Use of nitroglycerin in the active phase of tilt testing: is there a difference in elderly patients?

Introduction: The importance of tilt testing has been demonstrated in the evaluation of patients with syncope of unknown cause, and it is the gold standard technique for the diagnosis of neurocardiogenic syncope, particularly with the use of pharmacological provocative agents to improve diagnostic accuracy. Stimulation with sublingual nitroglycerin is generally well tolerated and increases test sensitivity, shortening the test duration; this also allows the test to be applied in elderly patients.

Objectives: To evaluate, in a population referred for syncope of unknown etiology, the value of tilt testing with sublingual nitroglycerin and to compare the responses obtained in elderly and younger patients.

Temporal variations in microvolt T-wave alternans testing after acute myocardial infarction.

Background: Microvolt T-wave alternans (TWA) have been accepted as a tool for assessing vulnerability to ventricular tachyarrhythmias. There is lack of data concerning prospective temporal variations in TWA measurements after acute myocardial infarction (AMI). We analysed the temporal patterns of TWA in post-AMI patients.

Drug-eluting stents in primary angioplasty long-term clinical outcomes.

Introduction: The use of drug-eluting stents in the context of mechanical reperfusion following ST-segment elevation myocardial infarction (MI) was initially viewed with concern. The main fear was that the drugs' action in unstable lesions could increase the risk of thrombotic stent occlusion. Furthermore, there was no evidence that the proven benefit of reduced instent restenosis could be extended to such patients, since they were excluded from the initial clinical trials.

Is chronic nitrate therapy associated with a different clinical presentation of acute coronary syndrome?

Background: Nitrate therapy can induce ischemic preconditioning with a consequent increase in tolerance to ischemia. In the context of acute coronary syndromes (ACS), nitrates may result in a different presentation. with greater protection.

Impact of combination medical therapy on mortality in patients with acute coronary syndromes.

Introduction: Conventional risk stratification after acute myocardial infarction is usually based on the extent of myocardial damage and its clinical consequences. However, nowadays, more aggressive therapeutic strategies are used, both pharmacological and invasive, with the aim of changing the course of the disease.

Objectives: To evaluate whether the number of drugs administered can influence survival of these patients, based on recent clinical trials that demonstrated the benefit of each drug for survival after acute coronary events.

Assessment of T-wave alternans after acute myocardial infarction: influence of the timing of PTCA on cardiac electrical stabilization.

Unlabelled: It is accepted that the timing of myocardial revascularization in patients undergoing PTCA for the treatment of acute myocardial infarction (AMI) may improve the clinical outcome. However, its impact on microvolt T-wave alternans (TWA), a recognized tool for assessing vulnerability to ventricular tachyarrhythmias that can cause sudden cardiac death in infarction survivors, remains unknown.

Aim: To analyze TWA in patients with AMI treated by PTCA and assess whether the timing of myocardial revascularization can influence TWA measurements.

Rupture of a congenital aneurysm of the non-coronary sinus of Valsalva into the right atrium.

We present the case of a patient evaluated for a continuous murmur, in which a ruptured congenital sinus of Valsalva aneurysm with fistulization to the right atrium was demonstrated by echocardiography. The authors review the relevant clinical features of this entity.

Usefulness of low-dose dobutamine echocardiography in idiopathic dilated cardiomyopathy.

Introduction: Low-dose dobutamine stress echocardiography is a common and useful technique to assess myocardial viability in patients with ischemic cardiomyopathy.

Objective: To evaluate the use of low-dose dobutamine stress echocardiography in determining the functional status of patients with idiopathic dilated cardiomyopathy (IDCM).

Methods: Prospective study of 28 patients with IDCM by transthoracic echocardiography (2D), low-dose dobutamine stress echocardiography, cardiopulmonary exercise testing (CPET) and measurement of pro-BNP.

Isolated cleft of the anterior mitral valve leaflet.

Isolated anterior mitral leaflet cleft (not associated with atrio-ventricular septal defect) is a rare cause of congenital mitral regurgitation, and the treatment consists of direct suturing of the cleft. We present a clinical case with this entity.

Infective endocarditis complicated by large aortic pseudoaneurysm after cardiac surgery.

A 66-year-old female with Streptococcus viridans aortic and tricuspid infective endocarditis develops, during the course of antibiotic therapy, rupture of a right coronary sinus of Valsalva aneurysm to the right ventricle. An urgent cardiac surgery is preformed with implantation of a mechanical aortic prosthesis and a right coronary sinus plasty. Six months later a huge aortic pseudoaneurysm is diagnosed and she is submitted to a second uneventful surgery.

The prognostic impact of renal failure in patients with ST-segment elevation acute myocardial infarction.

Introduction: Renal insufficiency (RI) is associated with higher morbidity and mortality in patients (P) with coronary artery disease and in P submitted to angioplasty. In ST-segment elevation acute myocardial infarction (STEAMI), this impact has not been well demonstrated.

Aim: To evaluate the impact of RI in P with STEAMI.

Cardiac extension of renal cell carcinoma.

We present the case of a sixty-two-year-old man evaluated for a dyspnea episode. Echocardiographic study revealed a tumor in the right atrium that was related to a right kidney neoplasm. Complete resection was possible with a combined thoracic and abdominal approach.

Multivalve endocarditis with multiple peripheral and pulmonary embolisms: a case report.

Fever of unknown origin in elderly patients is a difficult diagnostic problem. Infective endocarditis is often not diagnosed in this group of patients, in whom other etiologies like cancer are considered first. The authors report a case in which an elderly woman with subacute mitral and tricuspid infective endocarditis was correctly diagnosed only after a peripheral embolism.

Thromboembolic and/or bleeding complications in patients under oral anticoagulation followed at a tertiary hospital.

Unlabelled: A better understanding of the characteristics of patients that come to the anticoagulation (AC) clinic of a tertiary hospital could lead to better healthcare provision and reduce the number of thromboembolic and bleeding complications.

Objectives: To evaluate the characteristics of patients followed at our AC clinic and to determine which factors could predict an increased risk of complications.

Methods: Data obtained by doctors through a questionnaire from patients attending the AC clinic of our hospital were analyzed.

Tilt test in elderly patients with syncope of unknown etiology: experience with pharmacological stimulation with nitroglycerin.

Unlabelled: The importance of head-up tilt testing has been demonstrated in the evaluation of patients with unexplained syncope. In elderly patients, the prevalence of syncope increases, is associated with a worse outcome and frequently requires several complementary tests.

Objectives: To evaluate the utility of head-up tilt testing with sublingual nitroglycerin as a provocative agent, in elderly patients with unexplained syncope.

[Large pseudoaneurysm of left ventricle following cardiac surgery].

A 75-year old female patient, with previous inferior acute myocardial infarction (AMI) in December 2000, was admitted in April 2001 with angina and heart failure. Transthoracic echocardiography (TTE) was suggestive of a postero-inferior pseudoaneurysm (PA) of the left ventricle (LV), with 61x49 mm. of size and mitral regurgitation.

Non-invasive coronary artery evaluation with multidetector computed tomography.

Objectives: To evaluate the diagnostic accuracy of 16-slice multidetector spiral computed tomography in the non-invasive detection of coronary artery disease compared to invasive coronary angiography.

Design: Prospective study.

Patients: We studied 35 patients, 21 men and 14 women, mean age 63.

Long-term clinical outcome in patients with severe left ventricular dysfunction and an implantable cardioverter-defibrillator after ventricular tachyarrhythmias.

Unlabelled: Left ventricular ejection fraction (LVEF) is accepted as an important prognostic marker in patients (pts) with implantable cardioverter-defibrillators (ICD). The impact of this therapeutic approach in the survival of pts with life-threatening arrhythmias and severe left ventricular dysfunction remains a matter of discussion.

Objective: To evaluate the long-term clinical implications of severe left ventricular dysfunction in pts with an ICD implanted for secondary prevention of sudden cardiac death (SD).

Eisenmenger syndrome in the adult--experience with new drugs for the treatment of pulmonary hypertension.

Background: The last few years have seen significant progress in the treatment of advanced pulmonary arterial hypertension (PAH). The efficacy of new drugs has been proved mainly in idiopathic PAH or PAH associated with connective tissue diseases. As the pathophysiologic patterns are similar, it is reasonable to use these drugs also in Eisenmenger syndrome or in other congenital heart defects with PAH related to initial high pulmonary flow.

Selective pulmonary vasodilators for severe pulmonary hypertension: comparison between endpoints.

Unlabelled: The therapeutic approach to severe pulmonary arterial hypertension (PAH), whether primary or secondary to connective tissue disorders, thromboembolic phenomena or congenital heart disease with Eisenmenger syndrome, has evolved in recent years following the introduction of selective pulmonary vasodilators, including prostacyclin analogs and endothelin receptor antagonists.

Aim: To correlate three different endpoints (6-minute walk test, Tei index and peak tricuspid regurgitation velocity by Doppler echocardiographic study) during follow-up of PAH patients under selective vasodilator therapy.

Methods: Eleven patients (9 female, age 42 +/- 18 years) with severe PAH (> or = 65 mmHg), 64% with Eisenmenger syndrome, in NYHA class > or = II, were assessed during a follow-up of 11 +/- 8 months.

Primary coronary angioplasty in the elderly.

Background: Primary coronary angioplasty is the best therapeutic approach in acute myocardial infarction (AMI), and more so in the population aged over 75 years, in whom the hemorrhagic risk of thrombolysis becomes almost unacceptable.

Aim: To evaluate age-related influences on clinical evolution and in-hospital mortality in patients with AMI who undergo primary percutaneous coronary interventions (PCI).

Methods: We studied 245 consecutive patients (aged between 31 and 90, 63+/-13), who underwent primary PCI between January 2000 and December 2001.

Differences in outcome in primary angioplasty in women.

Background: In acute myocardial infarction (AMI), primary percutaneous transluminal coronary angioplasty (PTCA) has proved to be the best therapeutic approach. Several factors have been associated with worse outcome in AMI in females. Are there differences in outcome in women undergoing PTCA for AMI?

Aim: To evaluate gender influence on clinical outcome and in-hospital mortality in patients with AMI who undergo primary percutaneous interventions.

A systematic invasive strategy in non-ST elevation acute coronary syndromes: is age a limiting factor?

Introduction: A systematic invasive therapeutic strategy for acute coronary syndromes (ACS) is currently accepted as safe and effective and evidence is growing for its superiority compared to a conservative attitude. Elderly patients, given their greater susceptibility, are frequently excluded from this approach, and this may limit the potential benefits.

Objective: To evaluate the influence of age on the characteristics and clinical evolution of patients with ACS treated by an invasive strategy and to determine whether this in itself limits its adoption.

Prognostic value of neutrophil response in the era of acute myocardial infarction mechanical reperfusion.

Background: In ST-segment elevation myocardial infarction (STEMI) patients treated with primary angioplasty, neutrophil response and its prognostic significance are not entirely understood.

Methods: We retrospectively studied 305 consecutive and non-selected STEMI patients. They were divided into three groups according to the maximum neutrophil percentage in the first 48 hours.