A 34-year longitudinal study on long-term cardiac outcomes in DM1 patients with normal ECG at baseline at an Italian clinical centre.

Cardiac conduction and/or rhythm abnormalities (CCRA) are the most frequent and life-threatening complications in DM1. In order to determine prevalence, incidence, characteristics, age of onset and predictors of CCRA, CCRA progression and sudden cardiac death (SCD) in DM1, we collected ECG/24hECG-Holter data from a yearly updated 34-year database of a cohort of 103 DM1 patients without cardiac abnormalities at baseline, followed for at least 1 year. Fifty-five patients developed CCRA [39 developed conduction abnormalities (CCA) and 16 rhythm abnormalities (CRA)], which progressed in 22. Nine had SCD. Risk and incidence of CCRA amounted to 53.4 and 6.83% person-years (CCA: 37.9 and 4.8%; CRA 15.5 and 2%), respectively; risk and incidence of SCD amounted to 8.74 and 0.67% person-years, respectively. CTG expansion represented a predictor of CCRA incidence (HR 1.10, p = 0.04), CCRA progression (HR 1.28, p = 0.001) and SCD (HR 1.39, p = 0.002). MIRS progression during follow-up was associated with CCRA prevalence (OR 5.82, p = 0.004); older age and larger CTG expansion to SCD prevalence (OR 2.67, p = 0.012; OR 1.54, p = 0.005). Age of CCRA onset and CCRA progression was significantly lower in patients with larger CTG expansion and in those with MIRS progression. Age when SCD occurred was significantly lower in patients with larger CTG expansion. Amongst recorded cardiac abnormalities, both atrial flutter (OR 8.70; p = 0.031) and paroxysmal supraventricular tachycardia (OR 8.67; p = 0.040) were associated with SCD. Although all DM1patients may develop cardiac abnormalities at any time in their life, patients older than 30 years with larger CTG expansion and MIRS progression in particular should be carefully monitored via periodical ECG.

Association Between Lifestyle and Systemic Arterial Hypertension in Young Adults: A National, Survey-Based, Cross-Sectional Study.

INTRODUCTION: The prevalence of systemic arterial hypertension in young adults is increasing worldwide in association with modifiable risk factors. AIM: To assess the prevalence of high blood pressure (BP) in young adults participating to a screening campaign during the World Hypertension Day (17/05/2014), and to determine the possible association with lifestyle factors. METHODS: 493 individuals aged 18-35 years were selected in 13 Italian cities. All participants underwent BP measurement together with the administration of a questionnaire exploring: medical and drug history; traditional cardiovascular risk factors and diseases; dietary pattern; salt intake; sleep habits; mood disorders. RESULTS: High BP (≥140/90 mmHg) was found in 54 individuals, with a prevalence of 11% and awareness of 28%. Those with high BP values were more frequently men, reported a higher BMI and a greater use of corticosteroids and non-steroidal anti-inflammatory drugs, and had a lower anxiety score. Concerning dietary habits, they were more likely to eat cheese/cold cuts ≥3 times/week, to have their meals out ≥1/day and to eat in fast foods ≥1/week. In the multiple logistic regression analysis, male sex [OR 3.19, 95% CI (1.33-7.63)], BMI [OR 1.14 95% CI (1.04-1.25)], eating in fast foods [OR 3.10 95% CI (1.21-7.95)], and anxiety [OR 0.85 95% CI (0.75-0.97)], were independently associated with high BP. CONCLUSIONS: High BP values were found in 11 % young adults. Male sex, adiposity and alimentary habits were the main determinants of high BP values, indicating that young men are a suitable target for healthy lifestyle interventions.

Hypertension in Young People: Epidemiology, Diagnostic Assessment and Therapeutic Approach.

High blood pressure (BP) still remains one of the most relevant cardiovascular risk factors, also due to its persistently high prevalence and growing incidence in the general adult and elderly population. Since almost all hypertension-related cardiovascular complications, mostly including coronary artery disease, myocardial infarction, ischemic stroke, and congestive heart failure, occurred in adult and elderly individuals, evidence on both prevalence and clinical management of hypertension in young individuals are lacking. Therefore, the clinical impact of high BP levels in young populations remains to be explored. In the recent years, the attitude of the scientific community has changed and more attention was devoted to young individuals with hypertension, also in view of the fact that early identification of these subjects may prevent developing of established hypertension in adulthood. In addition, unhealthy lifestyle habits have progressively involved children and adolescents worldwide, thus contributing to further increase the risk of developing hypertension in young individuals. On the basis of these considerations, the present review is aimed at providing a brief reappraisal of the major aspects of hypertension in the young age, as well as at promoting interest and discussion on this important issue.

Hypertension in premenopausal women: is there any difference?

Hypertension is one of the most important cardiovascular (CV) risk factor, and that lowering blood pressure levels reduces the incidence of CV morbidity and mortality. The higher incidence of hypertension in post-menopausal than in pre-menopausal women raises the attention on the pathophysiological mechanisms potentially involved in post-menopausal ones and outweigh those involved in pre-menopausal women. However, CV disease is one of the leading causes of death in reproductive-age women. Thus, improved awareness, early identification and prompt clinical management of hypertension should be key elements in order to prevent hypertension-related CV morbidity and mortality in pre-menopausal women. However, available data in this specific age group of women are relatively poor and inconsistent, so that the clinical management of young hypertensive women is still debated. The aim of this review is to assess whether there are clear evidences on differences between men and women in epidemiological data, pathophysiological mechanisms, diagnostic options and therapeutic interventions of hypertension and its prognosis, in order to establish the correct approach to this group of hypertensive patients.

Do diabetes, metabolic syndrome or their association equally affect biventricular function? A tissue Doppler study.

Metabolic syndrome (MetS) and type 2 diabetes (T2DM) have been associated with an impairment of left (LV) and right ventricular (RV) function as well as an increased risk of heart failure (HF). However, it remains unclear whether these clinical entities or their associations promote a similar derangement of biventricular function. Overall, 345 patients without overt cardiovascular disease consecutively underwent routine blood chemistry including high-sensitivity C reactive protein (hs-CRP) and echocardiographical examination with conventional and tissue Doppler imaging (TDI) of both ventricles. According to the ATP III criteria and fasting glucose levels, the study population was stratified into four groups: (1) healthy controls (n=120); (2) MetS without T2DM (n=84); (3) T2DM without MetS (n=49); and (4) MetS+T2DM (n=92). The Myocardial performance index (MPI) of the RV and LV was obtained with a multi-segmental approach using TDI. Patients with MetS and T2DM exhibited a similar impairment of biventricular function compared with healthy controls, whereas a further decline was observed in patients having both MetS and T2DM. In addition to MetS markers, hs-CRP exhibited the strongest association with the MPI of both ventricles. Regression analyses indicated that individual MetS markers were inferior to MetS in identifying subtle cardiac dysfunction. Independent associations of MetS and T2DM with biventricular dysfunction were comparable, and the coexistence of MetS and T2DM exhibited the highest risk for biventricular dysfunction. Our findings emphasize the importance of MetS as an equivalent of T2DM and support a synergic effect of these clinical conditions on cardiac organ damage requiring more aggressive therapeutic strategies to prevent HF.

Inadequate RAAS suppression is associated with excessive left ventricular mass and systo-diastolic dysfunction.

BACKGROUND: Inadequate suppression of renin-angiotensin-aldosterone system (RAAS) following postural maneuvers may have detrimental effects on cardiac structure and function. In this study, we aimed to appraise the clinical significance of this phenomenon by assessing its relation with inappropriate ventricular mass (ILVM), an adverse phenotype of LV remodeling and dysfunction. METHODS: Both supine and upright plasma renin activity (PRA) and aldosterone concentrations (PAC) were measured in 115 young newly diagnosed hypertensive subjects. 24-h ambulatory blood pressure monitoring and echocardiographic evaluation including tissue Doppler imaging (TDI) were also performed. Patients were divided as follows: (1) normal PRA and PAC (N) (n = 63); (2) suppressible RAAS (SR) in supine position (n = 27); (3) not suppressible RAAS (NSR) (n = 25). ILVM was expressed as the observed/predicted LV mass ratio ×100 (%PLVM), while LV dysfunction (LVD) was identified by TDI-derived myocardial performance index (MPI). RESULTS: NSR showed a higher prevalence of ILVM than SR and N. As compared with N and SR, NSR patients had reduced indices of systolic and diastolic function. MPI of the LV as well as prevalence of LVD was also significantly higher in the NSR group. Regression models showed that lack of RAAS suppression was independently associated with ILVM and LVD. CONCLUSIONS: Prevalence of ILVM and LVD is higher in patients without clinostatic RAAS suppression. Our findings encourage the assessment of RAAS deregulation to better estimate individual cardiovascular risk in patients with arterial hypertension.

Relation between right and left ventricular function in patients undergoing chronic dialysis.

AIMS: Occurrence of heart failure during dialysis treatment is associated with high mortality. However, mechanisms underlying left ventricular dysfunction (LVD) in these patients are still elusive. In patients undergoing haemodialysis, arteriovenous fistula (AVF) is associated with right ventricular dysfunction (RVD) and a further impairment is observed when AVF is brachial rather than radial. However, it is not known whether AVF-induced RVD is associated with an impaired left ventricular function. We studied the relation between right and left ventricular function in 120 patients undergoing either haemodialysis or peritoneal dialysis and 100 healthy age-matched controls. METHODS: Echocardiography including tissue Doppler imaging (TDI) was performed for both ventricles. Average myocardial performance index (MPI) of the right ventricle (RV MPI) was obtained with a multisegmental approach by using TDI. RESULTS: RVD was higher in haemodialysis than peritoneal dialysis patients and a further increase was observed in haemodialysis patients with brachial access. Interestingly, RV MPI inversely correlated with indices of both left ventricular contraction and relaxation and the association was even stronger in haemodialysis patients, particularly in those with brachial AVF. Of note, dialysis patients in the upper tertile of RV MPI showed the larger impairment of left ventricular function. Regression analyses showed that RV MPI was independently associated with reduced left ventricular function. By contrast, LVD did not significantly affect right ventricular performance in this setting. CONCLUSION: AVF-induced RVD may contribute to LVD in dialysis patients. AVF plays a pivotal role in triggering LVD via right-to-left ventricular interdependence.

[Polytherapy in cardiovascular prevention: open issues]. / La politerapia in prevenzione cardiovascolare: problemi aperti.

Despite the considerable advances in preventive treatment achieved over the last two decades, the increasing burden of cardiovascular disease represents an urgent need for new therapeutic strategies to reduce cardiovascular mortality and morbidity. The current pandemic of obesity, hypertension and diabetes, as a result of unhealthy lifestyle and dietary habits together with predisposing genetic backgrounds, is the main cause of increased cardiovascular mortality and raised overall health expenditure. Despite the growing number of cardiovascular prevention campaigns, the control of cardiovascular risk factors remains largely unsatisfactory worldwide. Unhealthy lifestyles lead to an increased consumption of drugs to achieve target levels of cardiovascular risk factors, namely blood pressure and low-density lipoprotein cholesterol. This phenomenon results in a disproportionate increase in the number of cardiovascular drugs, already in the early stages of disease. Despite current guidelines encourage combination therapies in cardiovascular prevention, the adoption of polytherapy, commonly defined as the use of 5 or more drugs, is extremely frequent and is often paradoxically unsuccessful due to poor patient education and adherence, increased adverse effects and inappropriate drug prescribing. Moreover, increased life-expectancy resulting from early treatment of myocardial infarction and improved heart failure management has led to an older population characterized by an increased prevalence of comorbid conditions. This is a further reason for increased prescription of drugs leading to an impairment of patient adherence and increased adverse effects. In order to overcome the emerging problem of polytherapy, the use of a single "polypill" containing a combination of drugs for cardiovascular prevention has been postulated. Such an approach is providing promising results in the management of hypertension and dyslipidemia. However, available evidence is still preliminary and prospective data on cardiovascular outcomes are still lacking. This present article proposes a critical analysis of some open issues related to polytherapy in cardiovascular prevention.

Increased temporal dispersion of myocardial repolarization in myotonic dystrophy type 1: beyond the cardiac conduction system.

BACKGROUND AND OBJECTIVES: The most frequently mechanism underlying sudden cardiac death in myotonic dystrophy type 1 (DM1) is bradyarrhythmias due to cardiac conduction abnormalities. However the risk of ventricular tachyarrhythmias remains a concern in clinical management as well as in its determinant. We therefore assessed autonomic nervous system activity aiming to disclose differences in the QT variability index (QTVI)-a marker of temporal myocardial repolarization lability-between DM1 patients and healthy controls. We also investigated the possible differences within DM1 patients by subdividing them according either to the presence of first degree atrioventricular block (1st AVB) or to the cytosine-thymine-guanine (CTG) repeat expansion size. METHODS: Sixty-two DM1 patients and 20 healthy subjects underwent neurological and cardiological examinations, the latter including ECG, echocardiography and 24-hour Holter monitoring. All underwent a 5-minute ECG recording to assess heart rate variability power spectral components, and the QTVI values. RESULTS: Power spectral data, namely total power, low frequency power and high frequency power, were lower, whereas QTVI values were higher in DM1 patients than in controls (p<.0001). Higher QTVI values were found in DM1 subgroups with 1st AVB (p=.009) and more than 500 CTG repeat (p=.014) with respect to DM1 patients without 1st AVB and CTG<500. Spectral data did not significantly differ. At multivariable analysis, QTVI and age were independently associated with PR interval and CTG repeat. CONCLUSIONS: The increased values of QTVI argue in favour of an important heart involvement extending beyond the conduction system. Whether QTVI could be useful in predicting clinical course of DM1 clearly requires larger prospective studies.