Central and cardiovascular responses to emotional stimuli are normal in non-phobic subjects with Reflex Syncope.

OBJECTIVE: Reflex Syncope (RS) is a self-limited loss of consciousness due to systemic arterial hypotension resulting from widespread vasodilatation and/or bradycardia. Higher neural centres have been implicated in the pathophysiology of RS, particularly in blood/injury phobic patients. We investigated interictal central autonomic functions in non-phobic RS subjects compared to non-phobic controls evaluating their central and cardiovascular responses to emotional stimuli. METHODS: Cardiovascular responses to Valsalva Manoeuvre (VM), Deep Breathing (DB) and during presentation of 108 slides selected from the International Affective Picture System were assessed in 20 non-phobic RS subjects and 20 controls. Slide onset visual event-related potentials (ERPs) were also computed. RESULTS: No significant difference in cardiovascular responses and ERP amplitude were found in non-phobic RS subjects and controls at rest, in response to VM and DB or during picture presentation. CONCLUSIONS: Non-phobic patients with RS not only have a normal interictal autonomic control of the cardiovascular system but also a normal modulation and adaptation of central and cardiovascular response to emotional processing, in our experimental setting. SIGNIFICANCE: Non-phobic patients with RS present normal interictal central and cardiovascular responses. Autonomic dysfunction observed in phobic RS patients could be related to mechanisms underlying the phobia itself rather than the mechanisms causing RS.

The role of cardiac diseases in the comorbidity between migraine and stroke.

Several case-control and cohort studies have suggested an association between migraine and stroke. A significantly higher risk for stroke was found in women under the age of 45 years and for the subgroup with migraine with aura, the posterior circulation being significantly more frequently involved. The link between cardiac diseases and the comorbidity migraine-stroke has been evaluated considering both possible relationships: a higher prevalence of a vascular disease involving both heart and brain in migraineurs, or a cardiac disorder, more prevalent in migraineurs, with a possible aetiological role in migraine attacks.

Prophylaxis of thromboembolic events in congestive heart failure.

In patients with heart failure the incidence of thromboembolism is 0.9-5.5%/year (mean 1.9%/year), but no randomized studies are available to support the indication for anticoagulant therapy in those patients. Atrial fibrillation and previous thromboembolic events seem to be the major risk factors, whereas the effect of ventricular dysfunction has not been independently evaluated; nonetheless several studies suggest that thromboembolism is more likely among those patients with lower ejection fraction and lower peak exercise oxygen consumption. Anticoagulant therapy seems to be indicated also in patients with left ventricular aneurysm with mobile and protruding thrombi. Several studies of patients with dilated cardiomyopathy show that the incidence of thromboembolism ranges from 1.6 to 4.5%/year in patients not treated with anticoagulants, while it is virtually absent in anticoagulated patients. The clinical opportunity of long-term anticoagulant treatment in heart failure patients should be weighted not only on the clinical markers of thromboembolic risk, but also on the relative risk/benefit ratio of the single patient.

[Atrial fibrillation: incidence and prognostic factors of embolic risk]. / Fibrillazione atriale: incidenza e fattori prognostici di rischio embolico.

Atrial fibrillation (AF) carries a high risk of systemic embolism, in particular stroke. This is true not only when AF is associated with rheumatic valvular heart disease, but also in the so-called nonvalvular AF (NVAF). The recent randomized clinical trials assessing antithrombotic therapy as primary prevention in NVAF have shown that, untreated, disabling stroke occurs in 2.5%/year, ischemic stroke in 5%/year, stroke and transient ischemic attack in 7%/year, and stroke, transient ischemic attack and silent stroke in > 7%/year. All AF does not carry identical stroke risk. A risk stratification is important in order to decide long-term antithrombotic prophylaxis. A number of important clinical predictors of stroke have been identified. They include age, hypertension, congestive heart failure, previous arterial thromboembolism and previous myocardial infarction. Idiopathic or "lone" AF in patients < 60 years old, without hypertension and diabetes mellitus, carries an extremely low risk of stroke. Also in paroxysmal AF, when patients are < 60 years old and without organic heart disease, the embolic risk is low. The recent onset of AF does not seem to be associated with an excess of embolic risk, in comparison with long-standing AF. In conclusion, the underlying heart disease represents the main determinant of embolic risk. Within the broad spectrum of patients with NVAF a satisfactory risk stratification for thromboembolism can be accomplished by the analysis of clinical risk factors, possibly in association with echocardiographic variables.

[Clinical characteristics and prognostic factors in chronic heart failure secondary to primary dilated cardiomyopathy and ischemic heart disease]. / Caratteristiche cliniche e fattori prognostici dello scompenso cardiaco cronico secondario a miocardiopatia dilatativa primitiva ed a cardiopatia ischemica.

Natural history and prognostic factors in chronic congestive heart failure were investigated in 141 patients (100 males and 41 females), aged 58 +/- 14.5 years, who were hospitalized between 1981-1985. Heart failure was due to idiopathic dilated cardiomyopathy in 79 patients and ischemic heart disease in 62 patients. The following parameters were examined: sex, age, etiology, NYHA functional class, mean arterial blood pressure, heart rate, presence of 3rd heart sound, atrial fibrillation and left ventricular conduction delay, plasma sodium, echocardiographic shortening fraction, and treatment with vasodilators. Mean follow-up was 31 +/- 19 months. Overall survival was 83% at 1 year, 58% at 3 years and 49% at 5 years. No difference in mortality was evident between the two etiological groups, while the data on the cause of death showed a significant difference: sudden death was prevalent in the patients with ischemic disease (50% vs 24%), intractable heart failure predominated in patients with idiopathic dilated cardiomyopathy (69.7% vs 42.8%) (p less than 0.05). The multivariate analysis with the Cox model resulted in a negative prognostic significance of the male sex (p less than 0.02), III and IV NYHA functional class (p less than 0.04), heart rate at rest greater than 85 b/min (p less than 0.002) and the presence of left ventricular conduction delay on standard ECG (p less than 0.001).

[Hemodynamic and clinical effects of captopril in congestive heart failure]. / Effetti emodinamici e clinici del captopril nello scompenso cardiaco congestizio.

The acute and chronic effects of Captopril were evaluated in 8 patients (5 males and 3 females, age 49 +/- 17 years) with chronic severe congestive heart failure. Acute hemodynamic effects were studied according to a randomized, double blind, placebo controlled protocol, by using two doses of Captopril (25 and 50 mg). The usual diuretic and digitalis treatment was kept unchanged throughout the trial. The acute administration of placebo associate with the usual doses of diuretic and digitalis was followed after 2 hours by a significant reduction of mean pulmonary wedge pressure (-23%, p less than 0.05). One hour following a single administration of Captopril, the following significant (p less than 0.05) changes were observed, respectively for the doses of 25 and 50 mg: heart rate -9% and -6%, cardiac index +13% and +10%, mean pulmonary wedge pressure -27% and -35%, mean pulmonary arterial pressure -29% and -26%, systemic vascular resistances -20% and -17%. A longer duration of effects on heart rate and cardiac index was noted after the 50 mg dose. All patients received long-term treatment with Captopril 75 or 150 mg daily. The NYHA functional class improved in all cases and there was a significant decrease of the cardio-thoracic ratio (from 0.61 +/- 0.05 to 0.55 +/- 0.09, p less than 0.01). A repeated hemodynamic study after a mean period of 6.5 months (range 2.5-22 months) revealed in 7 cases a sustained effect of the drug.(ABSTRACT TRUNCATED AT 250 WORDS)