Minerva cardioangiologica
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Minerva cardioangiologica · Aug 2004
ReviewPerioperative assessment and management of patients with valvular heart disease undergoing noncardiac surgery.
Valvular heart disease in a variety of forms is not uncommon, especially among older patients undergoing noncardiac surgery, and can be associated with increased perioperative cardiac risk. Patients with aortic stenosis are at greatest risk, although other valve lesions also can pose the risk of increased perioperative morbidity. ⋯ Appropriate antibiotic prophylaxis reduces the risk of infective endocarditis. Finally, some patients with valvular heart disease and all patients with a mechanical valve prosthesis require long-term anticoagulation, which must be managed during the perioperative period.
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Minerva cardioangiologica · Oct 2003
Review Comparative StudyBalancing benefit against risk in the choice of therapy for coronary artery disease. Lesson from prospective, randomized, clinical trials of percutaneous coronary intervention and coronary artery bypass graft surgery.
The ageing world population faces a coming pandemic of high-risk coronary artery disease (CAD). Patients with CAD have 3 therapeutic options, which are based on objective clinical outcome: medical therapy and risk factor modification (Medicine), and 2 forms of revascularization, coronary artery bypass graft surgery (CABG), and percutaneous coronary intervention (PCI). More than 50 large (>100 patients), multicenter, prospective, randomized clinical trials (RCT) have compared these treatment options in terms of clinical benefits and patient risks. ⋯ Medically refractory is a useful high-risk marker of potential benefit from revascularization. CABG continues to be the complete revascularization option for patients with multivessel, multi-lesion CAD, in part because of its application to chronic occlusions. PCI is the acute stabilization method of choice for patients with on-going ischemia and acute MI, especially among patients with hemodynamic compromise, and/or major comorbidity.
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Minerva cardioangiologica · Oct 2003
Review Comparative StudyInterpretation of new treatment guidelines for non-ST-segment elevation acute coronary syndromes: "ischemia-guided" versus "early invasive" strategies.
The American College of Cardiology/American Heart Association Task Force on Practice Guidelines has recently published recommendations regarding the diagnosis and management of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS). Conventional therapy for non-ST-segment elevation acute coronary syndrome (NSTE ACS) has traditionally employed an "ischemia-guided" approach in which diagnostic cardiac catheterization and revascularization are only used in patients with objective-evidence of residual myocardial ischemia as identified by recurrent symptoms or provocative stress testing. More recent studies, however, have demonstrated improved clinical outcomes with the use of an "early invasive" approach, employing routine coronary angiography early in the patient's hospital course, followed by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery where appropriate. ⋯ For example, use of GP IIb/IIIa inhibitors and/or low-molecular-weight heparin prior to catheterization have been shown to reduce clinical events in NSTE ACS patients, and may reduce the risk of an invasive approach by plaque passivation prior to interventional therapy. Perhaps more importantly, the combined use of GP IIb/IIIa inhibitors and intracoronary stenting may reduce the potential early hazard of an invasive approach by specifically decreasing the incidence of death and non-fatal myocardial infarction associated with percutaneous intervention. In spite of the benefits of this synergistic combination of pharmacology and mechanical revascularization, risk stratification remains important in identifying high-risk individuals most likely to benefit from an "early invasive" approach.
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Minerva cardioangiologica · Apr 2003
ReviewEffects of ACE-inhibitors and beta-blockers on left ventricular remodeling in chronic heart failure.
In recent years, it has become increasingly recognised that a central feature of the disease progression associated with heart failure is the process of left ventricular remodeling. The remodeling process manifests as an increase in left ventricular volumes, leading to a rise in wall stress and a compensatory increase in myocardial mass. The left ventricle also gradually assumes a more spherical shape, resulting in functional mitral regurgitation leading to further haemodynamic overload, worsening myocardial function and an unfavourable clinical course. ⋯ Direct comparisons indicate that carvedilol has a similar safety and tolerability profile to ACE-inhibitors and thereby support the feasibility of administering this drug as first-line therapy in selected patients with mild to moderate chronic heart failure. Therefore, the decision to initiate treatment with carvedilol or an ACE-inhibitor might in future be tailored on an individual basis and followed thereafter by combination therapy at the earliest and safest opportunity. Finally, the possible development of treatment strategies addressing the cellular and molecular mechanisms responsible for the remodeling process and the recently published benefits of device therapies herald a combined, synergistic approach to the future management of heart failure.
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Minerva cardioangiologica · Dec 2002
[Spinal cord electric stimulation. Treatment of serious chronic ischemic syndromes of the limbs].
Aim of this study is to estimate the effectiveness of epidural electric stimulation of spinal cord for the treatment of patients with severe peripheral chronic arteriopathy who can't be surgically treated or when surgical therapy failed. ⋯ Epidural electric stimulation of spinal cord is a valid treatment in selected patients for ischemia pain control and limb savage.