[Transesophageal echocardiographic evaluation of tricuspid endocarditis from implanted pacemaker: description of two cases]. / Valutazione con ecocardiografia transesofagea dell'endocardite tricuspidale da impianto di pacemaker: descrizione di due casi.

Two cases of tricuspid valve endocarditis due to staphylococcus epidermidis have been examined in patients with permanent transvenous pacemaker. While transthoracic echocardiography was unable to detect any tricuspidal abnormalities, large vegetations located on the tricuspidal leaflets and the electrocatheter were detected by transesophageal echocardiography. Both cases required surgical removal of the electrostimulation system and valve toilet.

Above-normal left ventricular systolic performance during exercise in young subjects with mild hypertension.

Debate continues on whether left ventricular (LV) systolic function during exercise is abnormal in young subjects with mild hypertension and on whether the abnormal blood pressure (BP) trend observed in hypertensives during prolonged exercise is due to impaired LV function. LV function was measured by means of M-mode echocardiography during prolonged exercise in 13 physically trained, young, mild hypertensives and 12 age-matched, trained normotensives with similar working capacity. Systolic BP/end-systolic volume (SBP/ESV) and end-systolic stress/ESV at rest were greater in the hypertensives (P < 0.0001 and P = 0.034), while LV filling was impaired (P = 0.05). BP changes during the first 20 min of exercise were similar in the two groups, but thereafter the between-group BP difference tended to decline progressively. LV diastolic dimension was similar at rest. During exercise it slightly increased in the normotensives and slightly decreased in the hypertensives (P = 0.032). Exercise ejection fraction (P = 0.018), SBP/ESV (P < 0.0001) and stress/ESV (P = 0.027) were greater in the hypertensives throughout the test. SBP/ESV normalized for LV wall thickness (P < 0.0001) and the changes in SBP/ESV from rest to exercise were also greater in the hypertensives (P = 0.002). Stroke volume increased to a lower extent in the hypertensives, but the between-group difference was not statistically significant. The increase in SBP/ESV from rest to exercise was related to the concentric remodelling of the ventricle in the hypertensives (P < 0.0001) and the subjects grouped together (P < 0.0001), but not in the normotensives. In conclusion, increased LV systolic performance is present early in hypertension not only at rest but also during vigorous exercise. It is partly due to concentric remodelling of the left ventricle and partly to enhanced inotropic state.

Effects of ACE inhibition on endurance exercise haemodynamics in trained subjects with mild hypertension.

The aim of the study was to examine the effect of chronic angiotensin converting enzyme inhibition on haemodynamics and left ventricular performance during long-lasting exercise at the anaerobic threshold. For this purpose exercise haemodynamics and left ventricular performance were assessed in 14 physically trained hypertensives (aged 26 y) before and after 3 months on quinapril 20 mg once daily. During exercise intraarterial blood pressure was monitored using the Oxford method and left ventricular dimensions were measured by M-mode echocardiography. Quinapril significantly decreased mean blood pressure during the initial incremental phase of the exercise protocol and caused a slight, nonsignificant decline during the steady-state phase. The drug-induced fall in blood pressure was accounted for mainly by change in cardiac output. Exercise duration and left ventricular performance were not affected by treatment. In conclusion, quinapril 20 mg once daily smoothed the blood pressure increase which occurs during the initial phase of vigorous endurance exercise. This result was achieved without affecting physical performance or left ventricular contractility.

Red blood cell sodium heteroexchange in familial primary hypertrophic cardiomyopathy.

The hallmark of primary hypertrophic cardiomyopathy is an inappropriate myocardial hypertrophy, linked to myofibril disarray of the left ventricle. Its variable clinical expression may be due to genetic heterogeneity and variable penetrance. Since we have recently shown that abnormalities of cation transport in the erythrocytes are associated with cardiac hypertrophy in essential hypertensives and insulin-dependent diabetics, we have investigated the relationship between cardiac anatomy and function and red cell Li+/Na+ and Na+/H+ exchange in 33 relatives of a patient who died of cardiac failure and was found to have a primary hypertrophic cardiomyopathy at autopsy. According to echocardiographic examination, 11 members of the family also had a hypertrophic cardiomyopathy, with a family distribution compatible with autosomal dominant genetic transmission and variable penetrance. Red cell Li+/Na+ and Na+/H+ exchange were not significantly different in the affected members as compared to the unaffected, but in the former, after correction for potentially confounding variables, interventricular septum thickness was positively correlated to Na+/H+ exchange and diastolic function (Area E/Area A and Vmax E/Vmax A) negatively correlated to Li+/Na+ exchange. Since a generalized overactivity of the cell membrane Na+/H+ exchange, reflected by increased Na+/H+ and Li+/Na+ exchanges in the red cells, could favour cellular growth and diastolic dysfunction, our data suggest that abnormalities of cell membrane cation transport could play a role in the phenotypic expression of hypertrophic cardiomyopathy.

Left ventricular performance during prolonged exercise and early recovery in healthy subjects.

The effect of semi-supine long lasting exercise to exhaustion [61 (SD 10) min] on left ventricular systolic performance was studied by echocardiography in 16 young healthy volunteers. During the incremental phase of exercise, the ejection fraction increased from 65.2 (SD 4.1)% to 80.1 (SD 4.8)% (P < 0.0001), then it levelled off up to the end of exercise [81.7 (SD 4.4)%, P < 0.0001 vs rest]. During recovery, the ejection fraction rapidly and steadily decreased to a value similar to that at rest [66.1 (SD 5.0)%, n.s.). A similar pattern was shown by the systolic blood pressure/end-systolic volume coefficient, which rose from 3.2 (SD 0.8) mmHg.ml-1 to 7.5 (SD 2.7) mmHg.ml-1 (P < 0.0001) in the initial phase and subsequently did not change until the end of exercise [7.0 (SD 2.2) mmHg.ml-1, P < 0.0001 vs rest], to fall sharply after the cessation of exercise [2.9 (SD 1.1) mmHg.ml-1 at the 10th min, n.s. vs rest]. Exercise and recovery indices of left ventricular performance were not correlated with exercise duration, maximal heart rate and increase in free fatty acids. The present results indicated that, after the initial increase, left ventricular performance remained elevated during prolonged high intensity exercise and that conclusions on exercise cardiac performance drawn from postexercise data can be misleading.

Haemodynamics of recovery after strenuous exercise in physically trained hypertensive and normotensive subjects.

1. Central and peripheral post-exercise haemodynamics were studied in 18 physically trained male subjects (10 hypertensive and eight normotensive) engaging in sports activities for 3-5 h/week. After a preliminary multistage bicycle ergometric test to evaluate their maximal oxygen consumption and anaerobic threshold, they underwent prolonged exercise at anaerobic threshold in the semi-supine position at 30% grade until exhaustion (mean duration 60.0 +/- 16.7 min in the normotensive subjects and 61.0 +/- 5.7 min in the hypertensive subjects, not significant). During the recovery time, intra-arterial blood pressure, echocardiographic cardiac output and indium-gallium strain-gauge plethysmographic peripheral flow were measured, and total, forearm and leg peripheral resistances were calculated respectively from mean blood pressure/cardiac output and mean blood pressure/peripheral resistance. 2. Systolic blood pressure was decreased during the entire recovery period in comparison with the baseline values (-8.4 mmHg, -43.8 mmHg and -39.7 mmHg at the 1st, 5th and 10th min in the hypertensive subjects, P = 0.001, P = 0.0001 and P = 0.0001 respectively; -18.8, -25.5 and -24.1 mmHg in the normotensive subjects, not significant, P = 0.01 and P = 0.01, respectively) without any significant difference between the two groups, whereas the reduction in diastolic blood pressure was not statistically significant. Peripheral flow increased and peripheral resistance decreased in parallel in the forearm and the leg and showed similar trends in the hypertensive subjects and the normotensive subjects. The increase in cardiac output and left ventricular ejection fraction and the decrease in total resistance were also similar in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic significance of ventricular extrasystoles in healthy professional athletes: results of a 5-year follow-up.

To assess the natural history of ventricular extrasystoles (VE), a 5-year follow-up of 52 professional endurance athletes was made. All remained well during this period. Forty-four accepted to undergo repeat extensive noninvasive cardiologic examination. In the 23 athletes still in activity at the second study the prevalence of total and complex VE at 24-hour Holter monitoring was substantially unchanged, while in the 21 subjects who had stopped training, complex VE were no longer present (p = 0.01 vs. baseline). Echocardiographic dimensional parameters were significantly higher in the still active athletes than in the no longer active subjects; however, in the latter, left ventricular mass index was still greater than in a group of 40 sedentary subjects previously studied (107 vs. 81 g/m2; p = 0.001). High-intensity physical training does not seem to be harmful in athletes with complex VE, without evidence of underlying cardiac disease.

Spontaneous idiopathic subclavian arteriovenous fistula: a case report.

Systemic arteriovenous (AV) fistulas are a rare but correctable cause of hyperkinetic circulation and congestive heart failure. They are generally due to catheterization procedures, surgery, trauma, or aneurysms. A case of truly spontaneous AV fistula between left subclavian artery and left innominate vein is described. This patient presented with symptoms that might clinically be mistaken for a carpal tunnel syndrome. The discovery of a continuous to-and-fro murmur on her left upper sternal border led to the correct diagnosis. Surgical ligature of the fistula provided complete relief of the woman's symptoms.

Age and blood-pressure-related changes in left ventricular diastolic filling.

PURPOSE: To evaluate the influence of different clinical and echocardiographic parameters on left ventricular diastolic filling in 66 mild to moderate hypertensives and 49 normotensives. METHODS: All subjects underwent an echocardiographic study with a pulsed Doppler evaluation of left ventricular filling. The hypertensive subjects also underwent non-invasive 24-h blood pressure monitoring. RESULTS: The ratio of early to atrial peak diastolic filling velocity and the ratio of the corresponding areas under the curve (AUC) were significantly lower in the hypertensives compared with the normotensives (P less than 0.001). In the hypertensives, office blood pressure, average 24-h mean blood pressure, the left atrial dimension and the left ventricular mass index were each related both to age and to diastolic filling. The variable most closely related to diastolic filling independently of age and the R-R interval was 24-h blood pressure (ratio of early: atrial peak filling velocity versus 24-h blood pressure: r = -0.307, P less than 0.05; ratio of early: atrial AUC versus 24-h blood pressure: r = -0.261, P less than 0.05). When the normotensives and hypertensives were each grouped according to age less than or equal to or greater than 40 years, the normotensive-hypertensive mean difference was greater in the subjects aged greater than 40 years for both the early:atrial maximal velocity ratio and the early:atrial AUC ratio. CONCLUSIONS: Age is the strongest clinical correlate for left ventricular diastolic function indices, in both hypertensives and normotensives. In the present study, average 24-h blood pressure and, to a lesser extent, the heart rate were also associated with an impaired diastolic performance.

Haemodynamic effects of coffee and purified caffeine in normal volunteers: a placebo-controlled clinical study.

In order to evaluate the effects of 'espresso' Italian coffee on resting flow, blood pressure, and peripheral resistance, 15 non-coffee drinking healthy volunteers received 2 cups of regular coffee, 200 mg purified caffeine or placebo in a latin square double-blind crossover protocol. Before and 30, 60, 90 and 120 min after ingestion, segmental resting flow and BP were measured and peripheral resistance was calculated. An echocardiogram was also performed before and 60 and 120 min after caffeine intake. Both regular coffee and caffeine produced a significant decrease in resting flow and a significant increase in resistance; both systolic and diastolic BP also increased, although not significantly. No variation was observed in heart rate and in cardiac contractility. Placebo (highly decaffeinated coffee for regular coffee and china bitter extract for caffeine) did not produce any haemodynamic effect. In five other healthy volunteers used to drinking more than 5 cups of coffee a day, coffee administration had no effect. These data demonstrate that the caffeine contained in espresso Italian coffee is a vasoconstrictor agent whose effects however are completely blunted in usual coffee drinkers as a consequence of adaptation.

Ventricular ectopic activity in physically trained hypertensive subjects.

Exercise training is currently recommended in the management of mild hypertension, but the relationship between training and ventricular arrhythmias has never been investigated in hypertensive subjects. Forty hypertensive sportsmen were studied by means of 24-h ECG Holter monitoring and the results were compared with those obtained in 40 sedentary hypertensives, 40 normotensive sportsmen and 40 normotensive sedentary subjects. Among the hypertensive sportsmen 82.5% exhibited at least one ventricular extrasystole and 32.5% complex forms of ectopy, a prevalence higher than that observed in the sedentary hypertensives (50% and 17.5%; P = 0.002). In the normotensive sportsmen the prevalence of ventricular arrhythmias (62.5% and 22.5%) was lower than that in the hypertensive sportsmen, but the difference was not statistically significant. During a training session the prevalence of ventricular ectopy was similar in the two groups of trained individuals. Among the hypertensive sportsmen no correlation was found between the severity of ventricular arrhythmias and the degree of left ventricular hypertrophy and performance. The results of the present study suggest that exercise training may enhance left ventricular vulnerability in hypertensive subjects. Whether subjects who manifest complex ventricular arrhythmias should continue to train remains a matter for individual judgement.

[Role of ophthalmoscopy in arterial hypertension: a problem revisited]. / Ruolo dell'oftalmoscopia nell'ipertensione arteriosa: un problema rivisitato.

To evaluate the present role of fundal examination in the assessment of the hypertensive patient, 348 hypertensive subjects, mostly with borderline or mild hypertension, were studied with direct ophthalmoscopy. The exam was always performed by the same observer. The degree of left ventricular hypertrophy was also evaluated with ECG and echocardiography. Blood pressure was measured with 24-hour ambulatory monitoring, using either the Del Mar Avionics Pressurometer II and IV, the Spacelabs 5200 or the A & D TM-2420. Signs of hypertensive retinopathy were found in 51% of the subjects. The degree of retinopathy, defined according to a modified Keith-Wagener grading system, was highly correlated with average 24-hour mean blood pressure (r = 0.31; p less than 0.0001). Based on ECG, 16% of the subjects had left ventricular hypertrophy, while 23% showed an echocardiographic left ventricular mass, indexed by body surface area, above the normal limits. Left ventricular mass index was correlated with ambulatory blood pressure levels, but at a lower level of statistical significance (r = 0.19; p less than 0.001) compared to the degree of retinopathy. No correlation was found between 24-hour blood pressure and ECG findings. Ophthalmoscopy proved to be more sensitive than echocardiography and ECG in indexing 24-hour blood pressure load, while the specificity of the 3 exams was similar. The present data indicate that fundal examination is a sensitive indicator of the vascular consequences of increased blood pressure and is therefore useful in the assessment of the hypertensive patient, while the more expensive echocardiography is not of great clinical value in borderline and mild hypertension.

Haemodynamic effects of coffee and caffeine in normal volunteers: a placebo-controlled clinical study.

The acute haemodynamic effects of Italian coffee and 200 mg purified caffeine were investigated in 15 healthy non-coffee-drinkers compared to individuals who consumed placebo (highly decaffeinated coffee for regular coffee, and china bitter extract for caffeine). Before coffee and caffeine consumption and 30, 60, 90 and 120 min afterwards, rest flow and blood pressure were measured, and peripheral resistance in the arm was calculated; an echocardiogram was also performed before and 60 and 120 min after caffeine consumption. Both coffee and caffeine significantly decreased rest flow, and increased peripheral resistance. Systolic blood pressure increased by 10% and diastolic pressure increased by 5% for at least 2 h. No variation in heart rate or cardiac contractility was found. No effects were observed after placebo treatment. It is concluded that Italian coffee and caffeine increase blood pressure via vasoconstriction.

[Left ventricular filling studied by echo-Doppler in hypertensive and normotensive subjects]. / Studio del riempimento ventricolare sinistro mediante eco-Doppler negli ipertesi e nei normotesi.

Purpose of the study was to evaluate the influence of different clinical and echocardiographic parameters on left ventricular diastolic filling in a group of 66 mild to moderate hypertensive subjects (mean age = 45.9 +/- 13.9 yrs) and in 49 normotensive controls (mean age = 44.2 +/- 15.9 yrs). All subjects underwent an echocardiographic study with pulsed Doppler evaluation of left ventricular filling. In the hypertensives, a noninvasive 24-hour blood pressure monitoring was performed. The ratio of early to atrial peak diastolic filling velocity (VmaxE/VmaxA) and the ratio between the respective velocity flow integral (Earea/Aarea) were significantly lower in the hypertensives compared to the normotensives (p less than 0.001). As within the hypertensives, office systolic blood pressure, average 24-hour mean blood pressure (24MBP), left atrial dimensions, and left ventricular mass index (MAXIND) were related both to age and diastolic filling. To study the relation between these parameters and diastolic filling a partial correlation test was used. The only variable related to diastolic filling, independently of age, was 24MBP (VmaxE/VmaxA vs 24MBP: r = -0.307, p less than 0.05, Earea/Aarea vs 24MBP: r = -0.261, p less than 0.05). Linear multivariate analysis using the method of stepwise regression established that age, 24MBP and heart rate were responsible for 75% of the VmaxE/VmaxA variance in the hypertensive group. To evaluate if the difference between the indexes of diastolic filling in the normotensives and the hypertensives varied according to age, we divided each group into two classes of subjects older and younger than 40 yrs. Under the age of 40 only VmaxE/VmaxA was significantly different in the two groups (p less than 0.05), while in the subjects older than 40 yrs both VmaxE/VmaxA and Earea/Aarea differed to a great level of statistical significance (p less than 0.001). The results of the present study allow the following conclusions: 1) age has the greatest influence on diastolic filling in both hypertensive and normotensive individuals. Diastolic filling is impaired in mild to moderate hypertension, when systolic function is still normal; 2) the worsening of diastolic filling determined by hypertension is more evident in the subjects greater than 40 yrs; 3) the only clinical variable that influences diastolic filling, independently of age, is 24MBP, while office blood pressure, MAXIND and left ventricular ejection fraction do not seem to be related to this clinical entity.

[Familial hypertrophic myocardiopathy: complex ventricular arrhythmias in healthy family members]. / Miocardiopatia ipertrofica familiare: aritmie ventricolari complesse nei parenti sani.

The aim of the present study was to evaluate the electrocardiographic changes among the members of a family affected by hypertrophic cardiomyopathy. Seventeen unaffected members and 8 affected members were studied by 24-hour Holter monitoring. Twenty-five normal controls were also studied by 24-hour Holter monitoring. One out of 7 (12.5%) patients with hypertrophic cardiomyopathy, 8 out of 17 (47%) unaffected relatives and 20 out of 25 (80%) controls did not show ventricular arrhythmias. One out of 7 patients (12.5%), 4 out of 17 (23.5%) unaffected relatives and 3 out of 25 (12%) of the control group showed Lown classes I-II ventricular arrhythmias. Complex ventricular arrhythmias (III-V Lown classes) were detected in 5/7 (71.4%) of patients, in 5/17 (29.5%) of unaffected members and only in 2/25 (8%) of the normals. Among the unaffected members we compared the prevalence of complex ventricular arrhythmias between the offspring of patients with that of the unaffected first-grade relatives. Three out 7 (43%) of the offspring of the patients showed complex ventricular arrhythmias and none among the offspring of normal first-grade relatives showed such arrhythmias. Neither the patients nor their relatives in this study showed any significant ST segment changes during the 24-hour Holter monitoring. We suggest that in first-grade relatives of patients with familial hypertrophic cardiomyopathy, complex ventricular arrhythmias could be a marker of latent disease, without clinical and echocardiographic manifestations.

[Hemodynamic effects of "expresso" Italian coffee and pure caffeine on healthy volunteers]. / Effetti emodinamici del caffè espresso all'italiana e della caffeina pura in volontari sani.

In 15 healthy non-coffee-drinker subjects and in 5 usual coffee-drinkers, the effects were studied of 2 cups of "espresso" italian coffee and of 200 mg purified caffeine on blood pressure, heart rate, forearm rest flow and peripheral resistance. In the 15 non-coffee-drinkers, left ventricular ejection fraction, fractional shortening, cardiac output and end-systolic stress were also evaluated by a 2D-guided M-mode echocardiogram before and 60 and 120 min after oral administration of 200 mg purified caffeine. In the non-coffee-drinker volunteers, diastolic and systolic blood pressure and peripheral resistance increased both after "espresso" coffee and after caffeine. In the usual drinkers no hemodynamic effect was seen. No variation of cardiac contractility was observed. We conclude that caffeine contained in the "espresso" coffee obtained with the high-pressure italian procedure is a strong vasoconstrictor agent, while it has no action on cardiac contractility.

[Agenesis of the right carotid in a subject with dextrocardia. Diagnostic imaging in 1 case with unique characteristics]. / Agenesia della carotide destra in un soggetto con destrocardia. Imaging diagnostico di 1 caso con caratteristiche uniche.

A man aged 51 with dextrocardia and right common and internal carotid artery agenesis is described. Cerebral blood flow is allowed internally by the left carotid and left vertebral antegrade flow, while right artery has only the function to drain the blood from the left side of vertebral system. A small external right carotid does exist, but it is separated from the cerebral hemodynamics. Diagnosis of dextrocardia was made on the basis of the standard chest X-ray, that of carotid agenesis on the basis of selective digital arteriography, color-Doppler and magnetic resonance. The diagnosis of congenital agenesis was based on the absence of a foramen caroticus and of a canalis caroticus. Large anasthomosis between the left and right side of cerebral system permit a normal perfusion to left cerebral hemispherium and a quite normal life.

[Changes in arterial pressure and adrenergic activity during a holiday at a mountain at low altitude]. / Variazioni della pressione arteriosa e del tono adrenergico durante soggiorno montano di bassa quota.

To answer the question often asked by hypertensive patients whether it is advisable for them to spend a holiday in the mountains for fear of a rise in blood pressure, 12 untreated mild hypertensive and 12 normotensive subjects underwent 24-hour non-invasive blood pressure monitoring, plasma catecholamines assay (HPLC) and plasma renin activity determination at home (sea level) and in a mountain resort (1210 m). The 2 evaluations (at home and in the mountains) were performed in a cross-over fashion. The ICR Spacelabs Pressuromaster and the Del Mar Avionics Pressurometer IV were used: blood pressure was measured every 8 minutes during daytime and every 15 minutes during sleep. Blood pressure was also recorded during a 1.5 to 3 hour excursion by cable-car to a height of 3006 m. Average 24-hour blood pressure at sea level was 134/86.7 mmHg in the hypertensive subjects and 115.8/73.6 mmHg in the normotensive ones. At 1210 m, it rose to 140.6/90.2 mmHg (n.s.) and to 120.8/74.9 mmHg (n.s.) respectively. Twenty-four-hour profiles showed that the blood pressure difference was present only during waking hours, while during sleep blood pressure levels were similar at sea level and in the mountains.(ABSTRACT TRUNCATED AT 250 WORDS)

Time course of changes in blood pressure, aldosterone and body fluids during enalapril treatment: a double-blind randomized study vs hydrochlorothiazide plus propranolol in essential hypertension.

Aldosterone suppression is said to play a major role in the long term hypotensive efficacy of angiotensin converting enzyme inhibitors. However, in previous reports from other laboratories, plasma volume has been found mostly increased and sodium balance sometimes positive. The effects of the angiotensin converting enzyme inhibitor enalapril (10-40 mg/day, p.o., for 6 weeks) on blood pressure, body fluid volumes, renal function and plasma aldosterone were compared to those of hydrochlorothiazide (50 mg/day, p.o.) alone for 2 weeks and in association with propranolol (80-160 mg/day, p.o.) for 4 more weeks during a randomized double-blind parallel study in 14 essential hypertensives. Hydrochlorothiazide alone and in combination with propranolol induced slight and not significant change in either blood pressure and body fluids. The maximum hypotensive response to enalapril was achieved only after 2 weeks of continuous treatment possibly because after 1 week the hypotensive efficacy was lessened by a significant (P less than 0.05) fluid retention secondary to a transient and not significant fall in renal perfusion. At this time aldosterone was not significantly changed compared to pretreatment values. After 6 weeks on enalapril, blood pressure was significantly reduced, plasma aldosterone further but not significantly decreased and extracellular fluid volume was normal. These findings indicate that aldosterone suppression contributes to the blood pressure lowering effect of enalapril by offsetting the salt and water retention observed on starting treatment and due to direct vasodilation.