Long-Term Sports Practice and Atrial Fibrillation: An Updated Review of a Complex Relationship.

Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice, and it is an enormous burden worldwide because of its high morbidity, disability and mortality. It is generally acknowledged that physical activity (PA) is strongly associated with a significant reduction in the risk of cardiovascular (CV) disease and all-cause mortality. Moreover, it has been observed that moderate and regular physical activity has the potential to reduce the risk of AF, in addition to improving overall well-being. Nevertheless, some studies have associated intense physical activity with an increased risk of AF. This paper aims to review the main related literature to investigate the association between PA and AF incidence and draw pathophysiological and epidemiological conclusions.

Rationale and design of the Biventricular Evaluation of Gliflozins effects In chroNic Heart Failure: BEGIN-HF study.

AIMS: Sodium-glucose cotransporter type 2 inhibitors (SGLT-2i) represent a unique class of anti-hyperglycaemic agents for type 2 diabetes mellitus that selectively inhibit renal glucose reabsorption, thereby increasing urinary excretion of glucose. Several studies have demonstrated the cardioprotective effects of SGLT-2i in patients with heart failure (HF), unrelated to its glucosuric effect. It is unclear whether the benefits of SGLT-2i therapy also rely on the improvement of left ventricular (LV) and/or right ventricular (RV) function in patients with HF. This study aimed to evaluate the effect of SGLT-2i on LV and RV function through conventional and advanced echocardiographic parameters with a special focus on RV function in patients with HF. METHODS AND RESULTS: The Biventricular Evaluation of Gliflozins effects In chroNic Heart Failure (BEGIN-HF) study is an international multicentre, prospective study that will evaluate the effect of SGLT-2i on echocardiographic parameters of myocardial function in patients with chronic stable HF across the left ventricular ejection fraction (LVEF) spectrum. Patients with New York Heart Association Class II/III symptoms, estimated glomerular filtration rate > 25 mL/min/1.73 m2 , age > 18 years, and those who were not previously treated with SGLT-2i will be included. All patients will undergo conventional, tissue-derived imaging (TDI), and strain echocardiography in an ambulatory setting, at time of enrolment and after 6 months of SGLT-2i therapy. The primary endpoint is the change in LV function as assessed by conventional, TDI, and myocardial deformation speckle tracking parameters. Secondary outcomes include changes in RV and left atrial function as assessed by conventional and deformation speckle tracking echocardiography. Univariate and multivariate analyses will be performed to identify predictors associated with primary and secondary endpoints. CONCLUSIONS: The BEGIN-HF will determine whether SGLT-2i therapy improves LV and/or RV function by conventional and advanced echocardiography in patients with HF irrespective of LVEF.

Paradigm shift in heart failure treatment: are cardiologists ready to use gliflozins?

Despite recent advances in chronic heart failure (HF) therapy, the prognosis of HF patients remains poor, with high rates of HF rehospitalizations and death in the early months after discharge. This emphasizes the need for incorporating novel HF drugs, beyond the current approach (that of modulating the neurohumoral response). Recently, new antidiabetic oral medications (sodium-glucose cotransporter 2 inhibitors (SGLT2i)) have been shown to improve prognosis in diabetic patients with previous cardiovascular (CV) events or high CV risk profile. Data from DAPA-HF study showed that dapaglifozin is associated with a significant reduction in mortality and HF hospitalization as compared with placebo regardless of diabetes status. Recently, results from EMPEROR-Reduced HF trial were consistent with DAPA-HF trial findings, showing significant beneficial effect associated with empagliflozin use in a high-risk HF population with markedly reduced ejection fraction. Results from the HF with preserved ejection fraction trials using these same agents are eagerly awaited. This review summarizes the evidence for the use of gliflozins in HF treatment.

Sport activity in patients with cardiac implantable electronic devices: evidence and perspectives.

Demographic characteristics of patients with cardiac implantable electronic devices have significantly changed during the last few years, according to the ageing of the population and the consequent increase in the number of elderly individuals with indication for pacemaker implant and, on the other hand, to the increased number of young individuals implanted with an implantable cardioverter defibrillator for the primary prevention of sudden death. More and more often, both elderly and young patients ask the physician to deal with the device in their daily activities, which often include sport practice. This latter is advisable because of its recognized benefits on cardiovascular prevention, although there are many limitations for patients with a cardiac implantable electronic device. Hence, the need to balance the patient's request with the appropriate precautions emerging from existing evidence. The current article aims to provide an overview of the most recent data on this topic, derived from registries and observational studies. Over the years an attempt to standardize recommendations has been made, but robust evidence is still lacking. Substantial differences exist between countries based on their sports regulations. Official recommendations of European and American Scientific Societies are resumed. The future perspective is to obtain data to allow these patients a safer practice of sport activity also through technological advances in terms of device materials and programming improvement and the possibility of remote monitoring.

Association between Corrected QT Interval and C-Reactive Protein in Patients with Inflammatory Bowel Diseases.

Background and objectives: Electrocardiograph abnormalities (i.e., QT interval prolongation) have been described in inflammatory bowel diseases (IBD). We aimed to measure the QT interval in a cohort of patients with IBD and to analyze its relationship with clinical and inflammatory activity. Materials and Methods: We performed a cross-sectional study that included 38 IBD outpatients and 38 "age- and sex-matched" healthy controls. Nine patients had active IBD, and 29 were in clinical remission. Among the latter, 10 patients had sustained (lasting >1 year) and 19 had short-term remission (≤1 year). Corrected QT (QTc) interval was measured on standard 12-lead electrocardiograph. A systematic review of the literature on studies investigating the QT interval in patients with IBD was also performed. Results: QTc interval values were similar between IBD patients and healthy controls (417.58 ± 22.05 ms vs. 409.13 ± 19.61 ms, respectively; p: 0.479). Patients with active IBD had significantly higher QTc values (435.11 ± 27.31 ms) than both controls (409.13 ± 19.61 ms) and patients in remission (412.14 ± 17.33 ms) (p: 0.031). Post hoc analysis showed that the difference in QTc values between active IBD and remission was attributable to the group of patients with sustained remission (p < 0.05). Lastly, a significant correlation between QTc interval and C-reactive protein (CRP) values was observed (Spearman test: r = 0.563; p: 0.0005). Conclusions: Our study demonstrates an association between QTc duration and both clinical and inflammatory activity in patients with IBD. The higher the CRP value, the longer is the QTc duration. For practical purposes, all patients with active IBD should undergo a standard ECG. Prescription of drugs able to modify the QT interval should be avoided in patients with active IBD. The systematic review of the literature indicated that this is the first published study demonstrating an association between the QTc duration and CRP values in patients with IBD.

Contact-force monitoring increases accuracy of right ventricular voltage mapping avoiding "false scar" detection in patients with no evidence of structural heart disease.

PURPOSE: Electroanatomical mapping (EAM) could increase cardiac magnetic resonance imaging (CMR) sensitivity in detecting ventricular scar. Possible bias may be scar over-estimation due to inadequate tissue contact. Aim of the study is to evaluate contact-force monitoring influence during EAM, in patients with idiopathic right ventricular arrhythmias. METHODS: 20 pts (13 M; 43 ± 12 y) with idiopathic right ventricular outflow tract (RVOT) arrhythmias and no structural abnormalities were submitted to Smarttouch catheter Carto3 EAM. Native maps included points collected without considering contact-force. EAM scar was defined as area ≥1 cm2 including at least 3 adjacent points with signal amplitude (bipolar <0.5 mV, unipolar 3,5 mV), surrounded by low-voltage border zone. EAM were re-evaluated offline, removing points collected with contact force <5 g. Finally, contact force-corrected maps were compared to the native ones. RESULTS: An EAM was created for each patient (345 ± 85 points). After removing poor contact points, a mean of 149 ± 60 points was collected. The percentage of false scar, collected during contact force blinded mapping compared to total volume, was 6.0 ± 5.2% for bipolar scar and 7.1 ± 5.9% for unipolar scar, respectively. No EAM scar was present after poor contact points removal. Right ventricular areas analysis revealed a greater number of points with contact force < 5 g acquired in free wall, where reduced mean bipolar and unipolar voltage were recorded. CONCLUSIONS: To date this is the first work conducted on structurally normal hearts in which contact-force significantly increases EAM accuracy, avoiding "false scar" related to non-adequate contact between catheter and tissue.

Analysis of Risk Factors Independently Associated with Cognitive Impairment in Patients with Permanent Atrial Fibrillation: A Cross-sectional Observational Study.

BACKGROUND AND OBJECTIVE: Atrial Fibrillation (AF) is associated with an increased risk of stroke and development of cognitive impairment. Our cross-sectional study aims to identify risk factors for cognitive impairment in patients with permanent AF. MATERIALS AND METHODS: 212 consecutive outpatients with history of permanent AF lasting more than 1 year were enrolled and the Short Portable Mental Status Questionnaire (SPMSQ) was used to assess cognitive impairment (number of errors ≥5). The type of antithrombotic therapy, the time in therapeutic range (TTR) in case of treatment with warfarin and the degree of heart rate (HR) control (upon Holter ECG monitoring) were also assessed. RESULTS: ROC curve analysis indicated that TTR was associated with cognitive impairment (AUC 0.85 ± 0.03; 95% CI 0.77-0.88; p < 0.0001). Multivariate logistic regression analysis showed an independent association of previous cerebrovascular or cardiovascular events (OR 7.24, 95% CI 1.37-38.25; p = 0.020), aspirin therapy instead of anticoagulant therapy (OR 24.74, 95% CI 1.27-482.12; p = 0.034), warfarin use with TTR ≤60% (OR 21.71 , 95%CI 4.35-108; p < 0.001) and an average daily HR either <60 bpm or >100 bpm (OR 6.04, 95% 1.09-33.29; p = 0.039) with cognitive impairment. CONCLUSION: Among patients with permanent AF, cognitive impairment is more frequent in those with inadequate antithrombotic therapy (aspirin therapy instead of anticoagulant therapy) and with suboptimal oral anticoagulation (TTR ≤60%) or heart rate control. Efforts should be made to optimize therapies related to these parameters.

Coronary Artery Fistula Diagnosed by Echocardiography during NSTEMI: Case Report and Review of Literature.

Coronary artery fistulas are rare abnormal connections between a coronary artery and a cardiac chamber or a major vessel. Often, they are asymptomatic and the diagnosis is accidental. The case we present is the incidental finding of a fistula displayed with echocardiography during acute coronary syndrome (ACS). A 73-year-old man presented in the emergency room for non-ST-elevation ACS. Echocardiogram showed in a parasternal short axis view an abnormal diastolic flow inside the ventricular inferior wall. Angiography and CT confirmed the diagnosis of coronary fistula from the right coronary into the left ventricular cavity. A literature analysis with discussion about coronary fistulas classification and management was also performed.

A new educational program in heart failure drug development: the Brescia international master program.

: Despite recent advances in chronic heart failure treatment, prognosis of acute heart failure patients remains poor with a heart failure rehospitalization rate or death reaching approximately 25% during the first 6 months after discharge. In addition, about half of these patients have preserved ejection fraction for which there are no evidence-based therapies. Disappointing results from heart failure clinical trials over the past 20 years emphasize the need for developing novel approaches and pathways for testing new heart failure drugs and devices. Indeed, many trials are being conducted without matching the mechanism and action of the drug with the clinical event. The implementation of these novel approaches should be coupled with the training of a new generation of heart failure physicians and scientists in the art and science of clinical trials. Currently, drug development is led by opinion leaders and experts who, despite their huge personal experience, were never trained systematically on drug development. The aim of this article is to propose a training program of 'drug development in Heart Failure'. A physician attending this course would have to be trained with a major emphasis on heart failure pathophysiology to better match mechanisms of death and rehospitalization with mechanism of action of the drug. Applicants will have to prove their qualifications and special interest in heart failure drug development before enrollment. This article should serve as a roadmap on how to apply emerging general principles in an innovative drug-development-in-heart-failure-process as well as the introduction of a new educational and mentorship program focusing on younger generations of researchers.

Clinical profile of patients with heart failure can predict rehospitalization and quality of life.

BACKGROUND: The aim of this retrospective study was to identify clinical, humoral and echocardiographic variables predicting rehospitalization and poor quality of life (QOL) in patients with reduced or mid-range ejection fraction heart failure. METHODS: From 2009 to 2012, 310 patients were admitted having signs and symptoms of heart failure with reduced ejection fraction. All the patients were followed by phone, calling the patients or the referring general practitioner. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used as the instrument to evaluate QOL: MLHFQ less than 24 is a good QOL, 24-45 is moderate QOL and more than 45 is poor QOL. The primary event was poor QOL and/or rehospitalization at 4 years. RESULTS: Seventy-nine patients died at median time of 21 months; 4-year survival was 72 ±â€Š3%. Rehospitalization due to heart failure was recorded in 60 cases. Among 231 survivors, MLHFQ score was good in 99 (42%), moderate in 50 (21%) and poor in 88 (37%). Four-year freedom from death, poor QOL or rehospitalization was 51 ±â€Š3%. Multivariable analysis identified the following risk factors: heart rate at discharge at least 70 bpm, ischemic heart disease, atrial fibrillation, hypercholesterolemia, chronic pulmonary disease, N-terminal pro brain natriuretic peptide at discharge, severe tricuspid regurgitation and mitral regurgitation more than moderate. CONCLUSION: Clinical, laboratory and echocardiographic profile is crucial to predict long-term QOL of patients admitted for heart failure.

The role of bariatric surgery for improvement of hypertension in obese patients: a retrospective study.

OBJECTIVE: Evaluate if bariatric surgery can improve hypertension (HPT) control leading to both reduction of blood pressure values and antihypertensive therapy withdrawal. METHODS: Eight-hundred and sixty-four consecutive patients who referred to our hospital, from March 2001 to February 2011, because of morbid obesity were initially enrolled in this retrospective study. To obtain two comparable groups, propensity-matching was applied. Finally, the study included 444 (51% out of initial 864 patients), 222 on diet (group D) and 222 patients undergoing surgery (group S). RESULTS: In group D, sistolic blook pressure (SBP) showed a significant increase (135 ±â€Š14 vs 138 ±â€Š11 mmHg; P = 0.006); conversely in group S, SBP decreased (130 ±â€Š14 vs 124 ±â€Š9 mmHg; P = 0.001). In group D, diastolic blood pressure (DBP) showed a significant increase (80 ±â€Š6 vs 82 ±â€Š6 mmHg; P = 0.004); conversely in group S, DBP decreased (81 ±â€Š9 vs 79 ±â€Š8 mmHg; P = 0.015). Among 136 patients with HPT, 73 (53%) withdrew antihypertensive therapy: significantly more in group S (55/63, 87%) than in group D (17/56, 23%), P < 0.001. The median weight loss was significantly higher in group S than in group D at 6 months [4 (3-7) vs 15 (10-20)], 12 months [6 (4-9) vs 19 (12-28)] and 18 months [6 (2-10) vs 20 (13-32)]. Loss of weight is greater in the subgroup with HPT having surgery. CONCLUSION: Bariatric surgery is effective to improve SBP and DBP and leads to therapy withdrawal in obese patients; these changes are directly related to the amount of weight loss.

The Dark Side of the Moon: The Right Ventricle.

The aim of this review article is to summarize current knowledge of the pathophysiology underlying right ventricular failure (RVF), focusing, in particular, on right ventricular assessment and prognosis. The right ventricle (RV) can tolerate volume overload well, but is not able to sustain pressure overload. Right ventricular hypertrophy (RVH), as a response to increased afterload, can be adaptive or maladaptive. The easiest and most common way to assess the RV is by two-dimensional (2D) trans-thoracic echocardiography measuring surrogate indexes, such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler velocity of the lateral aspect of the tricuspid valvular plane. However, both volumes and function are better estimated by 3D echocardiography and cardiac magnetic resonance (CMR). The prognostic role of the RV in heart failure (HF), pulmonary hypertension (PH), acute myocardial infarction (AMI), and cardiac surgery has been overlooked for many years. However, several recent studies have placed much greater importance on the RV in prognostic assessments. In conclusion, RV dimensions and function should be routinely assessed in cardiovascular disease, as RVF has a significant impact on disease prognosis. In the presence of RVF, different therapeutic approaches, either pharmacological or surgical, may be beneficial.

Análise da qualidade sanitária da areia das praias de Santos, litoral do estado de São Paulo / Analysis of sand quality health in Santos beach, coast of São Paulo state

RESUMO: Em Santos, litoral de São Paulo, a avaliação da qualidade microbiológica da água das praias é realizada pela prefeitura e pela Companhia Ambiental do Estado de São Paulo (CETESB). Entretanto, a mesma atenção não é direcionada à areia das praias. A areia representa um potencial vetor de contaminação e pode constituir reservatório de microrganismos patogênicos. O objetivo deste estudo foi avaliar a qualidade microbiológica da areia das praias de Santos, São Paulo. Utilizou-se a técnica das membranas filtrantes para os grupos de coliformes fecais (Escherichia coli ) e enterococos. As amostras foram coletadas em sete pontos das praias de Santos. Os ensaios foram realizados mensalmente durante 8 meses e os resultados, expressos em unidades formadoras de colônias (UFC) de bactérias por 100 g de areia, variaram de 40.000 a 2.700.000 para E. coli e de não detectado a 95.000 para enterococos, encontrando-se acima dos valores orientadores existentes em âmbito nacional (3.800 UFC.100g-1 - Rio de Janeiro) e internacional (100.000 UFC.100g-1 - Portugal). O contato com areia contaminada pode causar diversas doenças, comprometendo a qualidade de vida da população. Torna-se importante a realização de estudos baseados em evidências epidemiológicas de exposição e análises de risco, para se estabelecer padrões de qualidade e políticas públicas para monitoramento e gerenciamento da qualidade sanitária da areia das praias do litoral de São Paulo.

ABSTRACT: In Santos, coast of São Paulo State, the evaluation of the microbiological quality of the beach water is performed weekly by the Companhia Ambiental do Estado de São Paulo (CETESB), the environmental agency of the São Paulo state government. However, the same attention is not given to the sand of the beaches. Sand represents a potential contamination vector and may constitute a reservoir of pathogenic microorganisms. This study aimed to evaluate the microbiological quality of sands from Santos beaches throughout the quantification of bacteria colonies from the groups of fecal coliforms (Escherichia coli ) and Enterococcus, using the membrane filter technique. The analyses were executed monthly during 8 months and the results, expressed in bacteria colony forming units (CFU) per 100 grams of sand, vary from 40,000 to 2,700,000 for E. coli and from not detected to 95,000 for Enterococcus, being above the currently guideline values in national (3,800 CFU.100g-1) and international (100,000 CFU.100g-1) levels. It's important to mention that these guideline values were based on results from microbiological analyses of sands collected from beaches that are distant from large urban areas. The contact with contaminated sand may cause diseases, provoking impacts on the population's life quality. There is a need for further studies based on epidemiological evidences of exposure and risk analysis, in order to establish quality standards and public policies aimed to monitoring and managing the sanitary quality of sands from São Paulo's coast beaches.

Evaluation of pulmonary atresia with 64-slice multidetector computed tomography (MDCT).

Pulmonary atresia with ventricular septal defect is a complex congenital heart disease. We report a case of a 46-year-old woman with pulmonary atresia and ventricular septal defect, surgically treated when she was 15 years old with an implant of a conduit between ascending aorta and left pulmonary branch. A 64-slice computed tomography was performed to assess the conduit patency. The contrast enhanced MDCT study showed the conduit was pervious and correctly connected with an enlarged left pulmonary artery implant of a conduit between ascending aorta and left pulmonary branch.

Should sports activity be encouraged or contraindicated in hypertensive subjects?

Hypertension is considered one of the major risk factors for cardiovascular disease. There are a number of different approaches to the prevention, control and treatment of hypertension. One of these provides lifestyle modification as a means to facilitate drug step-down or drug withdrawal in hypertensive patients subjected to a pharmacological treatment, but also as a means to control blood pressure and reduce the risk of developing hypertension in subjects that have abnormal blood pressure but are not candidates for drug therapy. Lifestyle modification includes physical activity, and there is an ever-increasing amount of evidence that physical activity can modify the history of hypertension, acting as a reducer either of blood pressure or of the other cardiovascular risk factors. The aim of this article was to analyse the effects of exercise on blood pressure (neuro-hormonal, hormonal and vessel effects), illustrate which are the influences of age and gender on exercise-induced reduction of blood pressure, indicate how much exercise (in terms of intensity, frequency and duration) is required to induce positive modification of blood pressure and evaluate current Italian criteria for sports ability in athletes with hypertension.