Supraventricular tachycardia, pregnancy, and water: A new insight in lifesaving treatment of rhythm disorders.

Pregnancy may predispose to paroxysmal supraventricular tachycardia (SVT), in subjects with or without identifiable heart disease. Many physiological conditions such as autonomic nervous system changes, altered systemic hemodynamics, etc. can contribute to the onset of arrhythmias during pregnancy. Some cases reported the occurrence of arrhythmias in relation to systemic fluid variations. We report the case of a pregnant woman who experienced SVT due to fluid depletion, detected by bioimpedance vector analysis (BIVA), which was successfully treated by water repletion under tight BIVA monitoring. Emergency physicians can overcome dangerous drug administration by considering historical examination and using fast and reproducible techniques such as BIVA.

Dolichocarotids: echo-color Doppler evaluation and clinical role.

AIMS: Dolichocarotids(DCs) represent a rare(2-6%) carotid imaging finding in the general population that may be free of clinical significance or be associated with cerebrovascular events. Their detection is traditionally assigned to carotid echo-color Doppler(ECD) and selective angiography(the standard method). The primary aim of this study was to estimate the sensitivity, specificity and accuracy of ECD in detecting DCs. Moreover, we monitored the DC curvature angle and the incidence of TIA, ischemic stroke, myocardial infarction and cardiovascular death over a five-year followup period. METHODS: A total of 112 consecutive patients with DCs(80 men, mean age: 61±7 years) were recruited for carotid ECD and carotid angiography due to the persistence of neurological symptoms not well explained on ultrasound evaluations, according to the current guidelines. RESULTS: ECD proved to have 100% sensitivity in detecting tortuosity and coiling and 96% sensitivity in detecting kinking, with an overall accuracy ranging from 92% to 100%. The specificity was 75% for tortuosity, 91% for kinking and 100% for coiling. During the five-year follow-up period, there was a statistically significant increase in tortuosity(61±11° at baseline versus 81±11° after five years, p＜0.001) and the kinking curvature angle(97±3° at baseline versus 100±3° at five years, p＜0.001), whilst no differences were observed with respect to coiling(136±10° at baseline versus 138±11° at five years, p=ns). Moreover, kinking was found to be more frequently statistically associated with cardiovascular death than tortuosity(p=0.005). CONCLUSIONS: DCs predispose patients to potentially disabling and fatal events. ECD plays a primary role in the detection of DCs and therefore should be considered to be a secure and reproducible technique.

Subacute stent thrombosis and stress-induced cardiomyopathy: trigger or consequence?

Stress-induced cardiomyopathy or Takotsubo cardiomyopathy (TCM) is a unique syndrome, characterized by transient left ventricular (LV) apical ballooning without significant coronary arteries stenosis, affecting mainly menopausal women. We present the case of a 70 year old woman with subacute stent thrombosis (ST) at the level of the right coronary artery and transient apical ballooning with normal flow of left and circumflex coronary arteries. TCM is frequently associated with emotional stress, but to date no case of ST triggering TCM have been reported.

Systemic vascular hemodynamic changes due to 17-ß-estradiol intranasal administration.

PURPOSE: According to the literature, estradiol has a direct vasodilator action by means of endothelium-derived relaxing factor synthesis. The present study aims to evaluate the acute hemodynamic effects of intranasal 17-ß-estradiol on cerebral and lower limb arterial circulation in postmenopausal women. METHODS: Sixteen healthy women in natural menopause (mean age: 54 ± 3 years) were investigated for at least 6 months, each receiving 300 µg of intranasal 17-ß-estradiol. We evaluated the heart rate, systolic/diastolic blood pressure, peak systolic velocity, end-diastolic velocity, and velocity-time integral (VTI) at the level of internal carotid and posterior tibial arteries, before and after 30, 60, and 180 minutes of drug administration. RESULTS: After intranasal 17-ß-estradiol administration, the internal carotid artery VTI showed statistically significant (P < .05) variations at all the time intervals after administration of the drug (30, 60, and 180 minutes) when compared with "time zero" (T0, ie, the speed recorded at baseline before drug administration). No significant variation was found at the posterior tibial artery. The systolic/diastolic blood pressure and heart rate did not significantly differ before and after drug administration. CONCLUSIONS: The administration of a single intranasal dose of 17-ß-estradiol in healthy postmenopausal women increased cerebral perfusions, whereas the effect on peripheral circulation was much more limited.

Endothelial function and cardiovascular risk in active inflammatory bowel diseases.

BACKGROUND: Endothelial dysfunction has been already reported in inflammatory bowel diseases (IBD). However, case series so far examined were rather heterogeneous as for disease severity and subsets investigated. OBJECTIVE: We evaluated endothelial dysfunction by brachial artery flow-mediated vasodilatation (FMD), and subclinical atherosclerosis by assessment of common carotid intima-media thickness (CCA-IMT) in a cohort of patients with Crohn's disease (CD) or Ulcerative colitis (UC) in active phase compared to healthy control subjects. METHODS: Forty-nine patients (mean age 41±16 years), 25 with CD and 23 with UC, and forty controls (mean age 45±15 years) were enrolled. Diagnosis was based on the standard clinical, endoscopic and histological criteria. Disease activity was assessed by Crohn's Disease Activity Index or Disease Activity Index. All patients, were under medical treatment as appropriate. RESULTS: FMD values were lower in IBD patients than controls (6.1±3.0 vs 8.2±3.4. p=0.003); no difference was seen between UC/CD groups (5.9±3.5 vs 6.3±2.6, p=0.67). No changes in statistical differences occurred after adjustment for age, gender, body mass index and family history of cardiovascular disease. Finally, no differences in IMT values were seen between IBD patients and controls. Disease duration and medical treatment did not affect endothelial function. CONCLUSIONS: Our study showed a lower FMD in IBD patients. Inflammation and immune response could explain endothelial dysfunction, which is the earliest stage of atherosclerotic process. IBD patients in active phase might therefore be at higher risk for atherosclerosis progression.

Impact of sleep respiratory disorders on endothelial function in children.

Obstructive sleep apnea syndrome (OSAS) in children can induce endothelial dysfunction, a well-known early marker of atherosclerosis. The study aimed to evaluate a link among endothelial function (measured by flow-mediated vasodilation (FMD)), obesity (evaluated by body mass index (BMI)), and sleep disordered breathing (SDB), assessed with apnoea/hypopnoea index (AHI), in a paediatric population. We demonstrated that our little OSAS patients showed an impaired endothelial function as compared to controls. In particular, the higher the AHI, the worst the FMD values and thus the endothelial function. Although the population sample is small, this study demonstrated that OSAS could impair endothelial function and worsen cardiovascular risk profile since childhood.

Shockwave therapy in patients with peripheral artery disease.

INTRODUCTION: Previous studies support the fact that extracorporeal shockwave (SW) induces angiogenesis and improves symptoms in patients affected by limb ischemia. The aim of this study was to evaluate the effects of SW therapy in patients with peripheral artery disease (PAD). METHODS: Twenty-two patients were enrolled in this study and were randomly assigned into two groups: SW treatment (12 patients, 67 ± 9 years) and control (10 patients, 68 ± 12 years). The inclusion criteria were the following: age over 40 years, PAD diagnosis, optimal medical therapy, and ankle-brachial index less than 0.9. SW therapy was administered using the Minilith® SL1 litotriptor with an ultrasound guide able to detect the target area using a B-mode technique and a 7.5 MHz convex probe emitting 2,000 impulses with an energy flux density of 0.03 mJ/mm(2). RESULTS: The variation in the degree of stenosis before and after treatment was statistically significant between the groups (-9% ± -10% vs. 0% ± 0%; P = 0.001). In addition, a significantly higher number of treated patients than controls showed a reduction in the Fontaine stage (12 [63%] vs. 0 [0%]; P < 0.001). This result was confirmed by analyzing the difference in patients' pain-free walking distance before and after SW therapy (76 ± 46 m vs. 0 ± 0 m for treated patients vs. controls; P < 0.001) and the difference in pain severity (measured on a pain scale; -1.4 ± 0.5 in the treated patients vs. -0.2 ± 0.4 in the controls; P < 0.001). CONCLUSION: On the basis of these results the authors hypothesized a direct effect of SW on the ultrastructural composition of the vessel walls, inducing a reduction in artery stenosis. These data support the application of SW therapy as a new medical tool to improve the natural clinical course of PAD.

Multigate quality Doppler profiles and morphological/hemodynamic alterations in multiple sclerosis patients.

Venous echo-color-Doppler (ECD) showed that chronic cerebrospinal venous insufficiency (CCSVI) syndrome is related to multiple sclerosis (MS). Study aims were to assess interobserver variability in ultrasound evaluation of MS patients and to relate echo-markers to MS clinical symptoms and the disability degree. 277 MS patients (117 men, mean age 43.05+10.04 years) admitted to the Neurology Department of Bari University General Hospital, underwent clinical, Expanded Disability Status Scale (EDSS) evaluation, and a cerebro-venous system ECD evaluation. Two operators reevaluated 32 patients to calculate interobserver variability. McNemar test confirmed the procedure reproducibility between two operators (p=ns). Septa/membranes correlated with deep cerebral veins reflux [right: 16% absence vs. 58% presence, p < 0.0001; left: 26% vs. 50%, p < 0.0001]; their absence in Primary Progressive (PP) MS form [right: 11% vs. 2%, p < 0.001; left: 12% vs. 2%, p < 0.001]. Internal jugular veins (IJVs) reflux absence was in Relapsing-remitting (RR) form [right: 60% vs. 74%, p=0.036; left: 56% vs. 85%, p < 0.0001] like hemodynamically significant stenosis [right: 57% vs. 69%, p=0.033; left: 49% vs. 73%, p < 0.001] not present in PP [right: 11% vs. 2%, p < 0.001; left: 10% vs. 3%, p=0.009]. A supine IJVs blocked flow was related to the EDSS class [right: 4.8±1.5 vs. 5.4±1.4, p=0.006; left: 4.7±1.6 vs. 5.5±1.2, p < 0.0001]; its absence was linked to RR [right: 60% vs. 76%, p=0.016; left: 58% vs. 79%, p < 0.001]. ECD has an important value in MS patients with IJV anomalies detection and a good interobserver procedure reproducibility. MS is associated with CCSVI, although further studies are needed.

Is there a correlation between OSAS duration/severity and carotid intima-media thickness?

BACKGROUND: Obstructive Sleep Apnea Syndrome (OSAS) is a common airways disease recognized as an independent cardiovascular risk factor. It is often associated with obesity, diabetes and dyslipidemia. Its pathophysiological consequences (hypoxia, hypercapnia, micro-arousals, sympathetic hyperactivity, oxidative stress, systemic inflammation and hyper-coagulability) are implicated in the development of hypertension, endothelial dysfunction and higher intima-media thickness (IMT) values, all elements known to lead to atherosclerosis. The study aim was to demonstrate a relationship between OSAS duration and IMT values and to confirm how OSAS severity could influence IMT (a marker of atherosclerosis). METHODS: We enrolled 156 patients (125 men, mean age: 60 ± 12 years) affected by OSAS of different severity: 111 (71%) were in CPAP therapy; some of the population were also affected by hypertension [102 (65%)], dyslipidemia [52 (33%)] and diabetes [38 (24%)]. Patients underwent evaluation of carotid artery IMT and answered a questionnaire investigating the time of onset (confirmed by a person aware of the patient's previous sleeping habits) and the duration of the disease. RESULTS: We found a statistically significant higher IMT value in patients with longer-lasting disease (OSAS duration in IMT < 0.9 mm: 120 (60-192) months versus OSAS duration in IMT ≥ 0.9 mm: 200 (120-310) months; p < 0.001). OSAS severity is positively related to IMT values. We found a positive relationship between IMT and OSAS duration [r = 0.34; p < 0.001] and between AHI and IMT [r = 0.51; p < 0.001]. CONCLUSIONS: Our study shows that the duration of OSAS and its severity are important factor related with higher values of IMT and hence with a higher risk of atherosclerosis.

Different functional cardiac characteristics observed in term/preterm neonates by echocardiography and tissue doppler imaging.

BACKGROUND AND AIM: To establish, using echocardiography, color-flow Doppler and tissue doppler imaging (TDI), physiological values of systolic/diastolic indexes in healthy term/pre-term newborns, and to identify how different degrees of maturity influence morpho-functional cardiac alterations during the transitional period. STUDY DESIGN AND SUBJECTS: 33 term newborns (M = 19, F = 14; gestational ages: 37th-41st week), and 20 pre-term infants (M = 11, F = 9; gestational ages: 31st-36th week) admitted to our department were studied. All infants underwent to clinical and Doppler ultrasound evaluations, carried out by the third to fourth day. Investigations included: M-mode echocardiography, color-flow Doppler and TDI. OUTCOME MEASURES AND RESULTS: Term and preterm neonates differed for: interventricular septum and left systolic/diastolic ventricle diameters (p<0.01 and <0.05 respectively); left ventricle posterior wall in systole (p<0.01); shortening and ejection fraction (p<0.05). Color-flow Doppler parameters on the tricuspid (peak E, peak A, ratio E/A; p<0.05) and on the mitral (peak E and E/A ratio; p<0.01) significantly differed between the two groups. Significant differences were also present for basal left ventricular lateral wall and right ventricular lateral wall in the Ew (p<0.01 and <0.05 respectively), Sw peak (p<0.01 and <0.05 respectively), and Ew/Aw (p<0.05). The isovolumetric relax time and the E/Ew measured on the medial mitral annulus also demonstrated significant differences (p<0.01) between the two groups. CONCLUSIONS: TDI is feasible in preterm neonates and enables assessment of myocardial velocities. With increasing gestational age, higher myocardial velocities and lower E/E' Πratios were found. TDI addition to standard neonatal echocardiography may provide further important information about cardiac function.

Morphological and functional vascular changes induced by childhood obesity.

BACKGROUND: To investigate endothelial dysfunction and morphological vascular changes in childhood obesity. METHODS: 93 overweight/obese children (body mass index 26 ± 5 kg/m(2); median 26 kg/m(2); interquartile range 22-28 kg/m(2)), mean age 10.9 ± 2.7 years, underwent a check-up of total, high-density lipoprotein- and low-density lipoprotein-cholesterol, triglycerides, C-reactive protein, erythrocyte sedimentation rate, and white blood cell count, together with ultrasound measures of flow-mediated dilatation, carotid intima-media thickness, and anterior-posterior diameter of the abdominal aorta. RESULTS: The body mass index of overweight/obese children had a statistically significant linear relationship (p < 0.05) with triglycerides, erythrocyte sedimentation rate, carotid intima-media thickness, anterior-posterior diameter of the abdominal aorta, and flow-mediated dilatation values. CONCLUSIONS: Overweight/obese children have an initial endothelial dysfunction and vascular damage, i.e., the first stage in the development of atherosclerosis.

Cardiovascular risk evaluation and prevalence of silent myocardial ischemia in subjects with asymptomatic carotid artery disease.

INTRODUCTION: Silent ischemia is an asymptomatic form of myocardial ischemia, not associated with angina or anginal equivalent symptoms, which can be demonstrated by changes in ECG, left ventricular function, myocardial perfusion, and metabolism. The aim of this study was to evaluate the prevalence of silent myocardial ischemia in a group of patients with asymptomatic carotid stenosis. METHODS: A total of 37 patients with asymptomatic carotid plaques, without chest pain or dyspnea, was investigated. These patients were studied for age, sex, hypertension, diabetes, dyslipidemia, smoking, and family history of cardiac disease, and underwent technetium-99 m sestamibi myocardial stress-rest scintigraphy and echo-color Doppler examination of carotid arteries. RESULTS: A statistically significant relationship (P=0.023) was shown between positive responders and negative responders to scintigraphy test when both were tested for degree of stenosis. This relationship is surprising in view of the small number of patients in our sample. Individuals who had a positive scintigraphy test had a mean stenosis degree of 35% ± 7% compared with a mean of 44% ± 13% for those with a negative test. Specificity of our detection was 81%, with positive and negative predictive values of 60% and 63%, respectively. CONCLUSION: The present study confirms that carotid atherosclerosis is associated with coronary atherosclerosis and highlights the importance of screening for ischemic heart disease in patients with asymptomatic carotid plaques, considering eventually plaque morphology (symmetry, composition, eccentricity or concentricity of the plaque, etc) for patient stratification.

Clinical correlates of endothelial function in chronic heart failure.

OBJECTIVE: There is a close link between heart failure and endothelial dysfunction. Brachial flow-mediated dilation (FMD) is a validated non-invasive measure of endothelial function. The aim of this study was to investigate the clinical correlates of FMD in patients with chronic heart failure (CHF). DESIGN, SETTING, PATIENTS: We evaluated 60 CHF outpatients (age 62 ± 14 years; 49 males, NYHA class 2.2 ± 0.7, left ventricular ejection fraction, LVEF, 33 ± 8%) taking conventional medical therapy (ACE-inhibitors and/or ARBs 93%, beta-blockers 95%) and in stable clinical conditions. MAIN OUTCOME MEASURES: The maximum recovery value of FMD was calculated as the ratio of the change in diameter (maximum-baseline) over the baseline value. RESULTS: As compared with patients with a higher FMD, those with FMD below the median value (4.3%) were more frequently affected by ischemic cardiopathy (50 vs. 23%; p = 0.032) and diabetes mellitus (20 vs. 3%; p = 0.044), had a higher NYHA class (2.5 ± 0.5 vs. 1.9 ± 0.7; p < 0.001) and NT-proBNP (2,690 ± 3,690 vs. 822 ± 1,060; p = 0.001), lower glomerular filtration rate estimated by Cockcroft-Gault (GFRCG: 63 ± 28 vs. 78 ± 25; p = 0.001) and LVEF (29 ± 8 vs. 37 ± 9; p = 0.001), as well as more frequently showing a restrictive pattern (40 vs. 7%; p = 0.002). In a multivariate regression model (R (2) = 0.48; p < 0.001), FMD remained associated only with the NYHA class (p = 0.039) and diabetes mellitus (p = 0.024). CONCLUSIONS: This study demonstrates that a better functional status and absence of diabetes mellitus are associated to higher FMD regardless of the etiology of the cardiac disease.

Feasibility and effectiveness of a disease and care management model in the primary health care system for patients with heart failure and diabetes (Project Leonardo).

PURPOSE: Project Leonardo represented a feasibility study to evaluate the impact of a disease and care management (D&CM) model and of the introduction of "care manager" nurses, trained in this specialized role, into the primary health care system. PATIENTS AND METHODS: Thirty care managers were placed into the offices of 83 general practitioners and family physicians in the Apulia Region of Italy with the purpose of creating a strong cooperative and collaborative "team" consisting of physicians, care managers, specialists, and patients. The central aim of the health team collaboration was to empower 1,160 patients living with cardiovascular disease (CVD), diabetes, heart failure, and/or at risk of cardiovascular disease (CVD risk) to take a more active role in their health. With the support of dedicated software for data collection and care management decision making, Project Leonardo implemented guidelines and recommendations for each condition aimed to improve patient health outcomes and promote appropriate resource utilization. RESULTS: Results show that Leonardo was feasible and highly effective in increasing patient health knowledge, self-management skills, and readiness to make changes in health behaviors. Patient skill-building and ongoing monitoring by the health care team of diagnostic tests and services as well as treatment paths helped promote confidence and enhance safety of chronic patient management at home. CONCLUSION: Physicians, care managers, and patients showed unanimous agreement regarding the positive impact on patient health and self-management, and attributed the outcomes to the strong "partnership" between the care manager and the patient and the collaboration between the physician and the care manager. Future studies should consider the possibility of incorporating a patient empowerment model which considers the patient as the most important member of the health team and care managers as key health care collaborators able to enhance and support services to patients provided by physicians in the primary health care system.