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Biomedical subjects

M Roffi

Publications and source records attributed to M Roffi.

At least 19 recordsLinked to original sources
PubMed2005

Thyrotoxicosis and the cardiovascular system.

Thyrotoxicosis is associated with increased cardiovascular morbidity and mortality, primarily due to heart failure and thromboembolism. Palpitations, caused by sinus tachycardia and occasionally by atrial fibrillation, are the most frequent cardiovascular symptom. As atrial fibrillation may be the only manifestation of thyrotoxicosis, thyroid hormone excess should routinely be excluded in patients with this rhythm disturbance. Heart failure occurs mostly in the presence of underlying heart disease or tachycardia-induced cardiomyopathy in patients with long-standing atrial fibrillation. On occasion, long-standing hyperthyroidism may lead to heart failure even in the absence of concomitant cardiac conditions. Beta-blockers offer symptomatic relief and at the same time slow the ventricular response in patients with atrial fibrillation. Amiodarone, and occasionally iodinated contrast agents, may cause iodine-induced thyrotoxicosis. Clinical suspicion is essential in the diagnosis of amiodarone-induced thyrotoxicosis (AIT), because the antiadrenergic effect of the drug may conceal symptoms. AIT should be considered in any patient on amiodarone in the presence of new-onset or recurrent atrial arrhythmias or unexplained weight loss. Beyond discontinuation of amiodarone, treatment options include propylthiouracil or methimazole, potassium perchlorate, steroids, lithium and, if pharmacological treatment fails, surgery. Amiodarone may potentially be used less frequently in the future since recent studies have shown that this drug is inferior to implantable cardioverter defibrillators in prevention of sudden cardiac death in patients with severe heart failure. In addition, non-iodinated amiodarone analogues are currently in advanced phase of clinical testing.

Adrenergic beta-Antagonists↗
PubMed2004

[Cardiac indications for oral anticoagulation].

While considering long-term oral anticoagulation one should assess benefit (i.e., reduction in thromboembolic events) and risks (i.e., bleeding complications) associated with therapy for each individual patient. The classic cardiac indications for oral anticoagulation include chronic atrial fibrillation, prosthetic heart valves, and left ventricular thrombus formation following anterior myocardial infarction. The value of anticoagulation in patients with impaired left ventricular function in stable sinus rhythm and in secondary prevention of coronary artery disease remains controversial. For decades warfarin has been the only compound available. Currently, promising results have been achieved with the oral thrombin inhibitor ximelagatran. In the future, oral anticoagulants, which are administered in fixed dose with no need for monitoring of the anticoagulation level, may replace warfarin. Safety and efficacy of double antiplatelet therapy (aspirin and clopidogrel) in the secondary prevention of thromboembolic events in patients with atrial fibrillation are currently being addressed in large-scale clinical trials.

Administration, Oral↗
PubMed2004

Time-effectiveness, observer-dependence, and accuracy of measurements of left ventricular ejection fraction using 4-channel MDCT.

PURPOSE: To evaluate the time-effectiveness, inter-observer variance, and accuracy of left ventricular ejection fraction (EF) measurements using retrospectively ECG-gated four-channel multi-detector row CT (MDCT) angiography in comparison with biplane cine-ventriculography. MATERIALS AND METHODS: Twenty consecutive patients underwent retrospectively ECG-gated MDCT angiography and conventional coronary angiography with biplane ventriculography. Raw MDCT data were reconstructed at 0 % - 90 % of the cardiac cycle in increments of 10 %. Ten geometrically identical multiplanar reformations parallel to the short axis of the heart were reconstructed in each patient. Three blinded readers segmented the left ventricle in the end-systolic and end-diastolic phase using standardized window settings in order to determine the EF. The EF was measured with biplane cine-ventriculography by two blinded readers and was compared with MDCT. The time needed for post-processing was recorded and the inter-observer agreement for both imaging techniques was assessed. RESULTS: Mean post-processing time was 63 +/- 3 min per patient for MDCT and 5.5 +/- 1.2 min for ventriculography. MDCT and ventriculography showed a good correlation (r = 0.83, p < 0.0001) for measurement of the EF. Mean errors of EF measurements for the three MDCT readers compared with the mean of the ventriculography were - 6.3 +/- 6.6 %, - 4.7 +/- 7.1 % and - 4.6 +/- 5.7 %, respectively. The mean differences between the three readers assessing MDCT were - 1.6 +/- 3.2 % (reader 1 versus 2, r = 0.96), - 1.6 +/- 5.6 % (1 versus 3, r = 0.95) and - 0.011 +/- 2.9 % (2 versus 3, r = 0.97, p < 0.0001). The mean differences between the two readers assessing ventriculography was 0.32 +/- 5.1 % (r = 0.88, p < 0.0001). CONCLUSIONS: MDCT correlates well with biplane cine-ventriculography but has the tendency to underestimate the left ventricular EF. Measurements using MDCT have a high inter-observer agreement, however, the time needed for additional MDCT data post-processing is still unacceptably long.

Aged↗
PubMed2002

Association of plasma homocysteine with restenosis after percutaneous coronary angioplasty.

AIMS: Restenosis after percutaneous coronary angioplasty remains an important limitation of this procedure. This study evaluates whether elevated total plasma homocysteine levels contribute to the development of restenosis after coronary angioplasty. METHODS AND RESULTS: Two hundred and five patients were recruited after successful angioplasty of at least one coronary stenosis (> or =50%). End-points were restenosis (> or =50%) and a composite of major adverse cardiac events. Of the 205 patients, 183 (89.3%) underwent 6 months angiographic follow-up. Patients with restenosis had significantly higher homocysteine levels than those without (10.9+/- 3.9 micromol x l(-1) vs 9.3+/-3.8 micromol x l(-1), P<0.01). Homocysteine levels were significantly correlated to follow-up diameter stenosis (r=0.24, P=0.0001), especially in small vessels (<3 mm) treated with balloon angioplasty only (r=0.40, P<0.0005). Late lumen loss at follow-up was significantly smaller with homocysteine levels below 9 micromol x l(-1) (0.62+/-0.82 mm vs 0.90+/-0.77 mm, P<0.01). Restenosis rate (25.3% vs 50.0%, P<0.001) and major adverse cardiac events (15.7% vs 28.4%, P<0.05) were also significantly lower in patients with homocysteine levels below 9 micromol x l(-1). Multivariate analysis did not weaken these findings. CONCLUSION: Total plasma homocysteine is a strong predictor of restenosis and major adverse cardiac events after coronary angioplasty. Thus, plasma homocysteine appears to be an important cardiovascular risk factor influencing outcome after successful coronary angioplasty.

Aged↗
PubMed2002

Platelet glycoprotein IIb/IIIa inhibition in acute coronary syndromes. Gradient of benefit related to the revascularization strategy.

AIMS: To assess the efficacy of platelet glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndromes primarily medically managed. METHODS AND RESULTS: We performed a meta-analysis of the randomized clinical trials of platelet glycoprotein IIb/IIIa inhibitor therapy in the medical management of non-ST-elevation acute coronary syndromes. Among 29570 patients, IIb/IIIa integrin blockade was associated with a reduction in death or non-fatal myocardial infarction at 30 days, from 11.5% to 10.7% (odds ratio 0.91,P =0.02). Patients undergoing percutaneous coronary intervention during index hospitalization sustained a greater reduction in ischaemic events (odds ratio 0.82, P=0.01) than patients medically managed (odds ratio 0.95, P=0.27). Among patients undergoing intervention, the benefit was more pronounced if the procedure was performed during glycoprotein IIb/IIIa inhibitor infusion (odds ratio 0.74; P=0.02), than if revascularization was performed after drug discontinuation (odds ratio 0.87,P =0.17). CONCLUSION: This analysis, including the entire large-scale trial experience of intravenous glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndromes primarily medically managed, demonstrates an overall significant, albeit moderate, reduction in 30-day death or myocardial infarction associated with therapy. Although not based on a prospectively defined hypothesis, the findings suggest a gradient of benefit conferred by these agents depending on the revascularization strategy used.

Acute Disease↗
PubMed2001

Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes.

BACKGROUND: Diabetes mellitus is a major risk factor for adverse outcomes after acute coronary syndromes (ACS). Because this disease may be associated with increased platelet aggregation, we investigated whether diabetic patients with ACS derive particular benefit from platelet glycoprotein (GP) IIb/IIIa receptor inhibition. METHODS AND RESULTS: We performed a meta-analysis of the diabetic populations enrolled in the 6 large-scale platelet GP IIb/IIIa inhibitor ACS trials: PRISM, PRISM-PLUS, PARAGON A, PARAGON B, PURSUIT, and GUSTO IV. Among 6458 diabetic patients, platelet GP IIb/IIIa inhibition was associated with a significant mortality reduction at 30 days, from 6.2% to 4.6% (OR 0.74; 95% CI 0.59 to 0.92; P=0.007). Conversely, 23 072 nondiabetic patients had no survival benefit (3.0% versus 3.0%). The interaction between platelet GP IIb/IIIa inhibition and diabetic status was statistically significant (P=0.036). Among 1279 diabetic patients undergoing percutaneous coronary intervention (PCI) during index hospitalization, the use of these agents was associated with a mortality reduction at 30 days from 4.0% to 1.2% (OR 0.30; 95% CI 0.14 to 0.69; P=0.002). CONCLUSIONS: This meta-analysis, including the entire large-scale trial experience of intravenous platelet GP IIb/IIIa inhibitors for the medical management of non-ST-segment-elevation ACS, shows that these agents may significantly reduce mortality at 30 days in diabetic patients. Although not based on a randomized assessment, the survival benefit appears to be of greater magnitude in patients undergoing PCI. Therefore, the use of platelet GP IIb/IIIa inhibitors should be strongly considered in diabetic patients with ACS.

Diabetes Complications↗
PubMed2001

Decreased rate of coronary restenosis after lowering of plasma homocysteine levels.

BACKGROUND: We have previously demonstrated an association between elevated total plasma homocysteine levels and restenosis after percutaneous coronary angioplasty. We designed this study to evaluate the effect of lowering plasma homocysteine levels on restenosis after coronary angioplasty. METHODS: A combination of folic acid (1 mg), vitamin B12 (400 microg), and pyridoxine (10 mg)--referred to as folate treatment--or placebo was administered to 205 patients (mean [+/-SD] age, 61+/-11 years) for six months after successful coronary angioplasty in a prospective, double-blind, randomized trial. The primary end point was restenosis within six months as assessed by quantitative coronary angiography. The secondary end point was a composite of major adverse cardiac events. RESULTS: Base-tine characteristics and initial angiographic results after coronary angioplasty were similar in the two study groups. Folate treatment significantly lowered plasma homocysteine levels from 11.1+/-4.3 to 7.2+/-2.4 micromol per liter (P<0.001). At follow-up, the minimal luminal diameter was significantly larger in the group assigned to folate treatment (1.72+/-0.76 vs. 1.45+/-0.88 mm, P=0.02), and the degree of stenosis was less severe (39.9+/-20.3 vs. 48.2+/-28.3 percent, P=0.01). The rate of restenosis was significantly lower in patients assigned to folate treatment (19.6 vs. 37.6 percent, P=0.01), as was the need for revascularization of the target lesion (10.8 vs. 22.3 percent, P=0.047). CONCLUSIONS: Treatment with a combination of folic acid, vitamin B12, and pyridoxine significantly reduces homocysteine levels and decreases the rate of restenosis and the need for revascularization of the target lesion after coronary angioplasty. This inexpensive treatment, which has minimal side effects, should be considered as adjunctive therapy for patients undergoing coronary angioplasty.

Angioplasty, Balloon, Coronary↗
PubMed2001

Percutaneous intervention for symptomatic vertebral artery stenosis using coronary stents.

BACKGROUND: There is very limited experience with percutaneous treatment of symptomatic vertebral artery disease. Angioplasty and stenting for vertebral artery stenosis are still evolving and have generally been performed for asymptomatic disease. We performed vertebral artery stenting in 12 patients with vertebrobasilar transient ischemic attacks and present our short- and intermediate-term results. METHODS: A total of 12 lesions affecting the vertebral artery were treated by coronary stent placement. The mean age was 72 +/- 8 years and 83% were males (10 males, 2 females). Baseline characteristics included hypertension (11/12); hypercholesterolemia (8/12); coronary artery disease (8/12); and diabetes (5/12). Mean lesion length was 8.6 +/- 2.7 mm, mean calipered stenosis was 78 +/- 8%, and mean arterial diameter was 4.1 +/- 0.3 mm. All patients were symptomatic, fulfilling our criteria for vertebral artery angioplasty. All patients were followed for at least 6 months after treatment. RESULTS: All 12 lesions were successfully stented, with a mean residual stenosis of 11 +/- 6%. Clinical follow-up showed resolution or improvement of symptoms in all patients. One patient had symptomatic restenosis seven months after the initial procedure requiring repeat angioplasty. CONCLUSIONS: Stent placement for symptomatic stenosis involving the vertebral artery is safe and effective for alleviating symptoms of vertebrobasilar ischemia. Coronary stents appear to be well suited to treat atherosclerotic lesions of the vertebral artery.

Aged↗
PubMed2001

Adventitial hematoma triggering coronary spasm during percutaneous coronary intervention.

During percutaneous coronary intervention of the left anterior descending coronary artery, a lumen narrowing was observed proximal to the stent just deployed. Intravascular ultrasound showed a hematoma localized outside the trilaminar wall structure in absence of a dissection flap or evidence of compression of the lumen. The luminal narrowing resolved after intracoronary administration of vasodilators. This finding is compatible with a coronary spasm triggered by an adventitial hematoma following stent deployment.

Angioplasty, Balloon, Coronary↗
PubMed2001

Self-expanding stents for carotid interventions: comparison of nitinol versus stainless-steel stents.

BACKGROUND: Angioplasty and stenting are becoming increasingly accepted techniques for the treatment of carotid stenosis. However, the optimal stent for carotid intervention is not known. METHODS: We compared the short- and intermediate-term results of carotid stenting using either nitinol or stainless-steel self-expanding stents in 178 high surgical risk patients undergoing carotid stenting at our institution. Of these 178 patients, eighty-nine received stainless-steel stents and 89 received nitinol stents. The groups were similar with respect to age, gender, diabetes, hypertension, left ventricular function, and symptom status. There were more patients with contralateral carotid occlusion in the nitinol stent group. Independent neurological evaluation was performed in all patients pre- and post-carotid stenting. RESULTS: At 6 months, there was a similar incidence of stroke (3.3% versus 2.2%) in the stainless-steel group and nitinol stent group, respectively. There was higher 6-month mortality noted in the stainless-steel stent group, but there were no neurological deaths in either group. CONCLUSIONS: In a single-center patient cohort with similar baseline characteristics, patients receiving nitinol stents and stainless-steel stents had similar neurological outcomes.

Aged↗
PubMed2001

Dual antiplatelet therapy with clopidogrel and aspirin after carotid artery stenting.

BACKGROUND: Carotid artery stenting is being used as an alternative to carotid endarterectomy, both within the context of clinical trials and in non-surgical candidates. Though stenting is known to activate platelets, the role of antithrombotic therapy in carotid stenting has not been fully characterized. METHODS AND RESULTS: Consecutive patients (n = 162) were followed in a single-center carotid stent registry. The cumulative rate of 30-day death, stroke, transient ischemic attack and myocardial infarction in those patients receiving a thienopyridine was determined, as were rates of stent thrombosis and intracranial hemorrhage. The mean age of the patients was 70.3 years and there was an extremely high prevalence of cardiovascular comorbidities, including 40% with unstable angina. The carotid lesion was symptomatic in 59% of patients. The average pre-treatment stenosis was 83%. The cumulative 30-day rate of death, stroke, transient ischemic attack and myocardial infarction was 5.6%. Specifically, in the patients who received ticlopidine (n = 23), the rate was 13%, versus 4.3% in the patients who received clopidogrel (n = 139) (p = 0.01). In this series, there were no cases of stent thrombosis and 1 intracranial hemorrhage. CONCLUSION: Dual antiplatelet therapy with clopidogrel plus aspirin in patients receiving carotid artery stents is associated with a low rate of ischemic events. Furthermore, clopidogrel appears superior to ticlopidine. Thus, our findings lend support to the dual antiplatelet strategy of clopidogrel plus aspirin for patients undergoing carotid artery stenting.

Aged↗