Relationship between B-type natriuretic peptide levels and ventilatory response during cardiopulmonary exercise test in patients with chronic heart failure.

AIM: Aim of the study was to evaluate if brain natriuretic peptide (BNP) levels, a cardiac neurohormone well correlated with prognosis in chronic heart failure (CHF), are associated with enhanced ventilatory response to exercise, in ambulatory patients with intermediate peak oxygen uptake (PVO2). METHODS: Resting BNP was measured in 129 consecutive stable CHF patients with mild to moderate heart failure (90% New York Heart Association (NYHA) class II or III) and intermediate (10-18 mL/kg/min) PVO2, assessed during cardiopulmonary exercise test. Mean (SD) left ventricular ejection fraction (EF) and pulmonary systolic pressure (PAP) were 41 +/- 3% and 47 +/- 14 mmHg, respectively. The enhanced ventilatory response to exercise (EVR) was assessed as a slope of the relation between minute ventilation and carbon dioxide production (VE/VCO2 slope) > 35. RESULTS: Thirty-three over 129 patients (26%) had EVR. Mean BNP plasma level was 394 +/- 347 pg/mL. A significant correlation between BNP and EVR (r = 0.310; p < 0.01), was observed. In the logistic multivariate model, a BNP plasma level > 100 pg/mL had an independent predictive value for EVR (95% IC 1.68 to 10.5, Odds Ratio 4.23, p = 0.02). We found a significant correlation between BNP and PAP (r = 0.390; p < 0.001), and between PAP and EVR (r = 0.511; p < 0.01). CONCLUSIONS: In CHF patients with intermediate PVO2, plasma BNP is clearly related to the enhanced ventilatory response to exercise. In this subset, BNP levels could represent an effective alternative tool for the clinical assessment in patients with unreliable cardiopulmonary exercise test.

Electrophysiological instability in the acute phase: prognostic significance of early ventricular fibrillation in acute myocardial infarction.

BACKGROUND: In the prognostic stratification of patients affected by AMI is important to evaluate, besides the assessment of left ventricular function and residual ischemia, the presence of electrophysiological instability. METHODS: We have analysed 15 patients all affected by AMI complicated by early ventricular fibrillation. During the hospital phase we evaluated the E.F.% (ECHO) and the presence of late ventricular potentials (SAECG). After hospital discharge we followed up the patients for 6 months. RESULTS: None of the patients died during the hospital phase while the posthospital cardiac mortality was 20%. The three patients dead during the follow-up had an AMI localized in the anterolateral wall of the left ventricle, an E.F.% less than 40% and LVP positive in the hospital phase. Besides the clinical course was complicated by cardiac failure. CONCLUSIONS: We conclude that these three patients are a "high risk profile subgroup" and should be submitted to extensive evaluation with cardiac catheterization, coronary arteriography and programmed ventricular stimulation.

[The effect of cardiovascular rehabilitation on the variability of the RR cycle after a first uncomplicated acute myocardial infarct]. / Effetto della riabilitazione cardiovascolare sulla variabilità del ciclo RR dopo un primo infarto miocardico acuto non complicato.

BACKGROUND: The aim of this study was to verify the changes in the autonomic balance by means of heart rate variability assessment in patients with myocardial infarction referred for cardiac rehabilitation. METHODS: We studied 122 patients (79 males, 43 females, mean age 56 +/- 5 years), with a first uncomplicated myocardial infarction (anterior 48, thrombolysis 72), Killip class 1, preserved left ventricular function (ejection fraction 49 +/- 6%). All patients were free of inducible residual ischemia. Four weeks after myocardial infarction, patients were randomized into two groups; Group 1 (n = 58) referred for an 8 week cardiac rehabilitation program (scheduled: 24 sessions); Group 2 (n = 64): normal daily physical activity. During a 24-hour Holter ECG monitoring the following parameters were calculated in pharmacological wash-out at randomization (T0) and at the end of cardiac rehabilitation/control period (T1): mean value of RR intervals (RR), its standard deviation (SDNN), pNN50, rMSSD in the time domain; low frequency (LF) and high frequency (HF) value and the LF/HF ratio in the frequency domain. T1-T0 changes in percent values (delta %) were considered and compared between the two groups. RESULTS: Thirty-one patients were excluded from the study either for insufficient adhesion to the cardiac rehabilitation program (< 13 sessions, 22 patients) or recurrent ischemia (3 Group 1 patients and 3 Group 2 patients) and non-assessable 24-hour Holter ECG monitoring (3 patients). Thirty-one Group 1 patients and 60 Group 2 patients completed the study with a first and a second 24-hour Holter ECG monitoring performed at 30 +/- 3 days and 60 +/- 4 days respectively. At the same time an ergospirometric test was performed to evaluate cardiopulmonary function by means of exercise time, maximum oxygen consumption, anaerobic threshold, exercise time at the anaerobic threshold, and maximum oxygen consumption at the anaerobic threshold. Twenty-eight Group 1 patients and 44 Group 2 patients completed the study with a first and a second ergospirometric test. Baseline heart rate variability parameters were comparable in the two groups. During the observation period only in Group 1 patients heart rate variability parameters changed significantly: RR (Group 1 = +18.3 +/- 21.3; Group 2 = +4.2 +/- 5.2, p = 0.000), pNN50 (Group 1 = 45.0 +/- 38.9; Group 2 = +24.2 +/- 34.7, p = 0.011), HF (Group 1 = +81.6 +/- 124; Group 2 = -28.7 +/- 75.4, p = 0.014) and LF/HF ratio (Group 1 = -26.0 +/- 16.1; Group 2 = -4.9 +/- 6.1, p = 0.062). There were no significant differences in SDNN, rMSSD and LF. A linear correlation between delta LF/HF ratio and baseline LF/HF ratio values was found in Group 1 (r = 0.489, p = 0.006), whereas no correlation was found between this parameter and age, ejection fraction, creatine phosphokinase, and infarct localization. Group 1 patients had a significant improvement in exercise tolerance compared to Group 2 patients. CONCLUSIONS: A cardiac rehabilitation program positively modifies the sympatho-vagal balance in patients with uncomplicated myocardial infarction, increasing the parasympathetic tone and exercise tolerance.

[The management of syncope in the hospital: the OESIL Study (Osservatorio Epidemiologico della Sincope nel Lazio)]. / Gestione della sincope in ospedale: lo Studio OESIL (Osservatorio Epidemiologico della Sincope nel Lazio).

BACKGROUND: While syncope is generally considered a frequent finding in clinical practice, no clear epidemiological evidence is available about the relevance of such an event in the general population of Italy. METHODS: The OESIL Study was designed and undertaken in 15 hospitals of the Italian region of Latium in order to assess the percentage of emergency-room visits and admissions due to syncope, as well as to analyze the in-hospital diagnostic work-up performed for this condition. RESULTS: During a two-month observation period, 781 (372 males and 409 females, mean age 55.2 (22.8 years) consecutive patients came to the emergency rooms of the 15 hospitals included in the investigation due to a syncope spell (0.9% of emergency room visits); 450/781 patients (57.6%) were subsequently hospitalized (1.3% of all admissions): 48.0% of the admissions were admitted to a general medical ward, 29.3% to an observation ward, 13.3% to a cardiology section, 1.6% to a neurology section and 7.8% to other clinical sections (neurosurgery, general surgery). The mean duration of in-hospital stay was 6.9 (5.8 days; range 1-40 days). During the hospitalization period, 93.1% of patients underwent an ECG, 51.0% an EEG, 44.3% a CT scan of the central nervous system, 40.2% an echocardiogram and 19.5% a tilt-test. The syncope spell was considered to have a cardiovascular origin in 33.8% of the cases and a non-cardiovascular in 11.6% of the cases, while the origin was unknown in 54.4% of the cases. CONCLUSIONS: Collected data support the idea that syncope represents a frequent event in the general population and is responsible for a significant percentage of emergency-room visits and hospital admissions. However, the performance of conventional diagnostic work-ups is far from being satisfactory.

[Late ventricular potentials and acute myocardial infarction]. / Potenziali tardivi ventricolari (PT) ed infarto miocardico acuto (IMA).

BACKGROUND: The presence of late ventricular potentials was evaluated in a group of patients following acute myocardial infarction hospitalised in our division. MATERIALS AND METHODS: Recordings were made between the 10th and 12th day of the pathology. The criteria for positivity were the presence of three parameters: QRSD > or = 114 msec, LAS 40 > or = 38 msec, RMS 40 < or = 20 mv. These were present in 21 patients (18 males and 3 females). Inferior acute myocardial infarction (AMI) was found to be present in 15 cases, anterior AMI in 4 cases and AMI with an unspecified localisation in 2 cases. The mean duration of qrsd was 122 msec, the mean duration of low amplitude potentials (LAS 40) were 53.5 msec, the mean amplitude of the last 40 msec (RMS 40 was 8.9 mv). CONCLUSIONS: In conclusion, the authors affirm that late potentials were present in the majority of patients with inferior AMI and the search for the latter represents an important stage in the post-AMI prognostic stratification. Delta is the positive correlation between late potentials and ventricular tachycardia in postinfarction. This non-invasive test is comparable to electrophysiological induction tests in terms of predictive capacity of arrhythmic event and/or sudden death.

[Comparison of anti-arrhythmic therapy guided by the transesophageal electropharmacologic test and emperic therapy in the prophylaxis of atrial fibrillation recurrence]. / Confronto tra la terapia antiaritmica guidata dal test elettrofarmacologico transesofageo e la terapia empirica nella profilassi delle recidive di fibrillazione atriale.

BACKGROUND: There is no written data about the efficacy of transesophageal electropharmacologic test (TEPT) to guide antiarrhythmic therapy in the prophylaxis of paroxysmal atrial fibrillation (PAF) recurrences. Aim of this study was to assess the efficacy of TEPT compared to empiric treatment in the prophylaxis of PAF. METHODS: One-hundred-sixty patients (pts) with previous episodes of PAF were randomized in two groups: Gr A (90 pts) was submitted to basal transesophageal electrophysiologic study (BTES); Gr B (70 pts) was submitted to randomized empiric antiarrhythmic therapy with flecainide (F), propafenone (P) and sotalol (S). The end-points of stimulation protocol in Gr A were the induction of sustained atrial fibrillation (SAF)- > or = 1 min duration- or the end of protocol. SAF was inducible in 68/90 pts (Gr A1) while it was not in 22/90 pts (Gr A2). Pts in Gr A1 were subsequently submitted to TEPT at steady-state of F, P or S randomized in first choice. Pts responders (R) (SAF non inducible) were submitted to TEPT with other antiarrhythmic drugs randomized in second choice: R were followed-up with the same drug in chronic oral assumption, while non responders (NR) were submitted to TEPT with the last drug and followed-up with the same drug both in R and NR case. The same stimulation protocol was employed in TEPT as in BTES. Pts in Gr A2 withdrew from the study. During follow-up all-pts were submitted to periodic specialist examinations every three months. In case of PAF recurrence pts withdrew from the study. RESULTS: Mean follow-up duration in the study population was 17.5 +/- 8.5 months. One-hundred-eight TEPT were performed in Gr A1: 36 tests with F, 40 with P and 32 with S. Twenty pts were R with F (55% of tests) and 17 finished the follow-up, 22 pts were R with P (55% of tests) and 16 finished the follow-up, 19 pts were R with S (59% of tests) and 15 finished the follow-up; 3 pts with F, 2 pts with P and 2 pts with S were NR in last choice and finished the follow-up. In Gr A1 61/68 pts (90%) were R and 55/68 (81%) finished the follow-up (13 pts withdrew from the study). In Gr B (70 pts) 23 pts were randomized to F and 20 finished the follow-up, 24 pts were randomized to P and 20 finished the follow-up, 23 pts were randomized to S and 20 finished the follow-up (10 pts withdrew from the study). PAF recurrences during follow-up in Gr A1 were in 15/55 pts (27%): 9/48 pts (19%) R and 6/7 pts (86%) NR, and in Gr B in 41/60 pts (68%). Gr A1 vs Gr B p < 0.001. Univariate and multivariate statistical analysis showed the empiric treatment as the only variable with high predictive value for PAF recurrences (risk ratio 1.53). PPV and NPV of TEPT were respectively 86 and 81%. CONCLUSIONS: TEPT-guided antiarrhythmic therapy in the prophylaxis of PAF recurrences seems to be an effective method in predicting the efficacy of the chronic antiarrhythmic therapy, when compared to the empiric treatment. The non inducibility of SAF at TEPT would have a high predictive value for event-free follow-up.

[Multiplane transesophageal echocardiography and adenosine in the study of coronary blood reserve]. / Impiego della metodica transesofagea omniplana con adenosina nello studio della riserva coronarica.

BACKGROUND: Coronary blood reserve is the capacity of coronary vessels to vasodilate and thereby to increase the blood flow, when the heart needs more energy. However, when a coronary stenosis occurs, the capacity to vasodilate is reduced or completely diminished. It is then necessary to use all the tools useful in evaluating the functional conditions of the coronary vessels. Above all, the intracoronary Doppler technique is used to measure the velocity of blood flow. Our purpose was to evaluate a non-invasive tool "Multiplane Transesophageal Echocardiography" in the study of velocity of the anterior descendent artery before and after adenosine infusion. METHODS: At first, we studied 28 patients (pts), which we divided in two groups: Group A, 18 pts 59.38 +/- 8.23 mean age, 15 M. and 3 F., with anterior descending disease; Group B 10 pts, 59.20 +/- 8.48 mean age, 7 M. and 3 F, without significant stenosis (> 75%). Echocardiography examinations were performed with a 5 MHz multiplane probe, connected to a 1000 Hewlett Parkard echocardiography. Before the test, Diazepam 1 mg i.v. and Lidocaine spray were administered to the patients. We introduced the transesophageal probe and after choosing the best position of the aortic short axis view, we studied the anterior descending artery and measured the maximum and mean diastolic and sistolic velocities (V.MAX D., V.MN.D., V.MAX S., V.MN.S.). RESULTS: Transesophageal echocardiography allowed us to study the anterior descending artery in 95% of pts. There were no side effects, except for one pt affected by severe bradicardia. In Group B there was an increase of the diastolic and sistolic velocity after adenosine infusion, resulting twice greater they the rest values. The adenosine/rest velocities ratios were statistically significant (V.MAX D. p < 0.02) (V.MN.D. p < 0.03). CONCLUSION: Our results demonstrated an higher capacity of the Multiplane Transesophageal Echocardiography in studiing coronary blood reserve. We used adenosine, as a vasodilator drug, because of its short half-life and because it can be replatedly infused. The flow velocity values increased up to more than twice the rest values only in normal subjects.

Prognostic value of high dose dipyridamole echocardiography in patients with chronic coronary artery disease and preserved left ventricular function.

OBJECTIVES: The prognostic value of dipyridamole echocardiography was assessed in patients with chronic coronary artery disease and preserved left ventricular function. BACKGROUND: Few data are available on the prognostic value of dipyridamole echocardiography in patients with a low risk of cardiac events. METHODS: Two hundred sixty-eight consecutive patients with stable, proven or suspected coronary artery disease and ejection fraction > or = 0.40 underwent high dose (up to 0.84 mg/kg body weight) dipyridamole echocardiography. In 204 patients definite exercise electrocardiographic (ECG) results were also available. RESULTS: During a mean (+/- SD) follow-up period of 16 +/- 8 months (range 6 to 36), 33 spontaneous events occurred: 15 "hard" events (cardiac death [n = 6], myocardial infarction [n = 9]) and 18 "soft" events (unstable angina). Events occurred more frequently in patients with positive findings on dipyridamole echocardiography (59% vs. 3%, p < 0.001; hard events 24% vs. 2%, p < 0.01). A positive response at the low dose (up to 0.56 mg/kg) identified patients with a high incidence of hard events (7 of 16 patients, sensitivity 50%, specificity 96%). In patients with an exercise ECG, a comparable sensitivity for cardiac events was found (89% vs. 93%, p = NS), but dipyridamole echocardiography was more specific (91% vs. 61%, p < 0.01). A positive response on the low work load exercise ECG (< 8 min) and a positive response to low dose dipyridamole echocardiography had similar accuracy (82% vs. 90%, p = NS). Cox analysis identified dipyridamole echocardiography as the best predictor of cardiac events (odds ratio [OR] 20.9, 95% confidence interval [CI] 10.8 to 37.9); the highest risk of hard events was found in patients with a positive response to low dose dipyridamole echocardiography (OR 25.4, 95% CI 12.2 to 54.1). CONCLUSIONS: In patients with chronic coronary artery disease and a low incidence of cardiac events, dipyridamole echocardiography was effective in prognostic stratification, and positive low work load exercise ECG results were a reliable predictor of subsequent events. Consequently, dipyridamole echocardiography should be considered a complementary tool in the presence of high work load positivity or ambiguous exercise ECG results.

[A comparison between flecainide and sotalol in the prevention of recurrences of paroxysmal atrial fibrillation]. / Confronto tra flecainide e sotalolo nella profilassi delle recidive di fibrillazione atriale parossistica.

OBJECTIVES: Aim of the present study was to assess the efficacy and safety of flecainide (F) and sotalol (S) for the prevention of recurrences of paroxysmal atrial fibrillation (PAF). METHODS: Sixty-six patients with PAF (> or = 3 episodes of atrial fibrillation in the last year) in sinus rhythm, were randomized to pharmacological oral treatment with F (20 patients-Group A), with S (20 patients-Group B) and placebo (P) (26 patients-Group C). During the follow-up (one year duration) were evaluated on I, III, VI and XII months the number and tolerance of the atrial fibrillation recurrences, cardiac and/or noncardiac side effects. The patients with more than two recurrences in the same follow-up interval withdrew from the study. In each patient 14 clinical and laboratory variables were evaluated. RESULTS: After 12 months were arrhythmia-free respectively 70% of Group A patients, 60% of Group B patients, 27% of Group C patients. Univariate analysis showed that treatment with F was related to decrease of atrial fibrillation recurrences (one recurrence 67%, two recurrences 81%, three recurrences 81%), treatment with S was related to decrease of recurrences (two recurrences 59%); the variable most significantly related to the risk of arrhythmia recurrence is the higher value of basal cardiac rate (one recurrence t = 2.15, two t = 2.22, three t = 2.96, four t = 2.06). There was not statistically significant difference in maintenance of sinus rhythm at the end of the follow-up between the groups of patients on F and S (p = 0.163); treatment efficacy was significantly higher than P (p = 0.002). Multivariate analysis showed that treatment with F and S decreases the risk of arrhythmia recurrence respectively of 85% and 76% versus placebo at the end of the follow-up. The incidence of cardiac and/or noncardiac side effects was not clinically significant. CONCLUSION: F and S are both effective and safe for prevention of PAF, with 70% and 60% respectively of patients arrhythmia-free after 12 months of treatment. Side effects were common, but clinically significant adverse events were uncommon. A higher value of basal cardiac rate was predictive of atrial fibrillation recurrences in the patients during treatment.

Electrocardiographic abnormalities in childhood spinal muscular atrophy.

Tremors of the isoelectric line in routine electrocardiograms have been described in patients with spinal muscular atrophy and have been interpreted as fasciculations of denervated muscles. In order to evaluate this phenomenon, 13 patients with spinal muscular atrophy have been studied (average age: 37.3 months). A first electrocardiogram was recorded routinely; a second tracing was then recorded with double sensitivity and double speed. In addition, all patients were evaluated clinically and had M-mode and cross-sectional echocardiography. Regular and constant spikes on the isoelectric electrocardiographic line were recorded in 12 patients (93.4%); their frequency ranged from 39 to 48 cycles/sec (average: 42.08 +/- 2.64). Contrary to previous reports, we found an "abnormal" electrocardiogram in all our patients with severe spinal muscular atrophy. The only patient with a normal electrocardiogram had a mild and clinically stable form of spinal muscular atrophy. We did not find any significant structural cardiac abnormality by clinical and echocardiographic evaluation. We conclude that continuous tremor on the isoelectric line of electrocardiogram represents a characteristic of spinal muscular atrophy in these patients. It is a result of muscle fasciculations and does not imply any abnormality of the heart.

[Effect of the acute administration of molsidomine in refractory congestive heart failure. A double-blind randomized non-invasive study]. / Effetto della somministrazione acuta di molsidomina nello scompenso cardiaco congestizio refrattario. Studio non invasivo randomizzato in doppio cieco.

The effect of vasodilator Molsidomine (M) vs placebo on left ventricular dimensions and function measured by echocardiography was evaluated in a randomized study on 23 patients (pts) with refractory congestive heart failure (R CF) (NYHA class III-IV). The pts were randomized in two groups: group A (12 pts) received M, group B received an identical appearing placebo. Adequate echocardiograms were obtained before and one hour after 2 tablets of M (4 mg) or P; left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD), mean rate of circumferential shortening and left ventricular fractional shortening were calculated on the echocardiograms obtained. At the same time mean arterial pressure (MAP) and heart rate were measured. In group A, the single-dose test induced a significant reduction in LVEDD (74.1 +/- 7.2 to 72.1 +/- 7.1 mm; p less than 0.01), in LVESD (64.4 +/- 8.4 to 61.6 +/- 7.4 mm; p less than 0.01) and in MAP (96.5 +/- 8.3 to 85.4 +/- 7.2 mmHg; p less than 0.05). No significant changes were noted in the other parameters. Moreover, changes of parameters evaluated in group A between pts with idiopathic cardiomyopathy and pts with ischemic heart disease showed no statistical differences. Thus, acute Molsidomine therapy is effective in reducing left ventricular diameters and MAP in pts with RCF without changes of echocardiographic contractility indexes.