Verapamil: prevention and treatment of cardio-renal syndromes in diabetic hypertensive patients?

Patients with diabetes mellitus (DM) often present other chronic comorbidities including arterial hypertension (AH), chronic kidney disease (CKD), ischemic heart disease (IHD) and heart failure with preserved ejection fraction (HFpEF). The frequent association of the latter conditions is considered part of the spectrum of cardio-renal syndromes (CRS), a group of disorders of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. Verapamil is a non-dihydropyridine calcium channel blocker (CCB) widely used in the treatment of hypertension, chronic stable angina, secondary prevention of reinfarction, paroxysmal supra-ventricular tachycardia and for rate control in atrial fibrillation/flutter. In addition to its antihypertensive and anti-ischemic actions verapamil exerts favorable effects also on glycemic control, proteinuric diabetic nephropathy, left ventricular diastolic dysfunction and sympathetic nervous system overactivity which may potentially benefit patients with DM and CRS. In this narrative review, we summarize the current evidence on the potential role of verapamil in the prevention and treatment of CRS in diabetic hypertensive patients.

[Chronic heart failure treatment in uremic patients with beta-blockers]. / La terapia dell'insufficienza cardiaca cronica con betabloccanti: dai presupposti fisiopatologici al razionale d'uso nei pazienti in dialisi.

The interpretation of congestive heart failure (CHF) in '80 was exclusively in haemodynamic terms. In accordance with such a pathophysiologic hypothesis, cardiovascular drugs, mainly positive inotropics and/or vasodilators were experimented with not significative results. From the second half of the 80's the attention starts focusing on the neurohumoral asset, strongly activated in patients suffering from CHF and that was it selves cause of worsening of CHF and responsible for the poor prognosis of these patients, so as to become therapeutic targets and to represent the rationale for using ace-inhibitors (ACE-I), betablockers and angiotensin II receptor blockers (ARBs). Evidence has been provided that these drugs can reduce morbidity and mortality. However, this evidence derives only from studies on general population. In uraemic patients there are no controlled trials dedicated and the nephrological guidelines recommends the use of ACE-I on the hypothesis that they may have similar efficacy than non uremic patients. Among all the medications used to treat CHF in the general population, only betablockers has been shown to be effective in a randomized trial in the dialysis population. Carvedilol was found to improve left ventricular function and decrease hospitalization, cardiovascular deaths and total mortality, remarking that pathophysiology, rationale for using and results may be similar in uremic and non uremic patients suffering from CHF.

[Beta-blockers in CHF: kidney's consequences]. / I betabloccanti nello scompenso di cuore: ripercussioni sul rene.

In the 1980s congestive heart failure (CHF) was exclusively interpreted in hemodynamic terms. In accordance with this pathophysiologic hypothesis, cardiovascular drugs, mainly positive inotropics and/or vasodilators were used but not with significant results. From the mid 1980s, attention started focusing on the neurohumoral asset, strongly activated in patients suffering from CHF, and that it was itself the cause of CHF and responsible for the poor prognosis in these patients; therefore, to become the therapeutic target and to represent the rationale for using angiotensin-converting enzyme inhibitors (ACE-I), beta-blockers and angiotensin II receptor blockers (ARBs). Evidence has been provided that these drugs can reduce morbidity and mortality. However, this evidence derives only from studies on the general population. In uremic patients, there are no dedicated controlled trials, assuming that the effect can be extended to these patients, but this is not necessarily true. The evidence based on retrospective analysis is a better survival in patients using ACE-I, but there are no prospective trials on mortality and morbidity available. Even less evidence is available on ARBs, in spite of their favorable pharmacokinetic characteristics. Uremia has been suggested as state of excess sympathetic activation; therefore, the benefit derived from beta-blockers should be even greater in uremic than in non-renal patients. Therapy with beta-blockers significantly reduces morbidity and mortality in the general population. These results are also specifically demonstrated in dialysis patients. Finally, only specifically designed trials will be able to answer the questions that cardiologists and nephrologists ask themselves in their daily practice.

Dilated cardiomyopathy in dialysis patients--beneficial effects of carvedilol: a double-blind, placebo-controlled trial.

OBJECTIVES: The aim of this study was to investigate in dialysis patients with symptomatic heart failure New York Heart Association (NYHA) functional class II or III whether the addition of carvedilol to conventional therapy is associated with beneficial effects on cardiac architecture, function and clinical status. BACKGROUND: Congestive heart failure (CHF) in chronic hemodialyzed patients, particularly when associated with dilated cardiomyopathy, represents an ominous complication and is an independent risk factor for cardiac mortality. METHODS: We enrolled 114 dialysis patients with dilated cardiomyopathy. All patients were treated with carvedilol for 12 months in a double-blind, placebo-controlled, randomized trial. The patients underwent M-mode and two-dimensional echocardiography at baseline, 1, 6 and 12 months after the randomization. Each patient's clinical status was assessed using an NYHA functional classification that was determined after 6 and 12 months of treatment. RESULTS: Carvedilol treatment improved left ventricular (LV) function. In the active-treatment group, the increase in LV ejection fraction (from 26.3% to 34.8%, p < 0.05 vs. basal and placebo group) and the reduction of both LV end-diastolic volume (from 100 ml/m2 to 94 ml/m2, p < 0.05 vs. basal and placebo group) and end-systolic volume (from 74 ml/m2 to 62 ml/m2, p < 0.05 vs. basal and placebo group) reached statistical significance after six months of therapy, compared with baseline and corresponding placebo values, and they remained constant at one year of treatment (p < 0.05 vs. basal and placebo group). The clinical status of patients, assessed by NYHA functional classification, improved during the treatment period. Moreover, at the end of the trial, there were no patients in NYHA functional class IV in the carvedilol group, compared with 5.9% of the patients in the placebo arm. CONCLUSIONS: One year of therapy with carvedilol in dialysis patients with CHF and dilated cardiomyopathy reduces LV volumes and improves LV function and clinical status.

Efficacy of carvedilol on complex ventricular arrhythmias in dilated cardiomyopathy: double-blind, randomized, placebo-controlled study.

AIMS: The aim of the present study was to investigate whether the addition of carvedilol to conventional therapy in dilated cardiomyopathy patients is associated with further benefits in the treatment of complex non-sustained ventricular arrhythmias (Lown class III, IV or V). METHODS AND RESULTS: We recruited 168 patients with ischaemic or idiopathic dilated cardiomyopathy, with complex ventricular arrhythmias. Patients able to tolerate low doses of carvedilol were randomized to treatment with carvedilol or placebo for 6 months. Carvedilol treatment improved ventricular function and reduced the incidence of arrhythmic episodes. Notably, by the end of the first month of treatment, the antiarrhythmic efficacy of the drug was significantly greater in patients with ischaemic than in those with idiopathic dilated cardiomyopathy, an effect that could probably be attributed to the anti-ischaemic properties of carvedilol. After 3 months, at a time when ejection fraction was significantly improved in all treated patients, the antiarrhythmic efficacy of carvedilol was similar in the two study groups. CONCLUSIONS: Carvedilol antiarrhythmic efficacy was paralleled by the improvement in ejection fraction, independent of the aetiology of heart failure. The possibility of adding to an already 'optimized' conventional therapy a drug able to reduce the incidence of complex non-sustained ventricular arrhythmias is a therapeutic option that should be considered in the treatment of these patients.

[Efficacy of diltiazem in uremic hemodialyzed patients with isolated diastolic dysfunction and dialysis hypotensive crisis]. / Efficacia del diltiazem in pazienti uremici emodializzati con disfunzione diastolica isolata e crisi ipotensive intradialitiche.

The aim of our study was to assess the effects of diltiazem on diastolic function, left ventricular mass and intradialytic hypotension, in uremic patients on maintenance hemodialysis. Forty-eight uremic patients on maintenance hemodialysis (mean age 46 +/- 5 years) with diastolic heart failure and normal systolic function (ejection fraction > 40%), although hemodialysis had been correctly performed, were included in the study. All patients had left ventricular hypertrophy. Diltiazem was given at the dosage of 60 mg, twice a day, for 3 months. At the end of this period, significant improvement of Doppler echocardiographic filling pattern and clinical symptomatology were observed, but left ventricular mass index was unchanged. Episodes of intradialytic hypotension were significantly reduced. We conclude that diltiazem improves symptoms and left ventricular diastolic filling in uremic patients with diastolic heart failure, without modifying left ventricular mass index; impaired diastolic function has an important role in recurrent dialysis hypotension.

[Angiotensin-II receptor inhibitors in hemodialysed uremia patients with arterial hypertension: candesartan cilexitil versus losartan]. / Inibitori recettoriali dell'angiotensina II in pazienti uremici emodializzati con ipertensione arteriosa: candesartan cilexitil versus losartan.

BACKGROUND: The aim of this study was to evaluate, in patients with chronic renal failure in hemodialysis and arterial hypertension, the effectiveness of a new angiotensin II receptor antagonist, the candesartan cilexitil, comparing it with losartan, the first of this new class of drugs. METHODS: We have selected 128 patients with chronic renal failure (92 males and 36 females, mean age 56 +/- 6 years) and arterial hypertension, subjected to hemodialysis 3 times a week, with hemodialytic seniority of 90 +/- 10 months. The inclusion criteria in the study were given from the presence, after 15 days of pharmacological wash-out, of values of diastolic blood pressure (DBP) > or = 95 mmHg and systolic blood pressure (SBP) > or = 150 mmHg, despite a hemodialysis correctly performed. Patients were divided into two groups whether they received single blind randomized candesartan cilexitil 16 mg or losartan 50 mg at hour 8.00 for a period of 8 weeks at the end of which, after a period of pharmacological wash-out of 15 days, the drugs were administered to inverted groups for other 8 weeks. After 4 and 8 weeks of treatment an evaluation of the anti-hypertensive effectiveness by means of medical complete visit and measurement of blood pressure were made. The statistical analysis was made by means of Student's t test for paired data. RESULTS: All the patients concluded the study. After 4 weeks of treatment SBP and DBP were reduced in the group with candesartan cilexitil with regard to baseline values (SBP 151.8 +/- 6.3 vs 159.8 +/- 5.1 mmHg, p < 0.05; DBP 93.6 +/- 4.5 vs 98.1 +/- 3.7 mmHg, p < 0.05). In the losartan group (SBP 151.8 +/- 6.3 vs 158.7 +/- 5.5 mmHg, p < 0.05; DBP 93.6 +/- 4.5 vs 97.5 +/- 3.8 mmHg, p < 0.05) no significant reduction in blood pressure values was observed compared with baseline values (SBP 158.7 +/- 5.5 vs 159.8 +/- 5.1 mmHg, NS; DBP 97.5 +/- 3.8 vs 98.1 +/- 3.7 mmHg, NS). After 8 weeks of treatment in the candesartan cilexitil group (SBP 128.3 +/- 5.9 vs 159.8 +/- 5.1 mmHg, p < 0.05; DBP 81.5 +/- 4.1 vs 98.1 +/- 3.7 mmHg, p < 0.05) and in the losartan group (SBP 151.7 +/- 5.1 vs 159.8 +/- 5.1 mmHg, p < 0.05; DBP 92.7 +/- 3.9 vs 98.1 +/- 3.7 mmHg, p < 0.05) blood pressure values were reduced in the same manner as at baseline. By comparing the two drugs, candesartan cilexitil proved to have a better antihypertensive effectiveness (SBP 128.3 +/- 5.9 vs 151.7 +/- 5.1 mmHg, p < 0.05; DBP 81.5 +/- 4.1 vs 92.7 +/- 3.9 mmHg, p < 0.05). CONCLUSIONS: Our experience suggests that angiotensin II receptor antagonists may be a therapeutic remarkable option in patients with chronic renal failure in hemodialysis and arterial hypertension; the antihypertensive effect seems to be class-specific. Nevertheless, at least for our data, a better and more rapid antihypertensive results was obtained with candesartan cilexitil.

[Complex ventricular arrhythmias and carvedilol: efficacy in hemodialyzed uremic patients]. / Aritmie ventricolari complesse e carvedilolo: efficacia in pazienti uremici emodializzati.

Carvedilol has been shown to be effective in systemic hypertension and coronary artery disease in patients with end-stage renal disease, on maintenance hemodialysis. The aim of our study was to assess the effects of carvedilol on ventricular arrhythmias in these patients. Ninety-eight uremic patients maintained on hemodialysis, with complex ventricular arrhythmias (class III, IV and V of Lown's classification), not only during dialysis, were included in the study. They were divided into two groups, with mild-to-moderate hypertension or coronary artery disease. The efficacy and safety of carvedilol (50 mg/day) was compared to placebo in a 6-week randomized, double-blind study. Carvedilol significantly reduced, in both hypertensive and ischemic patients, total ventricular premature contractions (82.7 +/- 11.3 vs 358.1 +/- 73.9, p < 0.001; 88.3 +/- 24.4 vs 369.9 +/- 77.8, p < 0.001), repetitive ventricular premature contractions (1.3 +/- 1.3 vs 6.3 +/- 3.5, p < 0.001; 1.2 +/- 0.7 vs 6.9 +/- 2.6, p < 0.001) and episodes of ventricular tachycardia (1.1 +/- 1.2 vs 11.8 +/- 7.5, p < 0.001; 1.4 +/- 1.2 vs 14.0 +/- 8.3, p < 0.001). In placebo-treated patients, instead, these parameters were not significantly changed (329.1 +/- 76.5 vs 361.7 +/- 71.7, NS, and 324.6 +/- 79.7 vs 359.3 +/- 58.1, NS; 6.2 +/- 3.7 vs 7.3 +/- 3.7, NS, and 4.9 +/- 2.2 vs 6.1 +/- 3.2, NS; 9.8 +/- 6.3 vs 13.3 +/- 8.0, NS, and 9.0 +/- 6.2 vs 12.4 +/- 7.8, NS). Carvedilol confirmed a significant effect on myocardial ischemia and systemic hypertension. No significant side effects were reported. Ventricular arrhythmias are frequent in patients with end-stage renal disease maintained on hemodialysis. They are often due to an underlying cardiac disease, namely systemic hypertension with left ventricular hypertrophy and coronary artery disease. The results of our study show that the antiarrhythmic effect of carvedilol is linked, at least partly, to an improvement of the underlying cardiac disease. Uremic patients have a chronic increase in adrenergic tone, with a direct correlation between norepinephrine plasmatic concentration and frequence of premature ventricular contractions. Beta-blockers are very important in these patients because of their modulation on the adrenergic system. They also reduce potassium flow, from extracellular to intracellular fluid. Therefore carvedilol can affect the sudden hypokalemia occurring in the first phase of hemodialysis treatment, that may be an important cause of intradialytic arrhythmias.

[Incremental doses of diltiazem in patients with coronary artery disease in end-stage renal failure maintained on hemodialysis: which is the optimal dose?]. / Diltiazem a dosaggi crescenti in pazienti uremici emodializzati con cardiopatia ischemica: qual è il dosaggio ottimale?

End-stage renal disease patients on maintenance hemodialysis suffering from coronary artery disease probably receive too low doses of calcium-antagonists, because the attempt to avoid adverse effects prevails the well-documented antianginal activity of the drug. The aim of our study was to assess the safety and efficacy of incremental doses of diltiazem in treating angina pectoris in hemodialyzed patients with coronary artery disease, to identify the optimal dose. Ninety-four chronic hemodialyzed patients (59 males and 35 females; mean age 55.2 +/- 3.3 years; on periodic dialysis for 80.3 +/- 25.6 months) with coronary artery disease and more than 5 min of transient myocardial ischemia during 48 hours of Holter monitoring were included in the study. A double-blind, randomized, placebo-controlled trial design was used. Incremental doses of diltiazem (from 120 to 240 mg/day) were administered in 4 months. At doses of 120 and 180 mg/day it was observed a statistically significant reduction in the number and duration of total and symptomatic ischemic episodes in 48 hours, compared with baseline (p < 0.001). Instead, the number and the duration of silent ischemic episodes did not significantly change (NS). The efficacy on silent myocardial ischemia was obtained only with the dosage of 240 mg/day (p < 0.001). If this dosage was obtained with a sustained-release formulation (120 mg twice a day), the efficacy was similar to the administration of 4 tablets/day of 60 mg, but the tolerability was better, especially during dialysis. The circadian variations of transient ischemic episodes showed two peaks in the 24 hours, one from 6.00 to 9.00 a.m. and another from 4.00 to 8.00 p.m., just during the dialysis. Both peaks were reduced only with 240 mg/day. In conclusion, this study demonstrates that sustained-release diltiazem (120 mg twice a day) is greatly useful in patients with coronary artery disease on maintenance dialysis because it reduces the frequency of silent ischemic episodes, has a good tolerability, and modifies the circadian pattern of ischemic episodes, reducing both peaks during the day.

[Syndrome X and microvascular angina]. / Sindrome X ed angina microvascolare.

The term X syndrome is used to indicate a group of patients who present anginous symptoms and ischemic-type electrocardiographic alterations which appear during exercise tolerance tests, dipiridamol tests or Holter's dynamic monitoring where coronary ultrasonography reveals no evident coronary lesions, vasospastic angina, arterial hypertension and/or diabetes mellitus, block of the left branch when resting or exercising, cardiomyopathy or valvulopathy. The highest incidence is in females with a mean age of around 50. A reduced reserve of coronary flow, highlighted both in response to vasodilatators or rapid stimulation and by positron emission tomography (PET), underlies this syndrome. It is thought to be caused by a dysfunction of the coronary microcirculation which consists in a deficit of the endothelium-dependent vasodilatory mechanisms, probably also owing to the accumulation of vasoconstrictive type substances, like endothelin-1. In addition to a dysfunction of the coronary microcirculation, one widely backed hypothesis concerns the existence of an altered perception of painful symptoms in patients with X syndrome: the anomalous constriction of prearteries might cause an increased release of adenosine, able to provoke angina despite the scarce signs of myocardial ischemia in terms of the metabolic or functional profile. From a therapeutic point of view, treatment of these patients is often ineffective: treatment should be based on the use of nitrates, calcium-antagonists or beta-blockers, if necessary moving on to other forms of therapy (aceinhibitors, xanthine methylate, estrogens, alphablockers, imipramine); the simultaneous use of tranquillizers may be useful in view of the anxious personality often characteristic of these patients.

[Effectiveness and tolerability of bisoprolol vs. nifedipine in uremic patients with ischemic cardiopathy in dialysis treatment]. / Efficacia e tollerabilità di bisoprololo e nifedipina in pazienti uremici con cardiopatia ischemica in trattamento dialitico.

The effects of bisoprolol on transient myocardial ischemia have been compared with those of nifedipine in patients with coronary artery disease in end-stage renal failure maintained on haemodialysis. We also evaluated the tolerability of both drugs. Sixty patients (42 males, 18 females, mean age 52 +/- 4 years) in renal failure maintained on haemodialysis, with coronary artery disease and more than four significant episodes of transient myocardial ischemia (> or = 1 min) during 48-hour Holter monitoring, were included in the study. All cardiovascular drugs were discontinued > or = 6 days before this 48-hour ambulatory ECG monitoring, with the exception of sublingual nitrates allowed for relief of anginal attacks. Patients were then randomized to receive either bisoprolol or nifedipine for 2 weeks. After a 15-day wash-out period, they were crossed over to receive either bisoprolol or nifedipine for other 2 weeks. Statistical analysis was carried out using the Student's t test. A p value < 0.01 was considered significant. Both bisoprolol and nifedipine reduced number and duration of transient ischemic episodes as well as the total ischemic burden. Reductions were statistically significant for both antianginal drugs. Only bisoprolol was effective in silent ischemia (p < 0.001). It also reduced heart rate (p < 0.001), while nifedipine raised it (p < 0.001). Both drugs reduced systolic and diastolic blood pressure. The circadian variations of transient ischemic episodes showed two peaks in the 24 hours. Both peaks were reduced with bisoprolol. Nifedipine brought a clear overall reduction in the number of episodes but the circadian pattern was unchanged. During the study, 10 patients taking bisoprolol and 12 patients taking nifedipine had drug adverse effects. No one of them had to be withdrawn from treatment. In conclusion, bisoprolol seems to be more useful than nifedipine because its effects, in transient ischemic episodes, are greatly superior to those of nifedipine, and because it is effective also in silent ischemia. Both drugs showed a good tolerability in these patients. Bisoprolol, reducing the two daily peaks of ischemic episodes frequency, has a protective role towards mortality due to coronary artery disease.

[Acute hepatitis following amiodarone administration]. / Epatite acuta dopo somministrazione di amiodarone.

A 61 year old man, treated with amiodarone since 1993 for resistant supraventricular arrhythmias, developed acute hepatitis after an intravenous amiodarone administration. Kidney and liver function tests were performed and pointed out abnormal results. Symptoms ascribable to hepatotoxicity were absent. These changes returned to normal levels within 20 days from withdrawal of the drug. Amiodarone hepatotoxicity can be related to prolonged therapy with a high dose. Intravenous amiodarone may cause acute hepatic disease, but it is suggested that polysorbate 80, a solvent added to the intravenous infusion, is a more likely cause of this complication.

[Myocardial infarct without Q wave in the elderly: diagnostic evaluation using vectorcardiography]. / Infarto miocardico senza onda Q in età geriatrica: valutazione diagnostica con tecnica vettorcardiografica.

The diagnosis of previous non-Q wave myocardial infarction by standard electrocardiographic investigation is uncertain, particularly in elderly patients because of concomitant disease. We have studied 31 elderly patients (aged 63-72 years) with a diagnosis of non-Q wave myocardial infarction between 1-6 months after this acute event. The patients underwent clinical-anamnestic examination, standard electrocardiography, vectorcardiography according to the Frank system and M-mode and 2-D echo-cardiography with continuous and pulsated Doppler. The ECG showed ST-T anomalies in 12 patients (38.7%) whereas the VCG showed anomalies of QRS-loop normal convexity in 27 patients (87%) and 16 of these (51.6%) showed bites criteria (duration > or = 10 msec, voltage > or = 0.1 mV, present at least on two planes). By echocardiography, regional hypo-akinesia was observed in 19 patients (61.3%). Although bites are not only present in myocardial infarction, they indicate an interruption of myocardial gradual electric activation, compatible with fibrous areas, and should be evaluated as a part of the clinical-anamnestic, laboratory and instrumental data.

[Infectious endocarditis in dentistry practice: recent controversies and modes of the use of antibiotic prophylaxis]. / L'endocardite infettiva nella pratica odontostomatologica: recenti controversie e modalità di applicazione dell profilassi antibiotica.

A survey by questionnaire to assess the daily practice of the antibiotic prophylaxis of infective endocarditis by physicians attending post-graduate schools of the Institutes of Oral Surgery and Stomatology (Group A n = 83) and Cardiology (Group B n = 46) of the Second University of Naples has been conducted. They were asked about dental procedure and cardiopathies that require prophylaxis for infective endocarditis, the relationship between infective endocarditis and rheumatic disease and the provision of antibiotic. Extraction of tooth and dental and oral surgery have been reported as the most risky procedures. Moreover provision of antibiotic prophylaxis was suggested to patients not at risk (pacemaker or coronary artery bypass), and was not suggested in high risk conditions (mitral valve prolapse with regurgitation and hypertrophic cardiomyopathy). Most of the 50-60% practitioners usually start the prophylaxis 24-48 hours before the procedure and prolong it for 48-72 hours. These results underline the need for improvement of the knowledge for the antibiotic prophylaxis of infective endocarditis.

[Silent ischemia in patients on dialysis treatment]. / Ischemia silente in pazienti in trattamento dialitico.

The authors carried out a perspective study to determine the frequency of silent ischemia (SI), in 50 consecutive patients with end stage renal failure, during dialysis by Holter monitoring. Twenty patients had SI. The number of cardiovascular risk factors, principally diabetes, smoking and the underlying renal disease was related to ischemic events. Dialysis may predispose to and facilitate the detection of myocardial ischemia by the simultaneous presence of hypotension, hypovolemia, hypoxia and tachycardia. Holter monitoring may allow the detection of ischemic events and the identification of a subgroup of dialytic patients with a high cardiovascular risk.

[Mitral prolapse and the ergometric findings]. / Prolasso della mitrale e rilievi ergometrici.

In evaluating the significance of arrhythmias and ECG changes during exercise, 42 consecutive patients (pts) with mitral valve prolapse (MVP) underwent a symptom-limited cycloergometer Exercise Stress Test (EST) with load increase of 25 watts every 3 minutes. Eight patients (19%) were positive for anamnestic cardiopalm. The patients were divided in 2 groups, according to echocardiographic evidence of the MPV: group A (12 patients, mean age 32 +/- 13) with prolapse of one mitral leaflet and group B (30 patients, mean age 30 +/- 13) with prolapse of both mitral leaflets. Exercise duration doesn't differ significantly in the two groups. No arrhythmias during EST were found in group A, while arrhythmias were present in 6 patients (20%) in group B. A strong correlation was found between anamnestic cardiopalm and arrhythmias during EST (6/8 = 75%). Three of four patients (75%) with ST impairment during EST, showed at thallium myocardial scintigraphy a non reversible perfusion defect after exercise. These data showed a higher incidence of arrhythmias during EST in patients with MVP of both leaflets and good relationship with symptomatology of cardiopalm.

[Vector cardiography features of right ventricular activation delays: nosologic classification and clinical correlation]. / La vettorcardiografia nei ritardi di attivazione ventricolare destra: inquadramento nosologico e correlazione clinica.

Electrovectorcardiographic features of 150 patients showing right ventricular activation delays (RVAD) has been analyzed. This analysis of RAVD, especially for type I, which is the group with the widest morphologic variability, has permitted a more detailed classification: a type I with 5 subtypes, a type II with 1 subtype, a type III and an intermediate type between type II and III. Fifty-five per cent of the patients were included in type I and its variant and most were classified, often without cardiac disease, as belonging to the classic type I. Thirty per cent of RVAD were of type II; 12% of type III and the remaining were in the intermediate group between type II and III. The various morphologies, moreover, were correlated with the clinical picture: the classic type I was never seen in subjects with cardiac disease, while the others types and subtypes were present either in subjects with cardiac disease or in elderly subjects, also without relevant pathologies (senile heart, especially, the type IA") or in otherwise healthy subjects. In a medical-social context, checking for RVAD, in the absence of cardiac disease, might usefully avoid further investigation. It is underlined the usefulness of this correlation for clinical prognostic judgement.