Giornale italiano di cardiologia
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Despite improvements in coronary care, cardiogenic shock (CS) remains the leading cause of death in patients with dramatic cardiac diseases of which acute myocardial infarction (AMI) is the most frequent event. Conventional therapy for CS with coronary care unit (CCU) monitoring and vasopressor agents to support blood pressure has historically been associated with an 80% to 90% mortality rate in large series. Intra-aortic balloon pump (IABP) therapy for shock results in initial favourable clinical and haemodynamic responses, but ultimately, in most patients, death is merely delayed and hospital mortality still exceeds 80%. In several recent non-randomised series, coronary revascularisation performed early in the course of CS with the use of coronary artery by-pass grafting (CABG) or coronary angioplasty (PTCA) resulted in an apparent reduction in the hospital mortality rate to less than 50% in selected patients with shock. ⋯ IABP is an useful device for stabilising patients in cardiogenic shock and safely performing angiography as well as PTCA, CABG or surgical correction of all mechanical complications with a more stable haemodynamic balance. Therefore, IABP is an useful tool to improve successful coronary revascularisation after direct PTCA or direct CABG. These data also suggest that the combination of successful coronary revascularisation and intra-aortic balloon pumping can improve survival in pts with cardiogenic shock complicating AMI with early pump failure.
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Echocardiography is the cardiological diagnostic test the use of which has increased most in recent years. However, despite the popularity and the massive use of the technique, there is little information regarding the usefulness and management impact of echocardiography as routinely ordered in current medical practice. Furthermore, clinical indications and expectations of physicians who ordered an echocardiogram (echo) have never been systematically evaluated in our country. ⋯ GPs ordered echoes mainly for screening or to evaluate suspected cardiac abnormalities for the purpose of reassuring their patients or documenting the presence or absence of a cardiac disease. C ordered echoes to evaluate clinically suspected cardiac abnormalities or to reassess known cardiac diseases with the purpose of modifying patients' therapy or clinical management. One echo out of 3 gave clinically unsuspected results. In 1 echo out of 2 clinical assessment of the severity of the most common morpho-functional cardiac abnormalities was cha
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Multicenter Study Comparative Study
[Comparison of outcome of primary PTCA for acute myocardial infarction in patients younger and older than 70 years of age].
The Primary Angioplasty in Myocardial infarction Study Group reported that the benefit of primary PTCA was observed mainly among patients who were classified as "not low risk" including those over age 70, with anterior infarction and heart rate > 100 bpm. The present study compares procedural success rate and in-hospital and one-month clinical outcome of primary PTCA in acute myocardial infarction patients < 70 and > or = 70 years of age. ⋯ In patients with acute myocardial infarction < 70 years of age primary coronary angioplasty is associated with low rates of mortality and cardiac events. Mortality rate remains high in patients over age 70, especially when shock is present on admission or PTCA falls.
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Comparative Study
[Acute changes in the hemodynamic profile and circulating levels of atrial natriuretic peptide induced by dobutamine in severe heart failure].
Sixteen patients (15 males, 1 female; mean age 63 years, range 45-78) with severe heart failure (NYHA class III = 5; class IV = 11) secondary to ischemic heart disease (8), dilated cardiomyopathy (5) and valvular heart disease (3), were evaluated for eligibility to intermittent Dobutamine (D) treatment. As a part of this evaluation, they were submitted to an acute dose-ranging test with D, up to 10 micrograms/Kg/min under hemodynamic and electrocardiographic monitoring. By inclusion criteria, all patients had:-cardiac index (CI) < 2.2 L/min/m2;-pulmonary wedge pressure (WP) > 18 mmHg;-left ventricular ejection fraction (EF) < 30%. At each step of the procedure, hemodynamic measurements and blood sampling for atrial natriuretic peptide (ANP) concentration were performed. ⋯ Patients with severe heart failure retain the ability to respond to acute administration of D. with a significant improvement in their hemodynamic profile. Response to D. administration is predicted by lower baseline pulmonary pressure and ANP levels and a lesser degree of left ventricular dysfunction. Despite high baseline ANP concentration, a significant decrease is obtained which parallels the decrease in pulmonary artery and pulmonary wedge pressure, but is not related to changes in right atrial pressure. These findings suggest that changes in left ventricular performance induced by D. are the major determinants of the decrease in ANP concentration in this clinical setting.
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Feasibility, safety and efficacy of prehospital management of acute myocardial infarction (AMI) and prehospital thrombolysis have been widely demonstrated. On this background, in March 1992 we started up an Emergency Medical Service (EMS)--Servizio per le Emergenze Cardiologiche Territoriali, SECT--aimed to prehospital care of overall cardiac emergencies (CE), including AMI. The Service, operating in the metropolitan area of Turin (130 Km2, 964,000 inhabitants), is based on a properly equipped ambulance, manned with a physician and a nurse, skilled in treatment of CE. ⋯ Our experience confirm efficacy of out-of-hospital management of AMI within an EMS designed to treat overall CE, considering successful treatment of complications and early thrombolysis with reduction of time delay. Inclusion of SECT in the growing up "118" Emergency Medical System raises logistic questions. Process will be completed when the "medical final authority" will submit each intervention to a full evaluation in terms of efficiency and efficacy, and will not only prepare, as now happens, dispatch and intervention protocols.