Giornale italiano di cardiologia : organo ufficiale della Federazione italiana di cardiologia : organo ufficiale della Società italiana di chirurgia cardiaca
-
G Ital Cardiol (Rome) · Jan 2010
Review[Role of invasive and non-invasive ventilation in the treatment of acute respiratory failure].
Mechanical ventilation is the most common invasive treatment for acute respiratory failure in intensive care units. According to non-intensivist clinicians, ventilation could be considered as a therapy for blood gas exchange, even though positive pressure ventilation can be extremely dangerous for injured lung tissue. Despite constant advances in ventilation software and modalities, aimed at optimizing patient/ventilator adjustment, the scientific community has addressed major attention in new protective strategies to ventilate the lung, trying to prevent and reduce life-threatening iatrogenic injuries that may derive from inappropriate use of mechanical ventilation. ⋯ Non-invasive ventilation, including both continuous positive airway pressure and pressure support ventilation, is considered the gold standard for chronic obstructive pulmonary disease exacerbations. There is an increasing interest in the clinical use of non-invasive ventilation outside intensive care units. Although many studies have analyzed risks and benefits of non-invasive ventilation in the intensive care setting, feasibility and organization processes to perform this technique in the non-intensive wards, by preserving efficacy and safety, need to be debated.
-
G Ital Cardiol (Rome) · Jan 2010
[Clinical competence in intensive cardiac care units: from practical needs to training programs].
Since the early 1970s, intensive cardiac care is applied in coronary care units (CCUs), initially developed to treat lethal arrhythmias in patients with acute myocardial infarction. In the last decades, treatments offered within the CCUs have greatly expanded. Thus, these units have been called intensive cardiac care units (ICCUs) to reflect such evolution of care and the different epidemiology of patients admitted (subjects with acute coronary syndromes, acute and advanced heart failure, rhythm disturbances or severe valve dysfunction). ⋯ Consequently, specific training programs on intensive cardiac care for cardiologists working in ICCUs are clearly warranted. The present paper describes the advanced training programs on intensive cardiac care endorsed by the European Society of Cardiology and the Italian Association of Hospital Cardiologists (ANMCO). Both projects aim at improving current knowledge and skills of intensive cardiologists on specific pharmacologic and technical procedures, extending the competence of trained cardiologists to the management of critically ill cardiac patients, and uniforming the quality of care in any ICCU.
-
The correct diagnosis of wide QRS complex tachycardia is an old problem, but it is still a new problem since no simple approach aimed at solving it is up to now available, despite the amount of research devoted to this topic. A wide QRS tachycardia can be: 1) ventricular tachycardia; 2) supraventricular tachycardia with bundle branch block that may be either preexisting or due to aberrant conduction, namely tachycardia-dependent; a further possibility is the effect of antiarrhythmic drugs, which slow down intraventricular conduction, resulting in marked QRS complex widening; 3) supraventricular tachycardia with conduction of impulses to the ventricles over an accessory pathway (preexcited tachycardia). The origin of a wide QRS complex tachycardia can be reliably identified using a "holistic" approach, namely taking into account all of the available items: no single criterion, thus, is able to provide a simple and quick solution to the problem in all cases. ⋯ A hard diagnostic problem is associated with preexcited tachycardia, the condition resulting whenever supraventricular tachycardia impulses are conducted to the ventricles over an accessory pathway. This situation is far more rare than ectopy and aberration, and can be ruled out in the presence of negative precordial concordance (QS complexes in all the chest leads) or deep q waves in a precordial lead other than V1. A QRS morphology not consistent with any of the typical patterns observed in the various locations of the accessory pathways rules out a preexcited tachycardia, too.
-
G Ital Cardiol (Rome) · Jul 2009
Review[Inotrope therapy in acute heart failure: a critical review of clinical and scientific evidence for levosimendan in the context of traditional treatment].
The clinical heterogeneity of acute heart failure and the low number of controlled trials, to date, are the main causes of the lack of agreement on therapeutic objectives, uncertainty on the most appropriate management, and difficulties to obtain robust evidence for the treatment of this syndrome. The inappropriate use of inotropic agents is one the most common pitfalls shown by registries. Two to 10% of patients admitted for acute heart failure present with a low output syndrome, a clinical profile associated with high mortality, where inotropes may be a rational therapeutic choice. ⋯ These effects may translate in myocardial ischemia, loss of cardiomyocytes and accelerated ventricular remodeling with worse prognosis. Levosimendan, a novel inotropic agent studied according to the principles of evidence-based medicine, augments myocardial contractility without changes in intracellular calcium concentrations, and with minimal impact on myocardial oxygen consumption. This paper, based on an expert consensus, aims to suggest criteria for the appropriate use of inotropic agents in acute heart failure, based on a critical appraisal of the existing evidence and clinical experience.