BackgroundThe independent prognostic impact of diabetes mellitus (DM) and prediabetes mellitus (pre‐DM) on survival outcomes in patients with chronic heart failure has been investigated in observational registries and randomized, clinical trials, but the results have been often inconclusive or conflicting. We examined the independent prognostic impact of DM and pre‐DM on survival outcomes in the GISSI‐HF (Gruppo Italiano per lo Studio della Sopravvivenza nella Insufficienza Cardiaca‐Heart Failure) trial.Methods and ResultsWe assessed the risk of all‐cause death and the composite of all‐cause death or cardiovascular hospitalization over a median follow‐up period of 3.9 years among the 6935 chronic heart failure participants of the GISSI‐HF trial, who were stratified by presence of DM (n=2852), pre‐DM (n=2013), and non‐DM (n=2070) at baseline. Compared with non‐DM patients, those with DM had remarkably higher incidence rates of all‐cause death (34.5% versus 24.6%) and the composite end point (63.6% versus 54.7%). Conversely, both event rates were similar between non‐DM patients and those with pre‐DM. Cox regression analysis showed that DM, but not pre‐DM, was associated with an increased risk of all‐cause death (adjusted hazard ratio, 1.43; 95% CI, 1.28–1.60) and of the composite end point (adjusted hazard ratio, 1.23; 95% CI, 1.13–1.32), independently of established risk factors. In the DM subgroup, higher hemoglobin A1c was also independently associated with increased risk of both study outcomes (all‐cause death: adjusted hazard ratio, 1.21; 95% CI, 1.02–1.43; and composite end point: adjusted hazard ratio, 1.14; 95% CI, 1.01–1.29, respectively).ConclusionsPresence of DM was independently associated with poor long‐term survival outcomes in patients with chronic heart failure.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00336336.

Transcranial Doppler sonography (TCD) can detect the passage through the middle cerebral artery of microbubbles present in intravenous injected saline when an intracardiac right-to-left shunt occurs. Given the increasingly recognized importance of patent foramen ovale (PFO) as a possible anatomical factor predisposing to stroke, we tried to assess the efficiency of TCD in the evaluation of PFO in comparison to the gold standard represented by transesophageal echocardiography (TEE). Seventy-two consecutive patients scheduled for TEE also underwent TCD, simultaneously in 18 cases. A 20-ml agitated saline bolus was injected into an antecubital vein through an indwelling catheter while the patient was performing a Valsalva manoeuvre. The procedure was repeated a maximum of 10 times or until the contrast medium was tracked from the right to left atrium (TEE+) and/or the high-intensity spike typical for embolism was recorded on TCD (TCD+). Among non-simultaneous cases, the first 14 were studied with a non-standardized protocol: the resulting sensitivity and specificity of TCD as compared to TEE were both 43% (TEE+/TCD+ = 3; TEE–/TCD– = 3; TCD+/TEE– = 4; TCD–/TEE+ = 4). In all the 18 simultaneous examinations, however, there was 100% agreement between TEE and TCD (TEE+/TCD+ = 12; TEE–/TCD– = 6). Moreover, when the protocol was standardized in 40 further patients studied non-simultaneously, sensitivity and specificity were 90 and 100%, respectively (TCD+/TEE+ = 19; TCD–/ TEE– = 19; TCD–/TEE+ = 2; TCD+/TEE– = 0) Standardization was obtained by timing of Valsalva manoeuvre to injection, delay of embolic signals, caliber of venous catheters, content of air bubbles in the saline, velocity of injection. In conclusion, when properly standardized techniques are applied, TCD can be used as a screening test for the detection of PFO.

Three cases of Churg-Strauss syndrome with myocardial involvement are reported. Cardiac disease is known to be the major cause of death in Churg-Strauss syndrome. Aggressive therapy (steroids and cyclophosphamide) may cure the myocardial dysfunction associated with the disease.

The purpose of this paper is to investigate whether the inhibitory action of purinic compounds (striadyne: STR) on the sinus node is quantitatively different on a pathological sinus node in comparison to a normal one and thus whether it is possible, as suggested by other authors, to use STR as a pharmacological test in the diagnosis of sick sinus syndrome (SSS). With this aim we investigated 55 patients, divided into 3 groups according to ECG and sinus function evaluation tests: 1--normal; 2--SSS (2a: flagrant SSS; 2b: latent SSS); 3--excess vagotonia and/or abnormal response to vagal stimulation. In all patients after a prophylactic insertion of a temporary pacemaker, 30 mg of STR were rapidly injected i.v. and the surface and intracavitary ECG continuously recorded until the basal state was regained; the following parameters were evaluated: average baseline sinus cycle (SC), minimum and maximum SC after the drug. In all patients STR caused first a slowing, then an acceleration of the sinus rate. SC lengthening was moderate in groups 1 and 3 [max SC was respectively 740-1820 ms (1198 +/- 290.9 ms) and 720-1440 ms (1157.5 +/- 223.3 ms)], but it was severe in patients with SSS [max SC in group 2a 2500-11880 ms (5398.3 +/- 2687.4 ms) in group 2b 1620-11140 ms. (4470.7 +/- 3660.6 ms)]. The difference between the max post STR SC of SSS patients, and the control group was highly significant P less than 0.001). Assuming as upper limit of the normal a value of 2071 ms. (corresponding to the mean + 3 standard deviations of the response of the control group) we recorded abnormal responses in 100% in group 2a and in 85.7% in group 2b, whereas there were no abnormal responses in group 3. In addition, nodal atrioventricular block occurred frequently. The authors believe this test could be useful in the diagnosis of SSS, but it is essential to insert a ventricular pacing catheter prophylactically if this test is used.

The authors studied, pre-operatively, the sinus node function in adult patients with secundum atrial septal defect and large left-right shunts, using Holter ECG and electrophysiological tests. Sinus node electrophysiological tests were found abnormal in 17 out of 26 patients; on the contrary, Holter monitoring was always within normal limits. The authors believe that concealed sinus node dysfunction existing before surgical correction may be a cause of early, acute, and reversible, post-operative sick sinus syndrome.