Giornale italiano di cardiologia
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In our centre, during the last five years, emergency operations (within 6 hours) and urgent operations (within 72 hours) have represented 1/4 of all coronary surgery. 295 patients (pts) have been operated on since 1972: of these, 279 with simple revascularization, 5 with combined major surgery, and 11 as a consequence of mechanical complications of acute myocardial infarction. These last were all in cardiogenic shock: the overall 30-day mortality rate was 5.4% (3.6% in those pts with simple revascularization, 20% in those with combined major surgery, and 45.4% in pts with cardiogenic shock). In the subgroup with simple revascularization, the incidence of non fatal perioperative acute myocardial infarction (AMI) was 4.7% in 253 pts with unstable angina, 52.2% in 23 pts with abrupt closure during coronary angioplasty, and obviously 100% in 3 pts surgically treated during evolving AMI. ⋯ In pts with simple revascularization, 30-day mortality and incidence of myocardial infarction are similar to those of elective surgery. In pts with abrupt closure as a consequence of coronary angioplasty the mortality rate seems very low, while the incidence of infarction remains extremely high. These observations have allowed the development of an integrated protocol of intervention in acute unstable coronary syndromes.
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In order to assess the current behavioural status of patients receiving emergency cardiological treatment and the emergency services in the Piedmont Region, our Division carried out a survey of the Region's DEA and first aid centres based on the compilation of a questionnaire for each patient who passed through these structures over a 5-month period. The study included only patients hospitalised within 12 hours of symptoms' onset. The questionnaire aimed to assess the time the patient took to reach a decision, the eventual call for a home visit, the type of doctor called, the time spent by the doctor, the use of either a private vehicle or of an ambulance for transport to hospital, the time taken to get to the hospital, and the overall time taken to admit the patient to the emergency cardiological ward. The statistical analysis of data was carried out using both single and multiple variables. The selection of prognostic variables was carried out using a stepwise method. ⋯ The critical factors causing delay in hospitalisation time are the poor levels of health education of the population in general, and the poor activation capacity of certain peripheral parts of the National Health Service. In particular, it is worth drawing attention to the delay due to the intervention of the family doctor in the current organisational model. Doctors called from first aid stations are able to provide a more rapid intervention, but are currently unable to meet the requirements of patients needing emergency cardiological treatments. These data confirm the rationale for intervention projects in cardiological emergencies, considering on one hand that a fleet of special vehicles be created, and on the other that doctors from first aid stations be specifically trained and increasingly involved.
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To determine the potential role of emergency surgical revascularization as treatment of acute myocardial infarction (AMI), results in 79 patients undergoing operation for myocardial revascularization during AMI from January 1986 to January 1991 were reviewed. Clinical characteristics for inclusion in the study were: 1) emergency operation; 2) persistent angina not controlled by medical therapy; 3) fixed ST segment elevation until surgical procedure, independently from magnitude of enzymatic levels. The 79 patients were divided in 2 groups: 27 with AMI or evolving AMI (Group 1); 52 with AMI due to complications during PTCA (Group 2). ⋯ The incidence of perioperative myocardial infarction was 30.4% (CL 24.9-35.1) for that one in the area of ischemic muscle and 2.6% (CL 0.8-4.1) for infarction in remote muscle. Multivariate analysis for the entire series (79 patients) identified as independent predictors of increased in-hospital mortality: preoperative cardiogenic shock (p = 1.000E-4) and hyperlipidemia (p = 0.008). In Group 1 multivariate analysis identified as independent predictors of increased in-hospital mortality: the attempt of revascularization by PTCA and hyperlipidemia; in Group 2: preoperative need of mechanical ventilatory support.(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparative Study
[Changes in modalities of left ventricular filling associated with aging in normal subjects: secondary to increase in blood pressure and left ventricular mass?].
The mechanisms by which aging alters the pattern of left ventricular diastolic filling are still uncertain. To gain more insight into this tissue, the independent contributions of age, sex, heart rate, arterial blood pressure and left ventricular mass (as well as various indexes of left ventricular morphology and function) to left ventricular diastolic filling abnormalities, were investigated by echocardiography in 81 normal subjects (18 to 84 years of age, mean 50), carefully screened to avoid the confounding effects of coronary artery disease and systemic hypertension. With advancing adult age, we found a significant increase in: body mass index (r = 0.25; p less than 0.02), systolic (r = 0.58; p less than 0.0001), pulse (r = 0.61; p less than 0.0001) and mean (r = 0.40; p less than 0.0001) arterial blood pressure; left ventricular wall thickness (r = 0.30; p less than 0.006); left ventricular mass (r = 0.32; p less than 0.004); left ventricular end-diastolic volume (r = 0.24; p less than 0.03); and peak systolic wall stress (r = 0.22; p less than 0.04). ⋯ Conversely, duration of isovolumic relaxation (r = 0.77; p less than 0.0001), peak late diastolic flow velocity (r = 0.39; p less than 0.001), and diastolic pressure half time (r = 0.34; p less than 0.01) increased significantly with age. "Stepwise" multivariate linear regression analyses showed that the ratio of early to late diastolic peak filling velocity was independently related only with age (R2 = 0.56; p less than 0.0001) while the isovolumic relaxation time was independently related with age (R2 = 0.48; p less than 0.0001) and duration of cardiac cycle (R2 = 0.06; p less than 0.008). Age-related changes in body mass index, blood pressure, peak meridional wall stress and left ventricular mass index did not show any independent relationship to Doppler parameters of left ventricular filling or duration of isovolumic relaxation. The results of the present study suggest that the effect of age on left ventricular filling modalities and duration of isovolumic relaxation are independent of age-related changes in blood pressure, left ventricular mass, morphology and systolic function.
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Comparative Study
[Transient hyperglycemia in acute myocardial infarct: the short- and long-term risk factor for mortality].
To evaluate the prevalence and prognostic significance of hyperglycemia in acute myocardial infarction, we studied 700 patients (mean age 63.3 +/- 10.97) subsequently admitted to the UCIC of Tradate Hospital during the period January 1976 to December 1987. Patients were followed up for a median period of four years. On the basis of fasting blood glycaemia values in the first five days of hospitalization, excluding the admission day, patients were divided into groups: 401 patients (57.0%) with constantly normal glycaemia; 84 patients (12.0%) with glycaemia equal or superior to 120 mg/100 ml, and with subsequent normalization; and 215 patients (31.0%) with diabetes mellitus diagnosed before hospitalization and/or with persistent hyperglycaemia. ⋯ Multivariate analysis shows that independent predictive variables are: for mortality in the first month, Killip class only; and after the first month, Killip class, metabolic classification, sex and supraventricular arrhythmias. The present study shows that transient hyperglycaemia has a low prevalence in the first days of acute myocardial infarction. Transient hyperglycaemia could be attributed not only to increased sympathetic tone elicited by acute myocardial infarction, but is probably a pathologic condition with an adverse outcome to which multiple factors contribute.