Physiologic risk assessment in stable ischemic heart disease: still superior to the anatomic angiographic approach.

In patients with ischemic heart disease (IHD), a functional risk assessment based on non-invasive tests may conflict with a health care policy oriented toward cost containment and direct reperfusion delivery. In this respect, a survey of the European Society of Cardiology has shown that noninvasive tests are underutilized, with wide variability between different countries, so that several patients without significant IHD directly undergo invasive coronary angiography. On the other hand, coronary lesions detected by coronary angiography often are revascularized even without the evidence that myocardial blood supply or mechanical function is altered. This \u27\u27anatomically oriented\u27\u27 invasive approach may negatively impact patient management, with consequent suboptimal medical treatment, inappropriate revascularizations, additional risks, and increased health costs. To investigate the prognostic power of gated SPECT in current practice, we recently studied a cohort of 676 consecutive patients admitted for known or suspected IHD.3 Each patient underwent a complete diagnostic work-up that included clinical evaluation, laboratory tests, 12-lead electrocardiogram, two-dimensional echocardiography, stress/rest gated SPECT, and coronary angiography. During follow-up (median, 37 months), 24 patients died from cardiac causes and 19 had a nonfatal myocardial infarction (MI). Several variables were independent predictors of event-free survival (cardiac death and non-fatal MI) in the different phases of diagnostic work-up. When the above predictors were tested together, summed rest score (SRS), summed difference score (SDS), serumcreatinine, and LDL/HDL cholesterol were the only final independent predictors of event-free survival (Table 1). The results of this study lead us to make some considerations on risk stratification in stable IHD

Impatto psico-emotivo della sindrome coronarica acuta

Background. Acute coronary syndromes can substantially disrupt the lives of our patients. However, patients\u27 view of their illness is usually scarcely considered in routine medical practice. We aimed to investigate the psycho- emotional impact of acute coronary syndromes. Methods.We studied 30 patients with acute coronary syndrome, aged <70 years. Before discharge, each patient was interviewed by a psychologist using a semi-structured interview; data were collected in the form of verbal reports. Results. After learning that they had had a heart attack, 16 patients (53%) reported a feeling of fear linked to the idea of death, sometimes real despair; 7 patients (23%) showed a weak emotional response, 4 (13%) reacted with denial, and 3 responded evasively. During the interview, 17 patients (57%) reported events relating to family life and 9 (30%) to work; all these events were negative and related to suffering, conflict, and stress. When compared to pre-admission status, 30% of patients experienced negative psychological changes, such as a sense of fragility, uncertainty and a redefinition of self-image, while 50% reported no change. Surprisingly, 6 patients (20%) referred positive psychological changes. This positive restructuring was related to the patients\u27 ability/need to change their lifestyle. This process entails a different vision of the past and the future, and is associated with a feeling of rebirth and physical wellbeing. Conclusions. The psycho-emotional effects of acute coronary syndromes may be immense, and may radically change the way the patient relates to himself and to the world. We often remain detached from these changes, and are sometimes even unaware of them

Cardiomiopatia post-chemioterapia: curare oggi pensando al domani.

Dilated cardiomyopathy post-chemotherapy. We describe the case of a dilated cardiomyopathy with angiographically normal coronary arteries in a 32-year old man who underwent head and spine radiotherapy and high dose antracicline chemotherapy at the age of 5 year for acute lymphoblastic leukemia. The long-term detrimental cytotoxic effect of remote life-saving chemotherapy should be considered in survivals of leukemia.Descriviamo il caso di un giovane di 32 anni affetto da cardiomiopatia dilatativa con quadro coronarografico normale trattato, all\u27et? di 5 anni, con radioterapia delle meningi e chemioterapia con antracicline ad alte dosi per leucemia linfoblastica acuta. L\u27effetto a lungo termine della citotossicit? di questo trattamento salvavita va considerato nei pazienti guariti da leucemia

Routine laboratory tests to risk-stratify patients with chronic coronary artery disease

AbstractBackgroundSeveral biohumoral variables, taken individually, are predictors of prognosis in patients with chronic coronary artery disease (CAD). We hypothesized that taken together, laboratory tests provide prognostic information that is additive to a complete diagnostic work-up.MethodsWe prospectively examined 2370 consecutive patients with chronic CAD, as shown by a >50% coronary stenosis (in 95% of patients), previous coronary revascularization (in 31% of patients), and/or previous myocardial infarction (MI, in 54% of patients). We tested the ability of laboratory and clinical variables to predict future cardiac events (cardiac death and non-fatal MI).ResultsDuring follow-up (median, 46 months), 147 patients (6.2%) died from cardiac causes and 81 (3.4%) experienced a non-fatal MI. Using multivariate analysis, after adjustment for clinical variables (including left ventricular ejection fraction and angiographic extent of coronary stenoses), a high-density lipoprotein cholesterol (HDLc) concentration<35mg/dL (p<0.0001), a neutrophil-to-lymphocyte ratio >2.4 (p=0.0014), and an fT3 serum level<2.1pg/mL with normal thyrotropin (low-T3 syndrome) (p=0.0260) showed an independent and incremental prognostic value, and were associated with an increase in the rate of cardiac events of 86%, 57% and 41%, respectively. When these variables were added to clinical and instrumental variables, the prognostic power of the model increased significantly (global chi-square improvement: from 157.01 to 185.07, p<0.0001).ConclusionLow HDLc, high neutrophil-to-lymphocyte ratio and low-T3 syndrome, both individually and taken together, provide prognostic information that is independent of and incremental to the main clinical and instrumental findings

Insulin resistance is a major determinant of myocardial blood flow impairment in anginal patients

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Different substrates of non-sustained ventricular tachycardia in post-infarction patients with and without left ventricular dilatation

Background: We investigated the relationship between nonsustained ventricular tachycardia (NSVT) and left ventricular (LV) dilatation, function, remodeling, and scar tissue extent in patients with previous myocardial infarction (MI). Methods and Results: Eighty-two patients (ages 64610 years) with first previous MI were referred for 24-hour electrocardiogram recording and cine and delayed enhancement (DE) cardiac magnetic resonance (CMR). LVvolumes, ejection fraction, systolic wall thickening, sphericity index, and core and peri-infarctual areas of scar tissue by CMR were evaluated. LV dilatation was observed in 39 patients. Episodes of NSVT were recorded in 32 patients: 23 with LV dilatation and 9 without. In the entire population, NSVTwas related to ejection fraction, LV volumes, LV mass, and sphericity index; end-systolic volume (P5.001) resulted in the only independent predictor at multivariate analysis. In patients without LV dilatation, the occurrence of NSVTwas only positively related with percentage of contracting segments with DE (P5.008). Conversely, in patients with LV dilatation, increase in LV mass (P5.020) and end-systolic volume (P5.038) were independent predictors of NSVT. Conclusions: Necrotic and viable myocardium coexistence within the same wall segments predicted occurrence of NSVT in patients without LV dilatation, whereas LV mass and end-systolic volume were predictors of NSVT in those with LV dilatation. (J Cardiac Fail 2010;16:61e68

Neutrophil-to-Lymphocyte Ratio Predicts Prognosis in Patients with Chronic Coronary Heart Disease

Purpose: A relationship between blood cell count and survival has been observed both in healthy individuals and in patients with stable angina, unstable angina, myocardial infarction or heart failure. We tested the hypothesis that a complete blood count with subfraction concentrations would provide prognostic information in patients with chronic coronary heart disease (CHD), and that this information is additive to a standard diagnostic work-up. Methods: We prospectively examined 2370 consecutive patients with chronic CHD, defined by a > 50% stenosis at coronary angiography and/or history of myocardial infarction (MI). We examined the association between complete blood count, clinical variables and future cardiac events (cardiac death and non-fatal MI). Results: During follow-up (median 46 months), 147 patients (6.2%) died of cardiac causes and 81 (3.4%) experienced a non-fatal MI. Using univariate analysis, reduced hematocrit (< 36% if male and < 40% if female) and a neutrophil-to-lymphocyte (N/L) ratio > 2.42, but not white blood cell count and platelet count, were significantly associated with a reduced cardiac event-free survival (P < 0.001 and P <0.0001, respectively). The impact of anemia and high N/L ratio on survival persisted after adjustment for age, diabetes mellitus, left ventricular ejection fraction and angiographic extent of coronary atherosclerosis. The negative prognostic impact of a high N/L ratio persisted even after adjustment for both clinical variables and other routine laboratory variables (risk ratio: 1.57, 95% confidence interval: 1.19 to 2.08, p = 0.0014). Conclusion: An elevated N/L ratio is a significant predictor of adverse prognosis in patients with chronic CHD