[Systolic, diastolic and pulse pressure: therapeutic options]. / Pressione arteriosa sistolica, diastolica e differenziale: implicazioni terapeutiche.

It is now universally accepted that antihypertensive therapy reduces cardiovascular morbidity and mortality both in young and older patients. The clinical relevance of the systolic, diastolic and pulse pressure as independent risk factors is well recognized. The reduction of cardiovascular morbidity and mortality in hypertensive patients is the main therapeutic goal. There is substantial agreement on the treatment of individual risk factors and associated clinical conditions, but the best drug therapy for systolic and diastolic hypertension and/or high pulse pressure is still controversial. The recommendations of the JNC VI are that diuretics or beta-blockers be used as first-step drug therapies. The WHO-ISH guidelines recognize calcium antagonists, ACE-inhibitors, alpha-blockers and angiotensin II receptor antagonists as first-step drug therapies together with diuretics and beta-blockers. All these drugs have a similar hypotensive potential and reduce cardiovascular risk, but with noticeable differences in tolerability and side effects. It has long been demonstrated that diuretics and beta-blockers significantly reduce the cardiovascular risk, but their side effects can be relevant. ACE-inhibitors have proved to be efficacious in hypertensive patients with chronic heart failure and diabetes. Calcium antagonists are useful in the prevention of stroke but results in patients at high risk of coronary artery disease and heart failure are controversial. Alpha-blockers have proved to be unsafe in patients with heart failure but showed beneficial effects in young patients with diastolic hypertension. Angiotensin II receptor antagonists have proved to be safe and efficient but their advantages in comparison to other drugs need to be confirmed.

Nonsustained ventricular tachycardia as a predictor for sudden death in patients with idiopathic dilated cardiomyopathy. The role of amiodarone treatment.

BACKGROUND: Sudden death frequently occurs in patients with idiopathic dilated cardiomyopathy. Ventricular arrhythmias are encountered in almost all cases. The prognostic significance of life-threatening arrhythmias such as successfully resuscitated ventricular fibrillation and sustained ventricular tachycardia is well known, while it is controversial for ventricular arrhythmias of a lower degree. Amiodarone has been used widely in these patients but its value in preventing sudden death is still uncertain. The aim of this study was to evaluate the prognostic significance of runs of nonsustained ventricular tachycardia (NSVT) as a hallmark for sudden death and the efficacy of amiodarone in preventing sudden death and reducing overall mortality in a large series of patients with dilated cardiomyopathy. METHODS: Over the period between 1983 and 1994, a series of 151 consecutive patients with idiopathic dilated cardiomyopathy underwent ambulatory electrocardiographic monitoring for a mean period of 191 hours/patient. Seventy-nine patients (56 male, mean age 50.7 +/- 13.1 years) (group A) had ventricular arrhythmias of Lown class < or = 4A, while 72 (53 male, mean age 48.6 +/- 12.8 years) (group B) had one or more NSVT runs. The two groups were well matched in terms of clinical features. Mean follow-up period was 86.8 +/- 38.7 and 74.7 +/- 39.5 months, respectively. In group A no antiarrhythmic drug was administered, while in group B 54/72 patients were treated with amiodarone (mean dosage 300 mg/day) for a mean period of 69.7 +/- 37.8 months (group B1). The remaining 18 patients received class I antiarrhythmic drugs, mexiletine (12) and propaphenone (6) for a mean period of 46.1 +/- 29.4 months, because amiodarone was contraindicated (3) or serious side-effects occurred during amiodarone treatment (15), which was discontinued after a mean period of 3.8 +/- 3.1 months (group B2). RESULTS: The cumulative survival probability in the whole population was 86.6% at two years and 65.6% at five years. The rate of sudden death was 6.0% at two years and 18.3% at five years. No statistically significant difference was observed in terms of all-cause mortality or sudden death in the three groups (A, B1, B2). In group B1, amiodarone determined the disappearance of NSVT at Holter monitoring in 50% of patients (27), with no significant difference in the rate of sudden death between the two subgroups. CONCLUSIONS: In unselected patients with idiopathic dilated cardiomyopathy, cardiovascular mortality does not differ between those with NSVT on chronic amiodarone treatment and those without NSVT who have not undergone antiarrhythmic therapy. There was a trend towards a higher overall and sudden mortality rate in patients with NSVT treated with other antiarrhythmic drugs vs patients with NSVT treated with amiodarone, but due to the small size of the first group no significant difference could be calculated. Assuming NSVT as a potential prognostic marker for sudden death, amiodarone treatment may have exerted a beneficial effect in these patients, but this statement is only a presumption due to the limitations of our study. The disappearance of NSVT during amiodarone treatment is not predictive of a reduced rate in sudden death, so that the potential effect of the drug does not appear to be related to the suppression of NSVT at Holter monitoring.

Prognostic value of systemic blood pressure response during exercise in a community-based patient population with hypertrophic cardiomyopathy.

OBJECTIVES: The present study was designed to prospectively evaluate the prognostic relevance of abnormal blood pressure response to exercise (ABPR), defined as hypotension or failed blood pressure increase (<20 mm Hg) with exercise, in a community-based hypertrophic cardiomyopathy (HCM) population representative of the overall disease spectrum. BACKGROUND: Abnormal blood pressure response to exercise has been proposed as a marker for hemodynamic instability and increased risk for disease-related mortality in highly selected patient populations with HCM. METHODS: The study population comprised 126 patients (aged 42+/-14 years) who underwent maximal symptom-limited cycloergometer exercise testing as part of the standard evaluation at our institution, and who were followed systematically for 4.7+/-3.7 years after testing. RESULTS: Of the 126 study patients, 98 (78%) had a normal blood pressure response during exercise, whereas the other 28 (22%) had ABPR, including nine with hypotension and 19 with failed blood pressure rise. During the follow-up period, nine patients (7%) died of HCM-related causes (three suddenly and six heart failure-related), of whom four had ABPR. In those patients aged < or =50 years, survival analysis after exercise testing showed a significantly increased risk for cardiovascular mortality associated with ABPR compared with a normal exercise response (p = 0.04), with an odds ratio of 4.5 (95% confidence interval: 1.1, 20.1). However, ABPR showed low positive predictive accuracy for cardiovascular mortality (i.e., 14%), whereas negative predictive accuracy was high (i.e., 95%). CONCLUSIONS: A hypotensive blood pressure response during exercise occurred in over 20% of a community-based patient cohort with HCM, and was associated with adverse long-term prognosis in patients <50 years old. However, the positive predictive accuracy of this blood pressure response is too low to justify modifications of clinical management or to allow identification of the high-risk patient based solely on an abnormal test result. By virtue of its high negative predictive accuracy for HCM-related mortality, the blood pressure response to exercise appears to be most valuable (in conjunction with the absence of other well recognized risk factors) as a screening test for the identification of low-risk subsets of patients.

Clinical utility and safety of exercise testing in patients with hypertrophic cardiomyopathy.

BACKGROUND: Exercise testing has long been employed in patients with hypertrophic cardiomyopathy (HCM), although concerns have constantly been expressed regarding its safety. This study reviews a large number of exercise tests performed in a community-based population with HCM, in terms of safety and clinical utility. METHODS: We analyzed a total of 243 maximal symptom-limited cycloergometer exercise tests performed at our institution in 138 patients with HCM (age 42 +/- 14 years, M/F 99/39), who were followed systematically for 9.4 +/- 6.5 years. RESULTS: In none of the 243 exercise tests did cardiac arrest, hemodynamic collapse or malignant arrhythmia occur, although 53 of the study patients (38%) had > or = 1 risk factors including previous cardiac arrest, recurrent syncope, malignant family history and resting left ventricular outflow obstruction. Early termination of the test was necessary in only 8 patients due to symptomatic hypotension with dizziness, but none had syncope. Mean predicted functional capacity achieved by the study group was 77 +/- 22%. Poor performance (< 60% of predicted functional capacity) was observed in 32 patients (23%), and it was associated with a NYHA functional class > 1 and an abnormal blood pressure response to exercise. Non-malignant arrhythmias occurred in 41 patients (30%), including multiple premature ventricular beats (PVB), paroxysmal atrial fibrillation, non-sustained ventricular (NSVT) and supraventricular tachycardia. The combined presence of multiple exercise-induced PVB and NSVT on Holter ECG had a 14% positive but a 97% negative predictive value for sudden death or cardiac arrest. CONCLUSIONS: 1) Exercise testing is safe in a community-based population of patients with HCM, and provides useful information regarding functional capacity, efficacy of treatment, blood pressure response to exercise and inducible ischemia. Thus, ergometry should routinely be included in the standard evaluation and follow-up protocols of HCM patients. 2) Conversely, the utility of ergometry in the evaluation of the arrhythmic risk in HCM patients appears to be limited to the identification of low-risk patients.

Prognostic value of non-sustained ventricular tachycardia and the potential role of amiodarone treatment in hypertrophic cardiomyopathy: assessment in an unselected non-referral based patient population.

BACKGROUND: Amiodarone has been reported to reduce the likelihood of sudden death in patients with hypertrophic cardiomyopathy (HCM). However, data regarding the clinical course in HCM have traditionally come from selected referral populations biased toward assessment of high risk patients. AIMS: To evaluate antiarrhythmic treatment for sudden death in an HCM population not subject to tertiary referral bias, closely resembling the true disease state present in the community. METHODS: Cardiovascular mortality was assessed in relation to the occurrence of non-sustained ventricular tachycardia (NSVT) on 24 or 48 hour ambulatory Holter recording, a finding previously regarded as a marker for sudden death, particularly when the arrhythmia was frequent, repetitive or prolonged. 167 consecutive patients were analysed by multiple Holter ECG recordings (mean (SD) 157 (129) hours) and followed for a mean of 10 (5) years. Only patients with multiple repetitive NSVT were treated with amiodarone, and in relatively low. doses (220 (44) mg/day). RESULTS: Nine HCM related deaths occurred: 8 were the consequence of congestive heart failure, but only 1 was sudden and unexpected. Three groups of patients were segregated based on their NSVT profile: group 1 (n = 39), multiple (> or = 2 runs) and repetitive bursts (on > or = 2 Holters) of NSVT, or prolonged runs of ventricular tachycardia, included 4 deaths due to heart failure; group 2 (n = 38), isolated infrequent bursts of NSVT, included 1 sudden death; group 3 (n = 90), without NSVT, included 4 heart failure deaths. Kaplan-Meier survival analysis showed no significant differences in survival between the three groups throughout follow up. CONCLUSIONS: In an unselected patient population with HCM, isolated, non-repetitive bursts of NSVT were not associated with adverse prognosis and so this arrhythmia does not appear to justify chronic antiarrhythmic treatment. Amiodarone, administered in relatively low doses, did not carry an independent and additive risk for cardiac mortality. Amiodarone may have contributed to the absence of sudden cardiac death in patients believed to be at higher risk because of multiple repetitive NSVT.

Risk for atrial fibrillation in patients with hypertrophic cardiomyopathy assessed by signal averaged P wave duration.

OBJECTIVE: To assess the relation between P wave duration and the occurrence of atrial fibrillation in hypertrophic cardiomyopathy (HCM). DESIGN: High resolution signal averaged electrocardiography was used in 110 patients with HCM to determine whether patients at risk for paroxysmal atrial fibrillation could be detected during sinus rhythm by measuring P wave duration. Filtered P wave duration was measured manually, over an average of 300 beats per patient. RESULTS: During follow up, 18 patients (16%) had at least one one clinical episode of paroxysmal atrial fibrillation, including four patients whose initial episode followed the signal averaged electrocardiogram. The 18 patients with overt atrial fibrillation had greater P wave duration than the 69 patients who did not develop atrial fibrillation: 150 (SD 20) v 126 (14) ms; P < 0.001. Another 23 patients without clinically evident atrial fibrillation had prolonged bursts of the arrhythmia on Holter recording, and showed a P wave duration (138 (15) ms) intermediate between patients with and without clinical atrial fibrillation. In assessing risk for atrial fibrillation, P wave duration > or = 140 ms was associated with sensitivity, specificity, and positive predictive accuracy values of 56%, 83%, and 66%. Multivariate analysis showed that duration of the P wave was the only independent variable associated with occurrence of atrial fibrillation; if P wave duration > or = 140 ms was combined with left atrial enlargement > 40 mm, the specificity and positive predictive accuracy for atrial fibrillation increased to 93% and 78%. CONCLUSIONS: Measurement of P wave duration in sinus rhythm by high resolution signal averaged electrocardiography may be a useful non-invasive clinical tool for identifying patients with HCM likely to develop electrical instability and atrial fibrillation.

[Clinical course of hypertrophic cardiomyopathy in a non selected population. The Experience of the Italian Multicenter Cardiomyopathy Study]. / Decorso clinico della cardiomiopatia ipertrofica in una popolazione non selezionata. Lésperienza dello Studio Policentrico Italiano Cardiomiopatie (SPIC).

BACKGROUND: Most of the information available on the clinical course and prognosis of hypertrophic cardiomyopathy (HCM) is based on data generated from international referral centres and as a result, it constitutes a potentially biased perspective of the disease process in this complex and diverse condition. A multicentric study was therefore set up with the aim of providing information on unselected patient populations with HCM. METHODS: The study group comprised 330 patients from 5 non-referral hospitals (mean age 42 +/- 16 years, M/F 226/104, 74-22%-obstructive, 299-91%-in NYHA class I-II) who were followed up regularly for 9.5 +/- 5.6 years. RESULTS: The vast majority of patients (n = 272, 82%) remained asymptomatic or mildly symptomatic during the follow-up period, whereas the remaining patients (n = 58, 18%) experienced clinical deterioration or died. Of the 18 patients (5%) who died of cardiovascular causes related to hypertrophic cardiomyopathy, 14 had progressive congestive heart failure and only 4 died suddenly. The annual mortality rate for cardiovascular disease was 0.57%, while the mortality rate due to sudden cardiac death was only 0.1%. The cumulative survival rate was 98, 95 and 93%, at 5, 10 and 15 years of follow-up respectively. Atrial fibrillation proved to be a relatively common (n = 81, 24%) and particularly unfavourable clinical feature, with higher mortality rate for cardiovascular causes related to hypertrophic cardiomyopathy. Syncope occurred in 47 patients (14%) but did not appear to have prognostic significance. CONCLUSIONS: In an unselected population, hypertrophic cardiomyopathy had a relatively benign prognosis that was inconsistent with its prior characterization as a generally progressive disorder, based primarily on the experience of selected referral institutions. Sudden unexpected cardiac death was distinctly uncommon, although a sizable proportion of patients, particularly the subset prone to atrial fibrillation, did experience clinical deterioration.

Signal-averaged P-wave duration and risk of paroxysmal atrial fibrillation in hyperthyroidism.

The onset of atrial fibrillation (AF) in hyperthyroid patients constitutes an unfavorable clinical event associated with high risk of cardiovascular complications, occurring in approximately one fifth of patients. Therefore, it is advantageous to define noninvasive markers that may identify patients at risk. The high-resolution, signal-averaged electrocardiogram was used to evaluate the relation between P-wave duration and occurrence of paroxysmal AF in a group of 50 patients with hyperthyroidism, of whom 24 had a history of paroxysmal AF and 26 did not. Filtered signal-averaged P-wave duration was measured over an average of 300 beats/patient while in sinus rhythm, both at the time of first diagnosis of hyperthyroidism and after restoration of euthyroidism by medical treatment. The 24 patients with paroxysmal AF had significantly greater P-wave duration than the 26 patients without it (135 +/- 7 vs 124 +/- 9 ms; p = 0.001). A P-wave duration cut-off value of 130 ms held specificity, sensitivity, and positive predictive accuracy values of 79%, 85%, and 83%, respectively. Of several variables, multivariate analysis showed P-wave duration to be the only independent variable significantly associated with the occurrence of paroxysmal AF. Thus, the high-resolution signal-averaged electrocardiogram may be a useful noninvasive clinical tool for the identification of electrical instability associated with paroxysmal AF in hyperthyroid patients.

Hypertrophic cardiomyopathy in Tuscany: clinical course and outcome in an unselected regional population.

OBJECTIVES: Our aim was to study a population of patients with hypertrophic cardiomyopathy from the well defined geographic region of Tuscany in central Italy, a group virtually free of selective referral bias and therefore probably closely representative of the true patient population with this disease. BACKGROUND: Most available information on clinical course, natural history and prognosis of hypertrophic cardiomyopathy is based on data generated from tertiary referral centers and therefore constitutes a potentially biased perspective of the disease process in this complex and diverse condition. METHODS: The study group comprised 202 patients aged 1 to 74 years (mean +/- SD 41 +/- 17) at initial diagnosis and followed up for 1 to 30 years (mean 10 +/- 5). RESULTS: Largely with the use of single or multiple drug therapy, the vast majority of patients (n = 154 [76%]) were asymptomatic or mildly symptomatic and in stable or improved condition over the period of follow-up, whereas the remaining patients (n = 48 [24%]) experienced deterioration, had substantial functional impairment or died. Of the 13 patients (6%) who died of cardiovascular causes related to hypertrophic cardiomyopathy, 11 had progressive congestive heart failure (including 6 in the end-stage phase) and only 2 died suddenly. The annual mortality rate for cardiovascular disease was 0.6% and that due to sudden cardiac death was only 0.1%; the cumulative survival rate was 97%, 95% and 92%, respectively, at 5, 10 and 15 years of follow-up. Atrial fibrillation proved to be a relatively common (n = 57 [28%]) and particularly unfavorable clinical feature, with premature death occurring in 9 of the 57 patients. The cumulative survival rate after 15 years was 76% for patients with atrial fibrillation versus 97% for patients with sinus rhythm. Syncope occurred in 33 patients (16%) but did not appear to be of prognostic significance. CONCLUSIONS: In an unselected regional population, hypertrophic cardiomyopathy had a relatively benign prognosis inconsistent with its prior characterization as a generally progressive disorder, based primarily on the experience of selected referral institutions. Sudden unexpected cardiac death was distinctly uncommon, although a sizable proportion of patients (particularly the subset prone to atrial fibrillation), did experience clinical deterioration.

Arrhythmias in mitral valve prolapse: relation to anterior mitral leaflet thickening, clinical variables, and color Doppler echocardiographic parameters.

Atrial and ventricular arrhythmias have been reported with variable incidence in symptomatic patients with mitral valve prolapse (MVP). The role of clinical and echocardiographic parameters as predictors for arrhythmias still needs to be clarified. One hundred nineteen consecutive patients (56 women and 63 men, mean age 40 +/- 17 years) with echocardiographically diagnosed MVP were examined. A complete echocardiographic study (M-mode, two-dimensional, and Doppler) and 24-hour electrocardiographic monitoring were performed in all patients. Complex atrial arrhythmias (CAAs) included atrial couplets, atrial tachycardia, and paroxysmal or sustained atrial flutter or fibrillation. Complex ventricular arrhythmias (CVAs) included multiform ventricular premature contractions (VPCs), VPC couplets, and runs of three or more sequential VPCs (salvos of ventricular tachycardia). The relation between complex arrhythmias and clinical parameters (age and gender) and echocardiographic parameters (left atrial and left ventricular dimensions, anterior mitral leaflet thickness [AMLT], and presence and severity of mitral regurgitation) was evaluated by multiple logistic regression analysis. CAA were present in 14% of patients and CVA in 30%. According to multiple logistic modeling, CAA correlated separately in the univariate analysis with age, presence of MR, and left ventricular and left atrial diameters; age was the only independent predictor (p < 0.001). CVA, in the univariate analysis, correlated with age, female gender, left ventricular end-diastolic diameter, and AMLT; only female gender and AMLT were independent predictors in the multivariate analysis (p < 0.01). The incidence of mitral regurgitation (59%) was higher than expected in a general population of MVP patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of verapamil on absolute myocardial blood flow in hypertrophic cardiomyopathy.

Angina, despite angiographically normal coronary arteries, is a common symptom in patients with hypertrophic cardiomyopathy (HC). Verapamil has been shown to ameliorate silent myocardial perfusion defects documented by thallium-201 in patients with HC. The aim of this study was to investigate the effects of verapamil on absolute regional myocardial blood flow and flow reserve, measured by positron emission tomography (PET) in patients with HC. Echocardiography, exercise stress testing, and measurements of myocardial blood flow at rest and after administration of intravenous dipyridamole (0.56 mg/kg) were undertaken in 20 patients with HC at baseline study and 8 +/- 2 weeks after double-blind randomization to either slow-release verapamil 240 mg or placebo once daily. During treatment, resting myocardial blood flow in the interventricular septum was 0.81 +/- 0.23 versus 0.96 +/- 0.42 ml/min/g in the placebo and verapamil group, respectively (p = NS between groups and when compared with respective baseline study); resting myocardial blood flow in the left ventricular free wall was 0.67 +/- 0.17 versus 0.74 +/- 0.45 ml/min/g, respectively (p = NS). After dipyridamole infusion, myocardial blood flow in the interventricular septum was 1.42 +/- 0.52 versus 1.92 +/- 1.23 ml/min/g (p = NS between groups and when compared with respective baseline study); myocardial blood flow in the left ventricular free wall was 1.25 +/- 0.41 versus 1.68 +/- 1.37 ml/min/g, respectively (p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of GM1 ganglioside on cardiac function following experimental hypoxia-reoxygenation.

Rat hearts made hypoxic for 20 min by perfusion with 95% N2/5% CO2 and reoxygenated for 20 min in a Langerdorff apparatus showed a dose-dependent reduction of lactate dehydrogenase release when incubated with ganglioside GM1 (0.1-10 microM). The decline of contractile force during hypoxia was also reduced dose dependently in the presence of GM1. Similar effects were observed in hearts obtained from animals treated i.p. with 40 mg/kg GM1 for 14 days. The levels of Na+,K(+)-ATPase in ventricular tissue were also reduced after hypoxia-reoxygenation and the reduction was prevented in hearts from GM1-treated animals. GM1 (1-30 microM) reduced the functional response to field stimulation of adrenergic nerve terminals in isolated atria. Rat atria made hypoxic in glucose-free media maintained normal stores of tissue noradrenaline in the presence of 1 microM GM1. In the rabbit, GM1 (40 mg/kg i.p. for 4 days) reduced the alterations of the ST segment of the ECG during acute occlusion of the left descending and circumflex coronaries artery. In conclusion, ganglioside GM1 reduces some effects of hypoxia-reoxygenation in the heart, through still unknown mechanisms.

[A "signal averaging" analysis of the P wave in patients with a history of isolated paroxysmal atrial fibrillation]. / Analisi dell'onda P "signal averaging" in pazienti con storia di fibrillazione atriale parossistica isolata.

The aim of this study was to verify the utility of the signal averaged electrocardiogram for the analysis of the P wave in patients with paroxysmal lone atrial fibrillation. We studied 22 patients with documented paroxysmal atrial fibrillation without cardiovascular or endocrine diseases. The results were compared with 24 normal subjects. Signal averaged electrocardiogram was recorded from bipolar orthogonal leads X, Y, Z using ART equipment mod. 1200 EPX, with 50-250 Hz filter and effective time-base resolution of 100 mm/sec and voltage of 1 mm/microV. Signal averaging of at least 300 beats was performed to reduce noise level under 0.3 microV. In patients with atrial fibrillation the duration of the P wave was significantly longer (135.0 +/- 13.0 msec) than in the normal subjects (109.4 +/- 11.4 msec) (p less than 0.000001). These results were steady in successive recordings (2-30 days after the first recording). The analysis of the P wave signal averaging seems useful in identifying patients with lone paroxysmal atrial fibrillation.

Electrocardiogram blood pressure and systolic time intervals long term monitoring in ambulant patients.

Ambulatory monitoring of the intra arterial blood pressure (IBP), through the Selyg-Oxford System, has been used so far primarily for studies on hypertension. Aim of our study is to explore the possibility of obtaining from IBP indications useful to extend its field of application. The study will investigate: the usefulness of the continuous monitoring of the systolic time intervals (STI), measured from IBP as ventricular performance indicators, the increasing of specificity of the ECG allowed by the simultaneous beat by beat estimate of the STI's, the possibility of achieving the same information from non invasive peripheral pressure transducers. In this paper we are presenting the results obtained from the combined analysis of the STI's, ECG and IBP in a first series of 13 patients, selected out of 50 on the basis of the highest number of episodes of IBP variations, to allow the evaluation of the algorithms performances in severe conditions.

The intraarterial blood pressure monitoring in the evaluation of patients with dizziness and/or fainting.

Ambulatory blood pressure (BP) monitoring has been extensively utilized, so far, for studying BP profile and hypotensive treatment in arterial hypertension. In this paper, preliminary data will be reported from a clinical study on the possible contribution of the combined ECG and BP monitoring in clarifying mechanisms of dizziness in patients with multiple or complex cardiovascular problems. Results are shown of three patients with ischaemia, arrhythmias and/or episodes of hypotension, and of three patients with borderline hypertension and marked fluctuations of BP.