care of the patient. For example, given a lengthy total time request by a satisfactory full ECG transmission, the system allows analysis of the ECG machine, of the cellular phone partial-only coverage along the ambulance pathway, of the transfer time in rush hours, etc., to determine which elements in the process can be improved to avoid future delays.

Heart rate variability patterns before ventricular tachycardia onset in patients with an implantable cardioverter defibrillator. Participating Investigators of ICD-HRV Italian Study Group

Time- and frequency-domain analysis of heart rate variability (HRV) has been proven effective in describing alteration of autonomic control mechanisms and in identifying patients with increased cardiac and arrhythmic mortality. Patients with implantable cardioverter defibrillators offer the opportunity to evaluate HRV patterns before ventricular tachycardia (VT) and under control conditions. We therefore analyzed time- and frequency-domain parameters of short-term HRV and power-law behavior of RR interval time series at rest, at 15 to 30 minutes, and immediately before VT. In comparison to control conditions, lower values of mean cycle length duration and total power were observed before VT. Spectral analysis indicated that the low- to high-frequency ratio was significantly higher (5.5 +/- 0.6 vs 2.8 +/- 0.3) immediately before VT than during rest. Both findings were consistent with the shift of sympathovagal balance toward sympathetic predominance and reduced vagal tone. Before VT, a more negative value of the scaling exponent beta of the power-frequency relation (-1.57 +/- 0.04 vs -1.33 +/- 0.04) also confirmed the presence of an altered HRV pattern in comparison to controls. Thus, both abnormal autonomic modulation and dynamic patterns of HRV seem to characterize the minutes before arrhythmia onset in these patients.

Time trends in the intracardiac potential recorded by pacemaker telemetry: comparison between steroid-eluting small area electrodes

We assessed the time course of electrograms sensed both in the atrium and ventricle by two different steroid-eluting electrodes: Medtronic Capsure SP (with an area of 5.5 mm2) and Z (with an area of 1.2 mm2). We considered 68 unipolar electrodes: 31 atrial (19 Capsure SP 4523 and 12 Capsure Z 4533) and 37 ventricular (24 Capsure SP 4023 and 13 Capsure Z 4033) implanted in 47 consecutive patients (30 men and 17 women, with an age of 72 +/- 9.4 years). The pacemaker model was Medtronic Elite 7077-7086 (DDD-DDDR) in 25 patients and Medtronic Legend 8419-8424 (VVIR-AAIR) in 22 patients. The endocavitary signal (all patients had spontaneous rhythm) was telemetrically obtained by a Medtronic 9790 device and acquired on a personal computer at implantation and 7, 30, and 180 days thereafter. The signal was studied both in the time domain and in the frequency domain by spectral analysis. The following parameters were calculated: amplitude (A): peak-to-peak value of the complex; slew rate (SR) peak negative first derivative; F0: frequency at which the power spectrum reaches its maximum value; and bandwidth (Bw): expressed as the distance between the -3 dB points and statistically analyzed by a two-way analysis of variance with factors "time" (four measurements) and "electrode" (Capsure SP and Z) and repeated measurements on the former. Ventricular sensing: no time or electrode effect (P > 0.1 in all comparisons) was found for F0, Bw, or SR, while a time effect (P < 0.04) not dependent on the type of electrode was found for the amplitude of the signal. In particular, a significant increase was found between the measurement at 6 months and that at implantation (P < 0.004). Atrial sensing: A, F0, and bandwidth were not affected by time or electrode (P > 0.09), while SR behaved differently over time (P < 0.05) in the two electrodes (the Capsure Z showed an increase at sixth month [P < 0.04] compared to implantation). In conclusion, the Medtronic Capsure SP and Z electrodes proved to be valid and substantially equivalent as far as concerns the measurement of the intracardiac potential despite the difference between their surface areas. Further studies should be devised to assess whether transitory decreases of atrial Bw in the first month of follow-up observed in a few patients for both electrodes could be responsible for clinical episodes of sensing deficit.

High impedance low energy pacing leads: long-term results with a very small surface area steroid-eluting lead compared to three conventional electrodes

We evaluated the handling performance at implant, and the long-term atrial and ventricular electrical performance of a new generation using a very small surface area (1.2 mm2) steroid-eluting electrode (Medtronic CapSure Z). We compared the performance of CapSure Z to that of traditional passive fixation leads, with and without steroid elution. The study was conducted during 2 years of follow-up. We studied 188 patients (105 males and 83 females; mean age 71 +/- 7 years). All of the patients were implanted with a dual chamber pacemaker and the same type of lead in both chambers. Forty-one patients received CapSure Z leads, 25 patients received Target Tip leads (8-mm2 surface area; no steroid elution), 63 patients received CapSure leads (8-mm2 surface area; steroid elution), and 59 patients received CapSure SP leads (5.8-mm2 surface area; steroid elution). The four groups were homogeneous in regards to sex, age, cardiac disease, and reason for implant. At follow-up, the CapSure Z lead showed sensing values comparable to the other leads, with lower pacing thresholds and higher pacing impedance in both chambers. We evaluated the mean current drained from the pacemaker by the different types of leads when using safe, low energy output settings. We found that by using CapSure Z leads, the mean current was significantly lower than that of the other types of leads (0.42 microA for CapSure Z ventricular lead vs 0.85 for CapSure SP, 1.42 for CapSure, and 1.54 for Target Tip). Thus, the use of the CapSure Z lead, combined with low energy output programming, will increase pacemaker longevity compared to the use of traditional leads and standard output programming.

[Electromechanical dissociation in myocardial infarction. Anatomical-clincal study of 82 cases]

In our experience electromechanical dissociation (EMD) is the most common mechanism of fatal cardiac arrest in patients with acute myocardial infarction (AMI).

METHODS

We reviewed retrospectively 82 autopsy cases of AMI in whom the medical record documented EMD as terminal cardiac arrest in order to outline the clinical and pathologic features of different subgroups: 26 cases with external cardiac rupture (CR) were compared with 56 cases without CR. In turn, inside the latter series, 16 cases of sudden EMD were compared with 40 cases of EMD occurring in the terminal phase of cardiac shock.

RESULTS

In comparison with those without CR, patients with CR showed at multiple regression analysis less evidence of left ventricular failure (p < 0.05); less extended infarct areas (p < 0.01); more frequent sudden EMD (p < 0.05). Most patients with CR had massive pericardial effusion; cardiac rhythm at the onset of EMD was seldom slow in those cases. In the group without CR no discriminant characteristics were found in cases of sudden EMD vs cases preceded by cardiac shock.

CONCLUSIONS

In case of CR EMD occurs in less extensively damaged hearts and is generally sudden; in AMI without CR EMD may affect patients with severe depression of pump performance, but not necessarily in shock. EMD after an AMI may result from several factors: cardiac tamponade is prevalent in the presence of CR; in cases without CR our data don't permit to conjecture a distinct pathogenesis for sudden EMD in comparison with cases preceded by shock.

Accuracy of telemetry signals in the post-implantation monitoring of electrograms sensed by pacemakers

Monitoring of electrograms (EGMs) sensed by pacemakers (PMs) during their lifetime is the utmost importance, since changes of these signals, due to modifications of the electrode-myocardial interface may occur compromising the proper functioning of the PM. Since after implantation these intracardiac signals are accessible only by means of a telemetry system, it is necessary to ascertain how faithfully the telemetric signals reproduce the direct ones. To this aim we devised an accurate method, based on linear system theory, which allows the estimation of the transfer function of the PM-telemetry system and the comparison of a set of time and frequency domain parameters (wave amplitude, slew rate, frequency at the spectrum peak and bandwidth) computed on both direct and telemetric signals. To overcome the problem that these two signals cannot be recorded simultaneously, an appropriate model of the input and output signals of the PM-telemetry system and of their interrelationship was identified. This model relies on a set of reasonable assumptions about the nature of the direct signal (supposed to have a fixed morphology within a predefined analysis window) and of noise sources corrupting both the direct and telemetric signals. Owing to the involvement of deterministic and stochastic signals, the theory of quasi-stationary signals was employed to obtain the system transfer function. To test our method, direct and telemetric recordings were performed on 12 patients with atrial sensing carrying Medtronic Pacemakers (Mod Elite 7077/7086, programmer Mod 9760) with unipolar steroid eluting leads (Medtronic Capsure 4523). The results we obtained demonstrate that the specific system considered acts as a low-pass filter with a -3 dB frequency at about 90 Hz this ensures that the telemetric signal contains almost all the information of the direct one and can be used to monitor the changes of the signals sensed by the PM.

[The early echocardiographic diagnosis of a massive pulmonary embolism]

BACKGROUND

In several cases of clinically suspected massive pulmonary embolism (MPE), a lung perfusion scanning and/or a pulmonary angiography are not quickly available or feasible.

METHODS

Fifty patients admitted to our ICU with a clinically suspected MPE underwent an echocardiographic (Echo) investigation very shortly after onset (within 2 hours in 38 cases, and within 6 hours in 12). An Echo-Doppler study was also performed in 18 patients.

RESULTS

Highly significant differences (p < 0.001) emerged between patients with PE and healthy age-mates for each type of Echo measurement and in all views. The RVDD/LVDD ratio turned out to be the most frequently affected parameter, being altered in 96% of cases. An abnormal diastolic leftward shift of the interventricular septum was detected in 81% of cases. Only one of our 50 patients failed to show any evidence of RV pressure overload; however, this was a patient with a severe dilated cardiomyopathy. In 22 cases in whom hemodynamic monitoring was performed, no significant correlation emerged between RVDD and LVDD, on one hand, mean PAP and cardiac index on the other. All 18 patients examined by Echo-Doppler had mild to moderate tricuspid regurgitation with a peak RV-RA gradient of 38 +/- 7 mm Hg (range 31-53 mm Hg). Seven patients (14%) were found to harbor right heart thrombi when first examined. Overall mortality in this uncommonly high risk population was as high as 28%.

CONCLUSIONS

In a clinical setting suggesting a MPE, an Echo study conducted very shortly after onset may corroborate a tentative diagnosis of PE, thereby permitting timely fibrinolytic therapy pending a lung scan and/or angiography, or in situations where such imaging facilities are not available or readily usable.

[Heart arrest in acute pulmonary embolism. An anatomo-clinical study]

The Authors describe the modalities and mechanisms of cardiac arrest (CA) in the course of acute pulmonary embolism (PE). Clinical data refer to 39 CA episodes occurred in 28 patients with massive or submassive PE; autopsy data are from 26 of 28 patients of the same series. One-third of 39 CAs proved at least momentarily reversible; two-thirds were irreversible. Data analysis showed that most CA episodes, reversible or otherwise, seen in the course of PE were due to electromechanical dissociation (EMD). In fact, EMD was responsible for 12 of 13 reversible CAs and 22 of 26 irreversible arrests. EMD usually follows shock, but may occur unheralded. When EMD-induced CA is at least temporarily reversible, the heart rate is often normal or high and QRS complexes are narrow. In most cases the sudden rise of right ventricular afterload came on top of a pre-existing myocardial damage, for the most part of ischemic, sometimes necrotic, origin. In this series, therefore, it seems quite difficult to tell "primary" from "secondary" forms of EMD. External cardiac massage continued for as long as 40 minutes was associated in some cases with a bolus fibrinolytic infusion within minutes from occurrence of CA. Five of 7 patients so treated made a temporary recovery and two survived; at autopsy, none of the 5 patients who died showed any evidence of bleeding attributable to local injury.

Antiaggregating therapy in acute myocardial infarction

The clinical benefit of aspirin in the acute phase of myocardial infarction is dramatically suggested by the results of the ISIS-2 trial. However, the time course of pathophysiological events that lead to such a determining involvement of platelets still appears uncertain and further study is needed to single out exactly how early and how long antiplatelet drugs should be given, since there is a risk of bleeding complications due to the combination of the different antithrombotic therapies. Thrombolytic agents and heparin are in fact widely used for patients with acute myocardial infarction, even if the optimal schedule of treatment, including anti-aggregating therapy, is not yet firmly established. To avoid rethrombosis and to enhance the efficacy of coronary thrombolysis, thus reducing early mortality, several newer antiplatelet agents other than aspirin, such as antibodies against the platelet receptor of adhesive proteins, the glycoprotein IIb/IIIa and the RGD peptides, are currently under investigation.

[Pulmonary embolism in the coronary care unit]

Massive pulmonary embolism (MPE), as seen in cardiac care units (CCU), is almost invariably characterized by severe obstruction of the pulmonary vasculature and/or a background of poor cardiorespiratory conditions, all contributing their share to a grave overall situation, often compounded by cardiogenic shock and not exceptionally eventuating in cardiocirculatory arrest (CCA). In such circumstances, echocardiography offers both direct and indirect diagnostic elements that may help, among other things, differentiate pulmonary embolism from acute myocardial infarction--the latter not always easily identified, also in view of its possible occurrence in association with MPE. Conversely, some problems are still open concerning the meaning and treatment of right-sided intracavitary thrombus formations revealed by echocardiography. Among less familiar hemodynamic aspects we must consider right-sided pulsus alternans and the so-called ventricularization of pulmonary pressure curves--a phenomenon to be viewed with caution because of possible modifications imputable to the recording system. Bedside pulmonary angiography, now generally feasible with standard CCU equipment, may readily diagnose or rule out MPE in situations where an angiography room is not available or momentarily not accessible. Numerous personal anatomoclinical observations bear witness to the role of electromechanical dissociation (EMD) as a cause of CCA in patients with MPE. Such dissociation may prove at least temporarily reversible, especially in cases not featuring bradycardia and showing narrow QRS complexes; the concurrent administration of fibrinolytic agents along with cardiopulmonary resuscitation may prove successful while it does not seem to invite important hemorrhagic complications.

[Amiodarone prophylaxis of ventricular tachycardia in ischemic cardiopathy]

Sustained ventricular tachycardia (VT) in coronary heart disease (CHD) represents a major risk factor for sudden death. The Authors evaluated the prophylactic efficacy of the chronic administration of amiodarone (A) on this arrhythmia and simultaneously the trend of ventricular extrasystole during the antiarrhythmic treatment. Twenty-three patients were examined, 17 with post-infarction cardiopathy and 6 with mixed angina. They showed either 1 or more episodes (2 patients) of sustained VT involving hemodynamic difficulties. The ejection fraction (EF) ranged between 20 and 45% average (35.2 +/- 9). All patients underwent a basal 24 hour ECG 3 days after the VT cardioversion, and every 6 months. All subjects took A orally for a period ranging from 7 to 67 months (average 23.04 +/- 14) at the dose of 800 mg/day 7 for days, and then 200 or 400 mg/day according to the presence or absence of ventricular extrasystoles (VE) greater than or equal to 30/hr and/or Lown's class (L) greater than or equal to 3. No patients died suddenly during the follow-up; 6 of them died for causes other than arrhythmia. Four of them showed only 1 sustained VT relapse after a period of 6 to 11 months. Two of these 4 patients showed a persistent increase of the number of VE and L-class while, in the remaining 2 patients, the number of VE remained substantially unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

[Informatics in cardiology: proposal for standardized terminology in clinical records and in permanent cardiac electrostimulation]

To make operative two medical computerized programs, one dedicated to the cardiological clinical record (PAC) and the other to permanent cardiac stimulation (PGP), we codified about 4000 terms concerning the general medical field and particularly the cardiological area. The importance of standardization of the medico-cardiological language is emphasized, specially in relation to the systematization of the information, necessary to work with computerized systems.

[Use of the subclavian vein for permanent cardiac stimulation]

The experience on 101 cases of permanent cardiac stimulation is reported; in all of them, the access was via the subclavian vein. Punction of the subclavian artery, transient injury of the brachial plexus and pneumothorax, were seen in 4.3 and 3% respectively. Early electrode luxation was observed in 5% of the patients. As late complications there where two cases of destruction of the electrode protecting sheet and one electrode rupture. In spite of the potential risks directly related to the vein puncture, the subclavian puncture offers an excellent alternative for placing definitive pacing electrodes.

[Comparative evaluation of mexiletine and propafenone by dynamic electrocardiography]

We have compared the efficacy of Propafenon and Mexiletine in 12 subjects (7 males and 5 females, age range of 22-61 year) affected by chronic ventricular extrasystolic beats. Propafenon and Mexiletine were orally administered in doses of 900 mg/day and 600 mg/day respectively in a single blind, cross-over fashion. Our results show that: Propafenon is better tolerated; Propafenon has caused a statistically significant reduction of the total number of ventricular ectopic beats/24 hours; the efficacy of Propafenon has been greater than that of Mexiletine (66% and 25% respectively); with both drugs, in 2 cases, there was an increase of the total number of ventricular ectopic beats/24 hours; Propafenon has induced clear-cut electrocardiogram changes (statistically significant lengthening of P-Q and Q-T intervals).

La Telecobaltoterapia Come Unico Trattamento Delle Neoplasie Laringee

194 laryngeal tumors were treated with cobalt teletherapy. They were classified according to the T.N.M. system and 168 have been evaluated statistically (T1 – T2 = 42; T3 – T4 = 124). The results are shown in a series of survival curves; the five-year survival rate is 21.6 %. This experience confirms the value of radiotherapy as a useful conservative treatment, although in many extensive cases (T3 – T4) radiotherapy ensures longer survival if combined with surgery.