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Without rescue drugs approved, holistic approach by daily hemodialysis, noninvasive ventilation, anti-inflammatory medications, fluid assessment by bedside ultrasound, and anxiolytics improved outcomes of a maintenance hemodialysis patient affected by severe COVID-19.
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Atrial fibrillation (AF) is the most common clinical arrhythmia and represents a major social and economic problem. The number of subjects with AF is constantly increasing as a result of aging and improved survival in several cardiac and non-cardiac diseases. Patients with AF are often symptomatic, have a reduced physical capacity and are at high risk for thromboembolic events. Moreover, AF is associated with increased mortality and independent of the management, based either on rhythm or rate control strategy. The safety and efficacy of most anti-arrhythmic drugs are questionable. Increasing attention has therefore been addressed to evaluate the possible therapeutic and/or preventive effects of forms of treatment coming from ancient medical traditions of Far East, like acupuncture and yoga. In traditional Chinese medicine, acupuncture has been found effective in managing patients with paroxysmal supraventricular tachycardia. Recently, also in the Western literature, reports have been published supporting the clinical efficacy of acupuncture to treat arterial hypertension and to reduce chest pain. Other studies have evaluated the effects of acupuncture and other methods of Eastern Medicine, i.e., Qigong, Tai Chi Chuan and Yoga, in the treatment of cardiac illnesses associated with supraventricular arrhythmias. Two reports on the effects of acupuncture in preventing or reducing the rate of AF recurrences in patients with persistent or paroxysmal AF have been recently reported . Another ancient traditional eastern form of therapy and prevention, i.e., yoga, has been recently shown to reduce episodes of atrial fibrillation and improve the symptoms of anxiety and depression often associated with this arrhythmia. Growing evidence indicates that acupuncture and yoga are safe, without any pro-arrhythmic effect and with limited cost. All these factors should be considered when evaluating the efficacy of therapeutic intervention for an epidemic disease such as AF.
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BACKGROUND: Subclinical inflammation and atrial stretch have been recognized as important contributors to atrial fibrillation (AF) onset and perpetuation. The aim of the study was to compare the predictive role of serum inflammatory markers (serum amyloid A [SAA], and C-reactive protein [CRP]) and N-terminal pro brain natriuretic peptide (NT-proBNP) an indice of atrial strain in relation to subacute arrhythmic recurrence rate in patients with persistent AF and normal left ventricular ejection fraction (LVEF). METHODS: We studied 57 patients with a mean LVEF of 58.7 ± 6%. NT-proBNP, SAA and CRP levels were determined few hours before electrical cardioversion and 3 weeks after cardioversion. RESULTS: Subacute AF recurrences were documented in 19 (33 %) patients. Whereas NT-proBNP levels did not predict arrhythmic outcome, higher SAA (> 6.16-6.19 mg/L) and CRP levels (> 2.99-3.10 mg/L) were significantly associated with AF recurrences (odds ratio [OR], 5.39; 95% confidence interval [CI], 1.59-18.26; P = 0.007 and OR, 14.93; 95% CI, 3.90-57.19; P < 0.001). Both SAA (OR, 18.29; 95% CI, 2.07-161.46; P = 0.009) and high sensitivity CRP (OR, 42.03; 95% CI, 4.83-365.45; P = 0.001) through the multivariate logistic regression analysis show an independent role in predicting the AF recurrence with a sensitivity of 100% (38/38) and a specificity of 52.6% (10/19). CONCLUSIONS: The present study demonstrates that in patients with persistent AF and preserved LVEF, SAA and CRP levels are independent predictors of AF subacute recurrence rate, whereas NT-proBNP, not associated with arrhythmic outcome, reflects the hemodynamic alterations secondary to arrhythmia presence. The simultaneous determination of SAA and high sensitivity CRP has a very high sensitivity (100%) in predicting the AF recurrence.
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Fibrilación Atrial/sangre , Fibrilación Atrial/terapia , Proteína C-Reactiva/metabolismo , Cardioversión Eléctrica/efectos adversos , Proteína Amiloide A Sérica/metabolismo , Anciano , Análisis de Varianza , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Estudios de Cohortes , Intervalos de Confianza , Cardioversión Eléctrica/métodos , Electrocardiografía , Femenino , Humanos , Mediadores de Inflamación/sangre , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Péptido Natriurético Encefálico/sangre , Oportunidad Relativa , Fragmentos de Péptidos/sangre , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Recurrencia , Medición de Riesgo , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Tasa de Supervivencia , Función Ventricular Izquierda/fisiologíaRESUMEN
In Traditional Chinese Medicine, stimulation of the Neiguan spot has been utilized to treat palpitations and symptoms related to different cardiovascular diseases. We evaluated whether acupuncture might exert an antiarrhythmic effect on patients with paroxysmal or persistent atrial fibrillation (AF). Two sets of data are reviewed. The first included patients with persistent AF who underwent electrical cardioversion to restore sinus rhythm. The second included patients with symptomatic paroxysmal AF. All subjects had normal ventricular function. Acupuncture treatment consisted of 10 acupuncture sessions on a once a week basis with puncturing of the Neiguan, Shenmen and Xinshu spots. In patients with persistent AF, the recurrence rate after acupuncture treatment was similar to that observed in patients on amiodarone, but significantly smaller than that measured after sham acupuncture treatment or in the absence of any antiarrhythmic drugs. In a small group of patients with paroxysmal AF, acupuncture resulted in a significant reduction in the number and duration of symptomatic AF episodes. In conclusion, we observed that acupuncture of the Neiguan spot was associated with an antiarrhythmic effect, which was evident in patients with both persistent and paroxysmal AF. These preliminary data, observed in 2 small groups of AF patients, need to be validated in a larger population but strongly suggest that acupuncture may be an effective non-invasive and safe antiarrhythmic tool in the management of these patients.
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INTRODUCTION: In traditional Chinese medicine, stimulation of the Neiguan spot has been utilized to treat palpitations. We evaluated whether acupuncture might prevent or reduce the rate of arrhythmia recurrences in patients with persistent atrial fibrillation (AF). METHODS AND RESULTS: We studied 80 patients with persistent AF after restoring sinus rhythm with electrical cardioversion. Twenty-six subjects who were already on amiodarone treatment constituted the AMIO reference group. The remaining patients were randomly allocated to receive acupuncture (ACU group, n = 17), sham acupuncture (ACU-sham group, n = 13), or neither acupuncture nor antiarrhythmic therapy (CONTROL group, n = 24). Patients in the ACU and ACU-sham groups attended 10 acupuncture sessions on a once-a-week basis. Only in the former group the Neiguan, Shenmen, and Xinshu spots were punctured. During a 12-month follow-up, AF recurred in 35 patients. Cumulative AF recurrence rates in the AMIO, ACU, ACU-sham, and CONTROL patients were 27%, 35%, 69%, and 54%, respectively (P = 0.0075, log-rank test). Ejection fraction (P = 0.0005), hypertension (0.0293), and left atrial diameter (P = 0.0361) were also significantly associated with AF recurrence. Compared with AMIO group, recurrence rate was similar in ACU patients (hazard ratio: 1.15, 95% CI: 0.38-3.49; P = 0.801) but significantly higher in ACU-sham and CONTROL patients (3.77, 1.39-10; P = 0.009 and 3.15, 1.23-8.06; P = 0.017, respectively) after adjustment for ejection fraction, hypertension, and left atrial diameter using Cox modeling. CONCLUSION: Our data indicate that acupuncture treatment prevents arrhythmic recurrences after cardioversion in patients with persistent AF. This minimally invasive procedure was safe and well tolerated.
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Terapia por Acupuntura , Fibrilación Atrial/terapia , Cardioversión Eléctrica , Terapia por Acupuntura/efectos adversos , Anciano , Amiodarona/uso terapéutico , Antiarrítmicos/uso terapéutico , Distribución de Chi-Cuadrado , Femenino , Humanos , Italia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Medición de Riesgo , Factores de Riesgo , Prevención Secundaria , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Cardiomiopatías/sangre , Periodo Periparto/sangre , Complicaciones Cardiovasculares del Embarazo/sangre , Prolactina/antagonistas & inhibidores , Prolactina/sangre , Recuperación de la Función/fisiología , Adulto , Cardiomiopatías/diagnóstico por imagen , Cardiomiopatías/tratamiento farmacológico , Femenino , Antagonistas de Hormonas/farmacología , Antagonistas de Hormonas/uso terapéutico , Humanos , Periodo Periparto/efectos de los fármacos , Embarazo , Complicaciones Cardiovasculares del Embarazo/diagnóstico por imagen , Complicaciones Cardiovasculares del Embarazo/tratamiento farmacológico , Recuperación de la Función/efectos de los fármacos , Factores de Tiempo , UltrasonografíaRESUMEN
OBJECTIVES: Cardiac extracellular matrix structure is largely under the control of the matrix metalloproteinases (MMPs) whose activity maintains a balance between connective tissue synthesis and degradation. MMP gene polymorphisms, by modifying the level of gene expression, may affect atrial structural remodelling and atrial fibrillation recurrence rate. The aim of this study was to evaluate the association between MMP-1 and MMP-3 polymorphisms and arrhythmia recurrence. METHODS: We studied 74 persistent atrial fibrillation patients who underwent electrical cardioversion to restore sinus rhythm. In both patient and reference control groups, identification of MMP-1 and MMP-3 gene polymorphisms was performed by means of polymerase chain reaction according to standard techniques. RESULTS: Distribution of MMP-1 and MMP-3 genotypes and alleles were similar in atrial fibrillation patients and controls. During a 3-week follow-up period, 37 patients showed atrial fibrillation recurrences. Risk for atrial fibrillation recurrence significantly differed among groups (P = 0.0139) according to 5A and 1G allele presence. In particular, atrial fibrillation recurred in 62% of the patients carrying both 5A and 1G alleles (reference group) compared with no recurrence in patients carrying neither of them. CONCLUSIONS: We observed a significant relationship between MMP-1 and MMP-3 polymorphism and atrial fibrillation recurrences in patients with persistent atrial fibrillation. These findings suggest that genetic factors contribute to determine arrhythmic recurrence rate in persistent atrial fibrillation.
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Arritmias Cardíacas/genética , Cardioversión Eléctrica , Metaloproteinasa 1 de la Matriz/genética , Metaloproteinasa 3 de la Matriz/genética , Polimorfismo de Nucleótido Simple , Anciano , Arritmias Cardíacas/enzimología , Arritmias Cardíacas/terapia , Fibrilación Atrial/enzimología , Fibrilación Atrial/genética , Fibrilación Atrial/terapia , Femenino , Frecuencia de los Genes , Predisposición Genética a la Enfermedad , Humanos , Masculino , Metaloproteinasa 1 de la Matriz/metabolismo , Metaloproteinasa 3 de la Matriz/metabolismo , Persona de Mediana Edad , Oportunidad Relativa , Reacción en Cadena de la Polimerasa , RecurrenciaRESUMEN
Atrial fibrillation (AF) is a common arrhythmia characterized by irregular ventricular response. During AF, beat-to-beat variability of arterial pressure (AP) is increased because of continuous changes in filling time, stroke volume and contractility. Only a few studies have analyzed short-term AP variability during AF but they were mainly focused on the effects of respiration. We therefore analyzed short-term systolic (S), diastolic (D) and mean (M) AP variability by autoregressive method and an FFT-based spectral estimation (Welch periodogram) in 26 patients with persistent AF before and after restoration of sinus rhythm by electrical cardioversion. A low frequency (LF) component (central frequency 0.07+/-0.02 Hz, mean+/-standard deviation) of SAP variability was observed in 23 out of 26 patients during AF. Frequency analysis of DAP and MAP also showed a LF component with a central frequency of 0.08+/-0.03 Hz (20 patients) and 0.07+/-0.03 Hz (25 patients), respectively. After recovery of sinus rhythm, we found significant reduction in mean SAP, DAP and MAP variability in all frequency bands. Squared coherence between SAP and heart rate variability after recovery of sinus rhythm revealed a weak and strong coupling within, respectively, LF and HF frequency bands. These data indicate that in patients with AF, in spite of an absence of rhythmical oscillation in RR interval time series, it is possible to observe a LF component in SAP, DAP and MAP variability signals. These 0.1 Hz fluctuations reflect the influence of the sympathetic fibres acting on the cardiovascular system.
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Fibrilación Atrial/fisiopatología , Presión Sanguínea/fisiología , Diástole/fisiología , Sístole/fisiología , Adulto , Arritmias Cardíacas/etiología , Arritmias Cardíacas/fisiopatología , Barorreflejo/fisiología , Relojes Biológicos/fisiología , Electrocardiografía , Corazón/inervación , Corazón/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Procesamiento de Señales Asistido por Computador , Sistema Nervioso Simpático/fisiopatologíaRESUMEN
OBJECTIVES: Maintenance of sinus rhythm after cardioversion of atrial fibrillation is a major clinical challenge also in patients with preserved left ventricular function. Subclinical inflammation and atrial strain have been recognized as important contributors to atrial fibrillation onset and perpetuation. Aim of the study was to compare the predictive role of C-reactive protein (CRP) and indices of atrial dysfunction in relation to subacute arrhythmic recurrence rate in patients with persistent atrial fibrillation and normal left ventricular ejection fraction (LVEF). METHODS: We studied 53 patients with a mean LVEF of 58.7 +/- 6%. Left atrial diameter and area, left atrial auricle emptying velocity, N-terminal pro-b-type natriuretic peptide (NT-proBNP) and CRP levels were determined few hours before electrical cardioversion. NT-proBNP and CRP levels were also measured 1 h and 3 weeks after cardioversion. RESULTS: Subacute atrial fibrillation recurrences were documented in 18 (33.9%) patients. Whereas none of the parameters reflecting atrial dysfunction predicted arrhythmic outcome, higher CRP levels (>3.0 mg/l) were significantly associated with atrial fibrillation recurrences [odds ratio (OR): 1.6; 95% confidence interval (CI): 1.4-2.5; P = 0.031]. No changes in CRP levels were evident after cardioversion independently of underlying rhythm. On the contrary, NT-proBNP levels, which were correlated with left atrial auricle emptying velocity, significantly decreased only in patients who maintained sinus rhythm (from 638 +/- 329 to 295 +/- 261 pg/ml; P < 0.001). CONCLUSION: The present study demonstrates that in patients with persistent atrial fibrillation and preserved LVEF, CRP level is an independent predictor of atrial fibrillation subacute recurrence rate, whereas none of the indices of atrial dysfunction is associated with arrhythmic outcome. NT-proBNP levels reflect, instead, the hemodynamic alterations secondary to arrhythmia presence.
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Fibrilación Atrial/diagnóstico , Fibrilación Atrial/terapia , Función Atrial/fisiología , Biomarcadores/sangre , Proteína C-Reactiva/análisis , Cardioversión Eléctrica , Volumen Sistólico/fisiología , Anciano , Fibrilación Atrial/fisiopatología , Femenino , Humanos , Masculino , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , RecurrenciaRESUMEN
Exercising muscle hypoperfusion stimulates afferents (metaboreceptors) involved in the regulation of ventilation. Atrial fibrillation (AF), particularly when combined with diseases causing endothelial (ED) impairment, such as hypertension (HP) and diabetes mellitus (DM), depresses the ED activity and enhances exercise hyperventilation. The relationship between these two functions and the underlying mechanisms have not been explored previously. In lone AF or AF associated with HP or DM (12 subjects in each cohort), we investigated the brachial artery flow-mediated dilatation (ED function) and ventilation during the recovery phase of handgrip (metaboreflex) exercise for subjects receiving placebo or oral vitamin C (double-blind crossover), both before and after cardioversion (CV) to sinus rhythm. Baseline ED impairment was increasingly more severe and the ergoreflex activity more pronounced in AF + HP and AF + DM compared with lone AF. Vitamin C and CV significantly improved both flow-mediated dilatation and metaboreflex activity in lone AF and AF + HP, and vitamin C did not produce any additive effect when administered after CV. In AF + DM, neither vitamin C nor CV was effective. This study provides the following information: AF generates oxidative injury, which is less when the arrhythmia is lone AF and greater when the arrhythmia is associated with HP. In DM, the oxidative injury generated by AF is refractory to a rather weak antioxidant, like vitamin C, or the baseline damage is such as to prevent any additive influence of AF. In AF, a cause-effect link exists between ED dysfunction and metaboreflex activity. Ventilatory advantages of CV seem to be inversely related with the extension of the underlying ED oxidative impairment.
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Fibrilación Atrial/fisiopatología , Endotelio Vascular/fisiología , Ejercicio Físico , Anciano , Antioxidantes/farmacología , Ácido Ascórbico/farmacología , Fibrilación Atrial/etiología , Arteria Braquial/diagnóstico por imagen , Arteria Braquial/fisiología , Complicaciones de la Diabetes/fisiopatología , Diabetes Mellitus Tipo 2/fisiopatología , Método Doble Ciego , Ecocardiografía , Cardioversión Eléctrica , Endotelio Vascular/efectos de los fármacos , Femenino , Humanos , Hipertensión/fisiopatología , Masculino , Persona de Mediana Edad , Reflejo/fisiología , Flujo Sanguíneo Regional/fisiologíaRESUMEN
Endothelial dysfunction and underperfusion of exercising muscle contribute to exercise intolerance, hyperventilation, and breathlessness in atrial fibrillation (AF). Cardioversion (CV) improves endothelial function and exercise performance. We examined whether CV is equally beneficial in diabetes and hypertension, diseases that cause endothelial dysfunction and are often associated with AF. Cardiopulmonary exercise and pulmonary and endothelial (brachial artery flow-mediated dilation) function were tested before and after CV in patients with AF alone (n = 18, group 1) or AF with hypertension (n = 19, group 2) or diabetes (n = 19, group 3). Compared with group 1, peak exercise workload, O2 consumption (Vo2), O2 pulse, aerobic efficiency (Delta Vo2/Delta WR), and ratio of brachial diameter changes to flow changes (Delta D/Delta F) were reduced in group 2 and, to a greater extent, in group 3; exercise ventilation efficiency (Ve/Vco2 slope) and dead space-to-tidal volume ratio (Vd/Vt) were similar among groups. CV had less effect on peak workload (+7% vs. +18%), peak Vo2 (+12% vs. +17%), O2 pulse (+33% vs. +50%), Delta Vo2/Delta WR (+7% vs. +12%), Ve/Vco2 slope (-6% vs. -12%), Delta D/Delta F (+7% vs. +10%), and breathlessness (Borg scale) in group 2 than in group 1 and was ineffective in group 3. The antioxidant vitamin C, tested in eight additional patients in each cohort, improved flow-mediated dilation in groups 1 and 2 before, but not after, CV and was ineffective in group 3, suggesting that the oxidative injury is least in lone AF, greater in hypertension with AF, and greater still in diabetes with AF. Comorbidities that impair endothelial activity worsen endothelial dysfunction and exercise intolerance in AF. The advantages of CV appear to be inversely related to the extent of the underlying oxidative injury.
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Fibrilación Atrial/fisiopatología , Complicaciones de la Diabetes/fisiopatología , Diabetes Mellitus/fisiopatología , Cardioversión Eléctrica , Endotelio Vascular/fisiología , Prueba de Esfuerzo , Hipertensión/complicaciones , Anciano , Antioxidantes/farmacología , Ácido Ascórbico/farmacología , Fibrilación Atrial/etiología , Fibrilación Atrial/terapia , Arteria Braquial/fisiología , Diabetes Mellitus Tipo 2/fisiopatología , Ecocardiografía , Femenino , Humanos , Hipertensión/fisiopatología , Masculino , Persona de Mediana Edad , Miocitos Cardíacos/fisiología , Especies Reactivas de Oxígeno/metabolismo , Flujo Sanguíneo Regional/fisiologíaRESUMEN
Lone atrial fibrillation may be associated with daily life disability and exercise limitation. The extracardiac pathophysiology of these effects is poorly explored. In 35 subjects with lone atrial fibrillation (mean age 67 +/- 7 yr), we investigated pulmonary function, symptom-limited cardiopulmonary exercise performance, muscle ergoreflex (handgrip exercise) contribution to ventilation, and brachial artery flow-mediated dilation (as a measure of endothelial function) before and after (average interval 20 +/- 5 days) restoring sinus rhythm with external cardioversion. Respiratory volumes and lung diffusing capacity at rest were within normal limits during both atrial fibrillation and after restoring sinus rhythm. Cardioversion was associated with the following changes: a decrease of the slope of exercise ventilation vs. CO2 production (from 35 +/- 5 to 29 +/- 3; P <0.01) and of dyspnea sensation (Borg score from 4 to 2) and an increase of peak oxygen uptake (Vo2; from 16 +/- 4 to 20 +/- 5 ml.min(-1).kg(-1); P <0.01), Vo2 at anaerobic threshold (from 11 +/- 2 to 13 +/- 2 ml.min(-1).kg(-1); P <0.05), and O2 pulse (from 8 +/- 3 to 11 +/- 3 ml/beat; P <0.01). After cardioversion, the observed improvement in ventilatory efficiency was accompanied by a significant peak end-tidal CO2 increase (from 33 +/- 2 to 37 +/- 2 mmHg; P <0.01) and no changes in dead space-to-tidal volume ratio (from 0.23 +/- 0.03 to 0.23 +/- 0.02; P=not significant). In addition, the ergoreflex contribution to ventilation was remarkably attenuated, and the brachial artery flow-mediated dilatation was significantly augmented (from 0.32 +/- 0.07 to 0.42 +/- 0.08 mm; P <0.01). Ten patients had atrial fibrillation relapse and, compared with values after restoration of regular sinus rhythm, invariably showed worsening of endothelial function, exercise ventilatory efficiency, and muscle ergoreflex contribution to ventilation. In subjects with lone atrial fibrillation, an impairment in ventilatory efficiency appears to be involved in the pathophysiology of exercise limitation, and to be primarily related with a demodulated peripheral control of ventilation.
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Fibrilación Atrial/fisiopatología , Disnea/fisiopatología , Ejercicio Físico , Hiperventilación/fisiopatología , Anciano , Arteria Braquial/fisiología , Dióxido de Carbono/metabolismo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oxígeno/metabolismo , Consumo de Oxígeno/fisiología , Reflejo/fisiología , Pruebas de Función RespiratoriaRESUMEN
AIMS: To evaluate the presence of an abnormal autonomic modulation before, during and immediately after paroxysmal atrial fibrillation (PAF). METHODS AND RESULTS: We analysed Holter recordings of 65 patients with 110 PAF episodes lasting more then 30 s. Mean RR interval, co-efficient of variation and short-term heart rate variability were measured before, during and after PAF episodes. We observed a significant correlation between the coupling interval and both the cycle length measured from 30 min up to few cycles before PAF onset, and ventricular response. When comparing the heart rate variability (HRV) before and after PAF we observed a significant reduction of the low frequency/high frequency components (LF/HF) ratio (from 6.2+/-7.4 to 3.2+/-4.1). A short-long-short cycle sequence was detectable in 37 PAF onsets associated with a greater incidence of atrial ectopic beats and a greater LF component (62+/-25 vs. 53+/-27 normalised units) in comparison to the remaining episodes. When onsets were divided for a LF/HF ratio cut-off value of > or = 2 to separate episodes with a predominant sympathetic, as opposed to those with a prevailing vagal (LF/HF<2) modulation, we observed opposite changes (from 9.1+/-7.8 to 4+/-3.7 and from 0.8+/-0.5 to 2+/-3.6, respectively) consistent with a recovery of a more physiological sympatho-vagal balance immediately after recovery of sinus rhythm. No changes in co-efficient of variation of ventricular response were detectable before PAF termination. CONCLUSIONS: A predominant sympathetic modulation characterises the majority of PAF onsets whereas a vagal predominance was detectable in about 30% of episodes. These patterns are no longer detectable after recovery of sinus rhythm.