IMA is a sensitive marker of ischemia and reflects themagnitude and duration of ischemia induced duringangioplasty.12–14 IMA has also been demonstrated tobe a sensitive marker of ischemia in patients present-ing to the emergency room with acute coronary syn-drome.5–7 It can be argued, however, that ST-segmentshifts after DCCV may represent repolarizationchanges not indicative of cardiac ischemia, and thatIMA increases as a consequence of muscle-relatedischemia. IMA has been shown to increase 24 to 48hours after exercise in marathon runners, possibly dueto delayed skeletal muscle ischemia.15 However, thismodel is not comparable to our study, and althoughskeletal muscle ischemia after DCCV is a possibility,there are no data assessing the effect of direct-muscleinjury on IMA levels. Creatine kinase-MB isoenzymeand cardiac troponin T levels increased slightly frombaseline after DCCV, although they remained withinthe normal range. This suggests that myocardial orskeletal muscle necrosis was not present in our group.Our findings of electrocardiographic changes and in-creased IMA levels suggest that DCCV may causetransient myocardial ischemia.

1. Bar-Or D, Lau E, Winkler JV. A novel assay for cobalt-albumin binding andits potential as a marker for myocardial ischemia-a preliminary report. J EmergMed 2000;19:311–315.2. Sadler PJ, Tucker A, Viles JH. Involvement of a lysine residue in theN-terminal Ni2� and Cu2� binding site of serum albumins. Comparison withCo2�, Cd2� and Al3�. Eur J Biochem 1994;220:193–200.3. Chan B, Dodsworth N, Woodrow J, Tucker A, Harris R. Site-specific N-terminal auto-degradation of human serum albumin. Eur J Biochem 1995;227:524–528.

4. Bar-Or D, Curtis G, Rao N, Bampos N, Lau E. Characterization of the Co(2�)and Ni(2�) binding amino-acid residues of the N-terminus of human albumin.An insight into the mechanism of a new assay for myocardial ischemia. EurJ Biochem 2001;268:42–47.5. Bhagavan NV, Lai EM, Rios PA, Yang J, Ortega-Lopez AM, Shinoda H,Honda SA, Rios CN, Sugiyama CE, Ha CE. Evaluation of human serum albumincobalt binding assay for the assessment of myocardial ischemia and myocardialinfarction. Clin Chem 2003;49:581–585.6. Wu AH, Morris DL, Fletcher DR, Apple FS, Christenson RH, Painter PC.Analysis of the albumin cobalt binding (ACB) test as an adjunct to cardiactroponin I for the early detection of acute myocardial infarction. CardiovascToxicol 2001;1:147–151.7. Christenson RH, Duh SH, Sanhai WR, Wu AH, Holtman V, Painter P,Branham E, Apple FS, Murakami M, Morris DL. Characteristics of an albumincobalt binding test for assessment of acute coronary syndrome patients: a mul-ticenter study. Clin Chem 2001;47:464–470.8. Jakobsson J, Odmansson I, Nordlander R. Enzyme release after electivecardioversion. Eur Heart J 1990;11:749–752.9. Adams JE III, Abendschein DR, Jaffe AS. Biochemical markers of myocardialinjury. Is MB creatine kinase the choice for the 1990s? Circulation 1993;88:750–763.10. Rao AC, Naeem N, John C, Collinson PO, Canepa-Anson R, Joseph SP.Direct current cardioversion does not cause cardiac damage: evidence fromcardiac troponin T estimation. Heart 1998;80:229–230.11. Kerber RE, Martins JB, Gascho JA, Marcus ML, Grayzel J. Effect ofdirect-current countershocks on regional myocardial contractility and perfusion.Experimental studies. Circulation 1981;63:323–332.12. Bar-Or D, Winkler JV, Vanbenthuysen K, Harris L, Lau E, Hetzel FW.Reduced albumin-cobalt binding with transient myocardial ischemia after elec-tive percutaneous transluminal coronary angioplasty: a preliminary comparison tocreatine kinase-MB, myoglobin, and troponin I. Am Heart J 2001;141:985–991.13. Quiles J, Roy D, Gaze D, Garrido IP, Avanzas P, Sinha M, Kaski JC. Relationof ischemia-modified albumin (IMA) levels following elective angioplasty forstable angina pectoris to duration of balloon-induced myocardial ischemia. Am JCardiol 2003;92:322–324.14. Sinha MK, Gaze DC, Tippins JR, Collinson PO, Kaski JC. Ischemia modifiedalbumin is a sensitive marker of myocardial ischemia after percutaneous coronaryintervention. Circulation 2003;107:2403–2405.15. Apple FS, Quist HE, Otto AP, Mathews WE, Murakami MM. Releasecharacteristics of cardiac biomarkers and ischemia-modified albumin as measuredby the albumin cobalt-binding test after a marathon race. Clin Chem 2002;48:1097–1100.

P-Wave Dispersion for Predicting Maintenance ofSinus Rhythm After Cardioversion of Atrial Fibrillation

Abdullah Dogan, MD, Alaettin Avsar, MD, and Mustafa Ozturk, MD

P-wave measurements and left atrial function wereinvestigated to predict the maintenance of sinus rhythmafter cardioversion of atrial fibrillation. Left atrial dimen-sion <45 mm (p � 0.02) and P-wave dispersion <46ms (p <0.001) were independent predictors of sinusrhythm maintenance, with a sensitivity of 89% and96%, respectively. Duration of atrial fibrillation, maxi-mum P-wave duration, and no spontaneous echo-cardiographic contrast were also univariatepredictors. �2004 by Excerpta Medica, Inc.

(Am J Cardiol 2004;93:368–371)

The prolongation of atrial conduction time and het-erogeneous propagation of sinus impulses in atria

cause the atrium to fibrillate.1–4 P-wave dispersion canreflect this abnormal conduction or propagation.3,4 Clin-ical and echocardiographic parameters were evaluated topredict maintenance of sinus rhythm (SR) after cardio-version of atrial fibrillation (AF).5–12 However, there hasbeen only 1 small study investigating P-wave durationand dispersion for rhythm maintenance12; this studyshows that mean P-wave duration is a useful marker forpredicting maintenance of SR. Furthermore, the maxi-mum duration and dispersion of the P wave have beenreported to be predictors of recurrence in patients withsymptomatic episodes of AF.4 P-wave duration by sig-nal-averaged electrocardiography may also identify pa-tients at risk for AF relapse after cardioversion.13 Thus,we investigated whether P-wave duration and dispersioncould be predictors for the maintenance of SR aftercardioversion of AF.

• • •

From the Departments of Cardiology and Public Health, MedicalSchool, Suleyman Demirel University, Isparta; and Public Hospital,Manisa, Turkey. Dr. Dogan’s address is: Yayla Mh. Ismet PasaCd. 1533 Sk., No:1/10 32100, Isparta, Turkey. E-mail:adogan35@hotmail.com. Manuscript received June 24, 2003; re-vised manuscript received and accepted September 29, 2003.

368 ©2004 by Excerpta Medica, Inc. All rights reserved. 0002-9149/04/$–see front matterThe American Journal of Cardiology Vol. 93 February 1, 2004 doi:10.1016/j.amjcard.2003.09.064

We prospectively studied 64 patients who had afirst episode of AF for �3 months and had successfulconversion to SR. No patient received any antiarrhyth-mic agent for arrthythmia suppression 4 weeks beforeand after cardioversion. However, � blockers wereadministered for ischemic heart disease and hyperten-sion. The duration of AF was obtained from patients’medical histories with electrocardiographic evidenceof AF. SR was restored spontaneously in 25 patients,pharmacologically in 21, and electrically in the re-maining 18. Pharmacologic cardioversion was per-formed with oral propafenone (a single dose of 600mg). Patients with AF persisting for �48 hours wereevaluated with transesophageal echocardiography forthrombi in the atria before cardioversion. If there wereno thrombi, they first underwent pharmacologic car-dioversion and then electrical cardioversion if theprevious attempt was unsuccessful. They underwentanticoagulation with warfarin for 4 weeks aftercardioversion.

Exclusion criteria were long-term AF persisting for�3 months, acute coronary syndromes, heart failure,severe pulmonary disease, pulmonary embolism, hy-perthyroidism, sick sinus syndrome, severe mitral oraortic valve disease, and open-heart surgery within 3months. All patients gave written consent.

A 12-lead electrocardiogram was recorded at astudy speed of 50 mm/s (voltage 10 mm/mV) 48 hoursafter cardioversion. There was no early AF relapsewithin the first 48 hours. Maximum (P maximum) and

minimum (P minimum) durations ofP waves were measured manuallyusing a magnifying glass and a scalegraded (in milliseconds) by 2 observ-ers in a blinded fashion. The onset ofthe P wave was considered to be thepoint of the first visible upward de-parture of the trace from the bottomof the baseline for positive wavesand as the point of downward depar-ture from the top of the baseline fornegative waves. A return of the bot-tom of the trace in positive wavesand of the top of the trace in negativewaves to baseline was also consid-ered to be the end of the Pwave.3,4,14–16 When the beginning orend of P-wave deflection could notbe identified satisfactorily, that leadwas omitted. The difference betweenP maximum and P minimum wasconsidered P-wave dispersion.3,4 In-terobserver coefficients of variationwere 4.1%, 3.4%, and 4.8% for Pmaximum, P minimum, and P-wavedispersion, respectively.

Transthoracic echocardiographywas performed in all patients beforecardioversion. In patients with per-sistent AF, transesophageal echocar-diography was also performed. Thediameters of the left atrium and left

ventricle were measured in the parasternal long-axisview. Left ventricular ejection fraction by Simpson’smethod, valvular functions, wall motion abnormali-ties, and spontaneous echocardiographic contrast werealso evaluated.

Patients were followed up for maintenance of SRfor 6 months. There were no withdrawals at follow-up.Control electrocardiograms were obtained once eachmonth. In addition, patients were told to go to thehospital whenever they experienced symptoms relatedto AF relapse.

All data are reported as mean � SD. Student’s ttest and the chi-square or Fisher’s exact tests wereused for analyses. Based on receiver-operating char-acteristic curves, the best cut-off value was consideredto be the optimal point with the highest sum of sen-sitivity and specificity for predicting SR maintenance.Logistic regression analysis was also performed toidentify predictors of SR maintenance in addition tocorrelation analysis.

During 6 months, 36 patients remained in SR andthe remaining 28 experienced recurrent AF. Demo-graphic and clinical characteristics of the study pop-ulation are listed in Table 1. Preconversion AF dura-tion was significantly shorter in patients whomaintained SR than in those who did not (p �0.001).AF lasting �5 days separated patients with SR fromthose with recurrent AF, with a sensitivity of 79% anda specificity of 96%. Other variables were not signif-icantly different between the 2 groups.

TABLE 1 Clinical Characteristics of Study Group

VariablesAll Patients(n � 64)

SR Maintenance(n � 36)

AF Recurrence(n � 28) p Value*

Mean age (yrs) 61.5 � 10.1 61.2 � 9.8 61.8 � 10.6 0.82Men/women 30/34 19/17 11/17 0.32Systemic hypertension 23 (36%) 10 (28%) 13 (46%) 0.19Coronary heart disease 16 (25%) 9 (25%) 7 (25%) 0.96Valvular heart disease 8 (13%) 3 (8%) 5 (18%) 0.28Lone AF 17 (27%) 8 (22%) 9 (32%) 0.41Use of � blockers 29 (45%) 17 (47%) 12 (43%) 0.80AF duration (d) 10.8 � 21.5 1.1 � 1.2 23.4 � 27.9 �0.001Type of cardioversion

Spontaneous 25 (39%) 16 (44%) 9 (32%) 0.44Pharmacologic 18 (28%) 10 (28%) 8 (29%) 0.98Electrical 21 (33%) 10 (28%) 11 (39%) 0.87

AF patternsRecent onset �48 h 35 (55%) 20 (56%) 15 (54%) 0.87Persistent �48 h 29 (45%) 16 (44%) 13 (46%) 0.87

*p �0.05 was statistically significant.

TABLE 2 Electrocardiographic and Echocardiographic Variables in Patients WhoDid and Did Not Remain in Sinus Rhythm (SR) After Cardioversion

SR Maintenance(n � 36)

AF Recurrence(n � 28) p Value

Maximum P-wave duration (ms) 108 � 5 118 � 6 �0.001Minimum P-wave duration (ms) 68 � 5 65 � 5 0.064P-wave dispersion (ms) 40 � 5 53 � 4 �0.001Left atrial diameter (mm) 41 � 3 47 � 3 �0.001Left ventricular ejection fraction (%) 57 � 9 55 � 8 0.35Presence of spontaneous echo contrast 5 (14%) 17 (61%) 0.0001

BRIEF REPORTS 369

P maximum and P-wave dispersion were signifi-cantly lower in patients with SR than in those withrecurrence of AF (both p �0.001). The left atrialdiameter and spontaneous echocardiographic contrastwere also significantly different in the 2 groups (Table2). According to receiver-operating characteristiccurves, a P maximum of 112 ms, P-wave dispersion of46 ms, and left atrial dimension of 45 mm discernedpatients who maintained SR from those with recur-rence of AF (Tables 3 and 4).

AF duration of �5 days, left atrial diameter �45mm, absence of spontaneous echocardiographic con-trast, P maximum �112 ms, and P-wave dispersion�46 ms were univariate predictors of SR maintenance(Table 3). By multivariate analysis, P-wave dispersion(p �0.001) and left atrial diameter (p � 0.02) wereindependent predictors of identifying patients whoremained in SR (Tables 3 and 4).

P-wave dispersion was correlated with AF duration(r � 0.66, p �0.001), left atrial size (r � 0.71, p�0.001), spontaneous echocardiographic contrast (r� �0.48, p � 0.001), and P maximum (r � 0.81, p�0.001). P maximum was also related to AF duration(r � 0.56, p �0.001), left atrial size (r � 0.63, p�0.001), and spontaneous echocardiographic contrast(r � �0.43, p � 0.001).

• • •In the present study, AF duration, P maximum,

P-wave dispersion, left atrial diameter, and absence ofspontaneous echocardiographic contrast were univar-iate predictors of SR maintenance in patients withshort-term AF after cardioversion. Of these parame-ters, only P-wave dispersion and left atrial size wereindependent predictors in multivariate analysis.

To date, several clinical and echocardiographic

predictors for maintenance of SRhave been reported in many studies.These are AF duration, use of anti-arrhythmic agents, left atrial size, leftventricular systolic function, andflow velocities of the left atrial ap-pendage.5–12 Left atrial enlargementhas been proved as a predictor of SRmaintenance in patients with AF insome studies,5–7,10,11 but not in oth-ers.8,9,12 A recent study10 has shownthat AF duration of �7 days, leftatrial size �44 mm, and absence ofspontaneous echocardiographic con-trast have a predictive value forrhythm maintenance in patients withAF lasting �1 year. This study’s re-sults agree with our findings.

A recent, small-size study of 36patients12 has shown that the meanduration of a P wave of �125 ms isthe only significant predictor of clin-ical recurrence of AF after electricalcardioversion in patients with AFlasting �3 months. No clinical andechocardiographic parameters wereassociated with long-term SR main-

tenance. Moreover, in that study, patients receivedantiarrhythmic drugs to prevent recurrence. However,we did not administer any drug for arrhythmia pre-vention except � blockers. AF duration in our studywas shorter than that in the study of Lin et al.12

P-wave dispersion has been recognized as a usefulmarker for identifying patients with systemic hyper-tension at risk for paroxysmal AF16 and those withlone paroxysmal AF.3,4,14 It is also considered a pre-dictor of recurrence in patients who had a history ofsymptomatic episodes of AF.4 Furthermore, P-waveduration from signal-averaged electrocardiogramsmay also predict a recurrence of AF in patients afterSR restoration at 6-month follow-up.13 That studyincluded 73 patients with AF that persisted for �7days, in whom SR was achieved pharmacologically in44 and electrically in the remaining 29. Quinidine,amiodarone, sotalol, and propafenone were adminis-tered to achieve SR, and 1 or a combination of thesedrugs was continued for maintenance. However, weadministered no medication for maintenance.

This study has some limitations. First, it consistedof patients who had different histories of clinical AF,AF duration, underlying heart disease, and types ofcardioversion. Second, P waves were measured man-ually instead of by computer. However, both methodshave been reported to produce similar results.17 Third,the plasma half-life of propafenone may last 15 to 20hours in poor metabolizers. However, there is noconsensus on how propafenone may affect P-wavemeasurements. Fourth, atrial stunning can occur afterconversion of AF to SR, and its duration may varydepending on AF duration, underlying heart disease,and atrial size.18 We do not know whether P-wavedispersion may be influenced by atrial stunning. Fi-

TABLE 3 Predictors of Sinus Rhythm Maintenance at Six-month Follow-up

Chi-square OR CI (95%) p Value

Univariate predictorsAF duration �5 d 39.3 128.3 14.5–1,138.8 �0.001P-wave maximum �112 ms 23.2 18 4.9–66.0 �0.001P-wave dispersion �46 ms 52.5 459 39.5–5,335 �0.001Left atrial dimension �45 mm 41.9 91.7 17.0–493.1 �0.001Absence of spontaneous echo contrast 14.8 9.3 2.7–31.2 �0.001

Multivariate predictorsLeft atrial dimension �45 mm 5.3 20.8 6.8–44.3 0.02P-wave dispersion �46 ms 13.5 151.9 38.2–393.2 �0.001

CI � confidence interval; OR � odds ratio.

TABLE 4 Diagnostic Values of Clinical, Electrocardiographic, andEchocardiographic Parameters for Maintenance of Sinus Rhythm

SENS SPEC PPV NPV

AF duration �5 d 79% 97% 96% 85%P-wave maximum �112 ms 86% 75% 73% 87%P-wave dispersion �46 ms 96% 94% 93% 97%Left atrial dimension �45 mm 89% 92% 89% 91%Absence of spontaneous echo contrast 63% 86% 77% 73%

NPV � negative predictive value; PPV � positive predictive value; SENS � sensitivity; SPEC �

specificity.

370 THE AMERICAN JOURNAL OF CARDIOLOGY� VOL. 93 FEBRUARY 1, 2004

nally, because AF recurrence was only detected withelectrocardiograms at predetermined intervals andwithout ambulatory recordings, asymptomatic recur-rences may have remained undetectable.

1. Chen YJ, Chen SA, Tai CT, Yu WC, Feng AN, Ding YA, Chang MS.Electrophysiologic characteristics of dilated atrium in patients with paroxysmalatrial fibrillation. J Intervent Card Electrophysiol 1998;2:181–186.2. Pandozi C, Santini M. Update on atrial remodelling owing to rate: does atrialfibrillation always beget atrial fibrillation? Eur Heart J 2001;22:541–553.3. Dilaveris PE, Gialofos EJ, Sideris SK, Theopistou AM, Andrikopoulos GK,Kyriakidis M, Gialofos JE, Toutouzas PK. Simple electrocardiographic markersfor the prediction of paroxysmal idiopathic atrial fibrillation. Am Heart J 1998;135:733–738.4. Dilaveris PE, Gialofos EJ, Andrikopoulos GK, Richter DJ, Papanikolaou V,Gialofos JE. Clinical and electrocardiographic predictors of recurrent atrial fi-brillation. Pacing Clin Electrophysiol 2000;23:352–358.5. Brodsky MA, Allen BJ, Caparelli EV, Luckett CR, Morton AR, Henry WL.Factors determining maintenance of sinus rhythm after chronic AF with left atrialdilatation. Am J Cardiol 1989;63:1065–1068.6. Flaker GC, Fletcher KA, Rothbart RM, Halperin JL, Hart RG. Clinical andechocardiographic features of intermittent AF that predict recurrent atrial fibril-lation. Stroke Prevention in Atrial Fibrillation (SPAF) Investigators. Am J Car-diol 1995;76:355–358.7. Volgman AS, Soble JS, Neumann A, Mukhtar KN, Iftikhar F, Vallesteros A,Liebson PR. Effect of left atrial size on recurrence of atrial fibrillation afterelectrical cardioversion: atrial dimension versus volume. Am J Card Imaging1996;10:261–265.8. Omran H, Jung W, Schimpf R, MacCarter D, Rabahieh R, Wolpert C, Illien S,

Luderitz B. Echocardiographic parameters for predicting maintenance of sinusrhythm after internal atrial defibrillation. Am J Cardiol 1998;81:1446–1449.9. De Piccoli B, Rigo F, Ragazzo M, Zuin G, Martino A, Raviele A. Transtho-racic and transesophageal echocardiographic indices predictive of sinus rhythmmaintenance after cardioversion of atrial fibrillation: an echocardiographic studyduring direct current shock. Echocardiography 2001;18:545–552.10. Antonielli E, Pizzuti A, Palinkas A, Tanga M, Gruber N, Michelassi C, VargaA, Bonzano A, Gondalfo N, Halmai L, et al. Clinical value of left atrialappendage flow of prediction of long-term sinus rhythm maintenance in patientwith nonvalvular atrial fibrillation. J Am Coll Cardiol 2002;39:1443–1449.11. Okcun B, Yigit Z, Kucukoglu MS, Mutlu H, Sansoy V, Guzelsoy D, Uner S.Predictors for maintenance of sinus rhythm after cardioversion in patients withnonvalvular atrial fibrillation. Echocardiography 2002;19:351–357.12. Lin JM, Lin JL, Lai LP, Tseng YZ, Huang SS. Predictors of clinicalrecurrence after successful electrical cardioversion of chronic atrial fibrillation:clinical and electrocardiographical observations. Cardiology 2002;97:133–137.13. Aytemir K, Aksoyek S, Yildirir A, Ozer N, Oto A. Prediction of atrialfibrillation after cardioversion by P wave signal averaged electrocardiography. IntJ Cardiol 1999;70:15–21.14. Aytemir K, Ozer N, Atalar E, Sade E, Aksoyek S, Ovunc K, Oto A, OzmenF, Kes S. P wave dispersion on 12-lead electrocardiography in patients withparoxysmal atrial fibrillation. Pacing Clin Electrophysiol 2000;23:1109–1112.15. Dogan A, Ozaydin M, Nazli C, Altinbas A, Gedikli O, Kinay O, Ergene O.Does impaired left ventricular relaxation affect P wave dispersion in patients withhypertension? Ann Noninvasive Electrocardiol 2003;8:189–193.16. Ciaroni S, Cuenoud L, Bloch A. Clinical study to investigate the predictiveparameters for the onset of atrial fibrillation in patients with essential hyperten-sion. Am Heart J 2000;139:814–819.17. Dilaveris PE, Batchvarov V, Gialofos J, Malik M. Comparison of differentmethods for manual P wave measurements in 12-lead electrocardiograms. PacingClin Electrophysiol 1999;22:1532–1538.18. Khan IA. Transient atrial mechanical dysfunction (stunning) after cardiover-sion atrial fibrillation and flutter. Am Heart J 2002;144:11–22.

Implications of Cardiac Resynchronization Therapy andProphylactic Defibrillator Implantation Among

Patients Eligible for Heart Transplantation

Chiara Pedone, MD, Francesco Grigioni, MD, Giuseppe Boriani, MD,Carla Lofiego, MD, Pier Luigi Vassallo, MD, Luciano Potena, MD, Fabio Coccolo, MD,Gaia Magnani, MD, Mauro Biffi, MD, Cristian Martignani, MD, Lorenzo Frabetti, MD,

Romano Zannoli, Bsc, Carlo Magelli, MD, and Angelo Branzi, MD

This study analyzed the relations and time-relatedchanges in eligibility for cardiac resynchronizationtherapy and prophylactic defibrillator implantation in161 potential candidates for heart transplantation.Although up to 62% of patients who fulfilled theseverity criteria for heart transplantation were eligi-ble for either device, this percentage increased asclinical/instrumental parameters of heart failure se-verity worsened. �2004 by Excerpta Medica, Inc.

(Am J Cardiol 2004;93:371–373)

Heart transplantation (HT) is the preferred thera-peutic option for patients with end-stage chronic

heart failure (CHF). Various devices have recentlybeen developed to improve symptoms, quality of life,

and prognosis of patients with CHF. Cardiac resyn-chronization therapy (CRT) and prophylactic implant-able cardioverter-defibrillators (ICDs) are 2 of themost remarkable device-based strategies.1–6 No studyhas defined the role of CRT and prophylactic ICD inpotential candidates for HT. A study of this type couldhelp clarify whether these strategies can provide avalid, synergic, therapeutic option in this group ofpatients. We set out to define the relations and time-related changes in eligibility for CRT and ICDs inpotential candidates for HT.

• • •All consecutive patients with CHF referred to the

heart failure and transplant clinic of our institution forroutine follow-up from June 1996 to June 2002 werescreened for this retrospective study. Inclusion criteriawere: (1) complete clinical, electrocardiographic,echocardiographic, cardiopulmonary, and hemody-namic assessment at the time of index evaluation; and(2) availability of an equivalent clinical and instru-mental assessment performed �6 months previously(i.e., prestudy evaluation). The presence of absolutecontraindications to HT were the only exclusion cri-

From the Institute of Cardiology, University Hospital S. Orsola Mal-pighi, Bologna, Italy. Dr. Magelli’s address is: Istituto di Malattiedell’Apparato Cardiovascolare, Ospedale S. Orsola Malpigli, viaMassarenti 9, 40138, Bologna, Italy. E-mail: bibcard@med.unibo.it.This study was supported by a grant from the University of Bologna,Bolgona, Italy. Manuscript received July 14, 2003; revised manu-script received and accepted October 8, 2003.

371©2004 by Excerpta Medica, Inc. All rights reserved. 0002-9149/04/$–see front matterThe American Journal of Cardiology Vol. 93 February 1, 2004 doi:10.1016/j.amjcard.2003.10.024