[The heart patient in the mountains: the behavioral indications]. / Il cardiopatico in montagna: indicazioni comportamentali.

Even today, a restrictive attitude frequently leads the physician to discourage the patient with cardiovascular abnormalities from sojourning at an altitude over 1000 m. This attitude, however, is not supported by any scientific proof. After a review of the major cardiovascular adaptations during high altitude exposure, we reported the principal studies of the effects of high altitude on patients with coronary heart disease, particularly during exercise. On the basis of personal experience and of other authors, we can state that the patient with ischemic heart disease, asymptomatic and with a recent clinical and functional evaluation, can stay in the mountains, even at altitudes of 2000-3000 m, and can hike and ski (cross-country and downhill). The risks appear to be related to factors independent of altitude, such as excessive cold or intense emotional stress due to dangerous situations, conditions that must consequently be avoided. On the other hand, an individual approach should be followed for the other congenital and acquired heart diseases, in which case we must consider, in addition to the clinical situation, some peculiar aspects of mountain environment (hypoxia, isolation, difficult access to medical facilities). Finally, the hypertensive patient, expected to have higher blood pressure values, especially diastolic, should frequently record his values during the first week at high altitude, eventually adjusting the therapy.

Italian high altitude laboratories: past and present.

Italy is a mountainous country with a total of 88 huts and bivouacs at altitudes higher than 3,000 m. Starting in the 19th century a great deal of research in high altitude pathophysiology has been carried out in Italy and many Italian physicians have been involved in mountain medicine. Most of the Italian research has been carried out at two locations: the scientific laboratories "Angelo Mosso" on Monte Rosa (Capanna Regina Margherita and Laboratorio Angelo Mosso), and the "Pyramid" in Nepal. The Capanna Regina Margherita, located on the top of Punta Gnifetti (Monte Rosa, 4,559 m), was inaugurated in 1893. With the support of Queen Margherita of Savoy, an Observatory for scientific studies was built beside this hut in 1894. In 1980 the hut was completely rebuilt by the Italian Alpine Club. The Istituto Angelo Mosso at Col d'Olen, at the base of Monte Rosa (at 2,900 m) was inaugurated in 1907. The high altitude laboratory named the "Pyramid" was built in 1990. Made of glass and aluminium, this pyramid-shaped structure is situated in Nepal at 5,050 m. The scientific laboratories "Angelo Mosso" on Monte Rosa (mainly the Capanna Regina Margherita) and the Pyramid form a nucleus for high altitude research: the former is especially devoted to research regarding acute mountain sickness and the response to subacute hypoxia, whereas the latter is a unique facility for research responses to chronic hypoxia, the effect of exposure to very high altitude, and the study of the resident population living in the Himalayas for at least 25,000 years.

Effects of high-altitude chronic hypoxia on platelet alpha 2-receptors in man.

During chronic high-altitude (HA) exposure, basal and exercise-induced noradrenaline (NA) increases do not parallel blood pressure (BP) changes observed; unlike beta-adrenergic receptors, to our knowledge no data are available on alpha-receptors. We studied platelet alpha 2- and leucocyte beta-receptors and basal catecholamine levels in 11 trained climbers before and after they had spent a 15-day period at a height of over 4400 m. In six of the climbers we also evaluated catecholamines after maximal bicycle ergometer exercise. After chronic high-altitude exposure, a significant decrease was found in platelet alpha 2-receptor density and affinity [Bmax from 92.6 +/- 6.7 to 54.6 +/- 4.2 fmol mg-1 protein (P < 0.001) and KD from 1.271 +/- 0.034 to 1.724 +/- 0.077 nmol L-1 (P < 0.05)], although no changes to beta-receptors were observed. No changes were found in basal pre- and post-expedition NA and adrenaline (A), and there was only a slight decrease in post-expedition NA after maximal exercise. Our results suggest that prolonged exposure to hypoxia induces a down-regulation of alpha 2-receptors, which may be a contributory factor in the regulation of the physiological vascular response to acclimatization.

Cardiovascular neural regulation during and after prolonged high altitude exposure.

Eight young healthy male subjects, members of a Himalayan expedition, underwent 24 h Holter monitoring before departure, after 1 and 4 weeks at high altitude (5000 m) and after return to sea level. At high altitude, the circadian reciprocal changes in low and high frequency (LF, HF) were absent, with no significant reduction in the LF to HF ratio over the 24 h; moreover, the proportion of adjacent R-R intervals that differed by more than 50 ms (pNN50) decreased significantly and remained lower after return to sea level. Urine catecholamines increased at high altitude, but only norepinephrine, after 1 week of exposure, rose significantly. Upon return to sea level the density, but not the affinity, of [alpha]2-adrenergic receptors on platelets decreased significantly compared to pre-expedition values. At high altitude increased sympathetic activity was indicated by elevation of urine norepinephrine and by the loss of circadian rhythm in spectral components. The simultaneous reduction of HF and pNN50 demonstrated decreased vagal tone. The persistence of increased sympathetic activity could explain the downregulation of adrenergic receptors after prolonged high altitude exposure.

Long-term echocardiographic Doppler monitoring of Hancock bioprostheses in the mitral valve position.

Echocardiographic and Doppler studies were performed in 134 patients with a Hancock bioprosthesis in the mitral valve position during a follow-up period of 1 to 216 months. Among the xenografts, 57% were clinically normal and 43% had severe dysfunction. Among the normal bioprostheses, 35% had echocardiographically thickened mitral cusps (> or = 3 mm) with normal hemodynamic function; by setting the lower 95% confidence limit of valve area at 1.7 cm2 these patients had a significantly (p < 0.01) smaller valve area than that of normal control subjects. Evaluation of all thickened normal mitral valves showed the highest incidence of thickening at 9 years after implantation. Valve replacement surgery was subsequently performed in 33 patients with dysfunctioning bioprosthetic and echocardiographic diagnosis was confirmed in 91% of explanted valves (bioprosthetic stenosis 21%, incompetence 46%, and combined stenosis and regurgitation 33%). In 2 valves that were found to be stenotic on echocardiographic examination, a calcium-related commissural tear was also observed at reoperation, and in another, a paravalvular leak was found. Dystrophic calcification, isolated (64%) or occasionally associated with fibrous tissue overgrowth (21%), was the main cause of failure. Pannus was present in prostheses with longer satisfactory function (168 +/- 31 vs 124 +/- 21 months; p < 0.001). Long-term performance was evaluated by the Kaplan-Meier method for up to 18 years of follow-up. Freedom from structural valvular disfunction after mitral replacement was 89% at 6 years, 77% at 8 years, 56% at 10 years, 31% at 12 years, 16% at 15 years, and 15% at 18 years.

Reversible and irreversible left ventricular dysfunction after acute myocardial infarction.

Left ventricular function after acute myocardial infarction depends on several mechanisms leading to left ventricular remodeling: (a) infarct size and healing and (b) adaptive changes involving both the dysfunctioning but viable myocardium (hibernating and stunned myocardium) and the nonischemic myocardium. The prognosis after acute myocardial infarction is strongly related to regional and global left ventricular function and the loss of dysfunctioning viable myocardium is a main factor in the worsening in left ventricular function in survivors of the acute phase. Thus, medical strategies should exert their beneficial effect on the "mechanical instability" of ventricular myocardium by saving the viable myocardium. beta-Blocker therapy has been shown to be effective in improving the prognosis via anti-ischemic and antiarrhythmic actions. The combination of metoprolol and nisoldipine seems to be able to preserve the contractile function of viable myocardium in the first 6 months after acute myocardial infarction.

Exercise-induced left ventricular dysfunction in coronary heart disease. A model for studying the stunned myocardium in man.

The concept of myocardial stunning encompasses a wide variety of settings with major pathophysiological differences. Stresses, such as exercise-provoked myocardial ischaemia and dysfunction, are accompanied in most patients by a flow-limiting coronary stenosis, while contractile dysfunction persists in some with cessation of exercise. Twenty-six patients with proven coronary artery disease were studied by exercise echocardiography. Left ventricular (LV) volumes, wall motion and myocardial thickening were detected in apical four- and two-chamber views at rest and during upright bicycle exercise. All patients had an increase in total asynergy score and a decrease in ejection fraction (EF) during exercise. Myocardial dysfunction persisted after exercise in 22 patients (84%) as shown by the persistence of low values of LVEF on recovery up to 30 min. When compared to control, nisoldipine reduces total asynergy score and prevents the decline in LVEF during exercise by reducing the extent of myocardial ischaemia. The value of LVEF on recovery is normal. Thus, this particular form of myocardial stunning after exercise-induced ischaemia offers an interesting model for studying (1) the susceptibility of an individual patient and (2) to test the capability of a drug to prevent and to reverse myocardial stunning.

Changes in structure and function of the human left ventricle after acclimatization to high altitude.

To analyse the role of changes in structure and function of the left ventricle in determining cardiac function at rest and during exercise, several two-dimensional and Doppler echocardiographic measurements were performed on 11 healthy subjects immediately before an Himalayan expedition (Nun, 7135 m), during acclimatization (3 weeks) and 14 days after the return. At rest decreases were found in cardiac index (CI) (3.23 l.min-1.m-2, SD 0.4 vs 3.82 l.min-1.m-2, SD 0.58, P less than 0.01), left ventricular mass (55.3 g.m-2, SD 9.4 vs 65.2 g.m-2, SD 13.5, P less than 0.005) and left ventricular end-diastolic volume (LVEDV) (53.9 ml.m-2, SD 6.9 vs 64.8 ml.m-2, SD 9.1, P less than 0.001) after acclimatization; by contrast the coefficient of peak arterial pressure to left ventricular end-systolic volume (PAP/ESV) (7.8, SD 1.6 vs 6.0, SD 1.8, P less than 0.005) and mean wall stress [286 kdyn.cm-2, SD 31 vs 250 kdyn.cm-2, SD 21 (2.86 N.cm-2, SD 0.31 vs 2.50 N.cm-2, SD 0.21), P less than 0.005] increased. After return to sea level, low values of CI and mass persisted despite a return to normal of LVEDV and preload. A reduction of PAP/ESV was also observed. At peak exercise, PAP/ESV (8.7, SD 2.4 vs 12.8, SD 2.0, P less than 0.0025), CI (9.8 l.min-1.m-2, SD 2.5 vs 11.6 l.min-1.m-2, SD 1.6, P less than 0.05) and the ejection fraction (69%, SD 6 vs 76%, SD 4, P less than 0.05) were lower after return to sea level than before departure.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term nifedipine unloading therapy in asymptomatic patients with chronic severe aortic regurgitation.

Vasodilating agents acutely reduce regurgitant volume and improve left ventricular performance in aortic regurgitation, but more information is necessary about their long-term efficacy. To evaluate the effects of 12 months of therapy with nifedipine, a randomized, double-blind, placebo-controlled trial was performed in 72 asymptomatic patients with severe aortic regurgitation. At 12 months, patients receiving nifedipine had a significant reduction in left ventricular end-diastolic volume index (110 +/- 19 versus 136 +/- 22 ml/m2, p less than 0.01) and mass (115 +/- 19 versus 142 +/- 16 g/m2, p less than 0.01) measured by two-dimensional echocardiography. They also had a reduction in left ventricular mean wall stress (360 +/- 27 versus 479 +/- 36 kdyne/cm2, p less than 0.001) and an increase in ejection fraction (72 +/- 8% versus 60 +/- 6%, p less than 0.05). These data show that the long-term unloading action of nifedipine is able to reverse left ventricular dilation and hypertrophy and suggest that such therapy has the potential to delay the need for valve replacement in asymptomatic patients.

[Prognostic value of late exercise test after myocardial infarction]. / Valore prognostico della prova da sforzo tardiva dopo infarto miocardico acuto.

The parameters of a maximal exercise stress test, without therapy, 30 to 186 days after myocardial infarction were related to cardiac death, recurrent nonfatal infarction, coronary artery by-pass surgery, development of angina pectoris and ST segment depression during subsequent stress test in 209 patients. During a follow-up period of 9.5 to 119 months (medium 52) 12 patients died, 14 developed recurrent nonfatal myocardial infarction, 4 were submitted to coronary surgery, respectively 53 and 69 patients presented angina and ST segment depression at the first test, 23 and 33 developed them subsequently. Among the exercise parameters only the systolic blood pressure less than 140 mmHg was predictive of future mortality. Angina and ST segment depression when present at the first stress test were significantly related between them and with low heart rate, low maximal systolic blood pressure and low work load, but not with cardiac mortality, reinfarction and by-pass surgery. Our results show a low predictive value of the late maximal exercise test after a myocardial infarction. Probably that depends on evolution of coronary disease, which does not provide long-term prognostic informations.