Benthic foraminifera response and geochemical characterization of the coastal environment surrounding the polluted industrial area of Portovesme (South-Western Sardinia, Italy)

To study the benthic foraminifers' response to heavy metal pollution and analyse the geochemical parameters, samples of surface sediments were collected in 2005 and 2006 from a polluted coastal zone shorefront to the industrial complex of Portoscuso-Portovesme (Sulcis, South-Western Sardinia). The samples came from the upper 1-2 cm of the undisturbed sediments in water less than 2m deep, along coastline (about 8.5 km in length) proximal to emerged alluvial plain. The entire examined marine area represents a shallow inner shelf, which is physiographically fairly protected and characterized by low turbulence, but subjected to southwards littoral drift. Geochemical analyses of seawater, sediments and foraminiferal tests correlated to biotic indexes (Dominance, Shannon-Weaver, Simpson, Eveness, Menhinick, Margalef, Equitability, Fisher-alpha, Berger-Parker and Q-mode Cluster Analyses--Ward Method) and provide data on environmental stress. A total of 38 benthic foraminiferal species were identified. Increasing pollution results in low species diversity, low population density and more frequent abnormal specimens. Results from ESEM images allow recognition of a strong infestation on the calcareous foraminiferal tests by microbial communities developed in the polluted environment.

Association between psychiatric disorders and Marfan's syndrome in a large Sardinian family with a high prevalence of cardiac abnormalities

BACKGROUND

Marfan's syndrome is an inherited disorder of connective tissue associated with characteristic abnormalities of the skeletal, ocular, and cardiovascular systems. Marked clinical variability and age dependency of all manifestations of Marfan's syndrome may render the unequivocal diagnosis difficult in mildly affected, young subjects.

HYPOTHESIS

The study and care of a 32-year-old woman with evidence of Marfan's syndrome, several cardiac abnormalities, and paranoid schizophrenia led to an investigation of her consenting relatives to verify the penetrance of Marfan's syndrome and the degree of comorbidity between the disease and psychiatric disorders.

METHODS

The patient and 12 subjects belonging to three generations of her family underwent cardiovascular, skeletal, ophthalmologic, and psychiatric examinations. Two-dimensional and Doppler echocardiography were performed.

RESULTS

One female index patient and six of her first-degree relatives were found to be affected by Marfan's syndrome. All seven patients were found to have mitral valve prolapse associated with other cardiac abnormalities. Four of these patients were affected by the following psychiatric disorders: generalized anxiety disorder, major depressive disorder, paranoid schizophrenia (two cases). Six more relatives without Marfan's syndrome showed mitral valve prolapse in association with other echocardiographic features. Two of these were found to be affected by a major depressive disorder.

CONCLUSIONS

The present data support the hypothesis that a psychiatric condition, associated with a significantly high frequency of cardiac involvement, may be part of the phenotype of Marfan's syndrome.

Can menopause be considered an independent risk factor for cardiovascular disease?

Following the menopause, women develop coronary artery disease at the same rate as men. The best documented change observed in the risk factors linked to ovarian exhaustion is an alteration in lipid composition. More recent studies, however, suggest that the increased cardiovascular morbidity and mortality after menopause cannot be fully explained by changes in plasma lipoproteins, and support the concept that ovarian hormone deprivation has a widespread impact on the cardiovascular system, with a direct harmful effect on vessel-wall physiology. After the menopause, subjects free from cardiovascular diseases show vascular hyperactivity and a poor vasodilator reserve; the rate of increase in the incidence of arterial hypertension in women is higher than that observed among males of the same age; altogether, cardiovascular diseases become the number one cause of death among women. A large number of mechanistic studies have shown that estrogens, through either direct or genomic-dependent activities, produce beneficial effects on the factors controlling blood flow and plaque formation. Nevertheless, results from recent randomized clinical trials are challenging the belief that postmenopausal hormone therapy protects against coronary artery disease.

Effects of acute administration of natural progesterone on peripheral vascular responsiveness in healthy postmenopausal women

Peripheral vascular responses to acute administration of natural progesterone were studied in 12 postmenopausal women (mean +/- SD age 50.3 +/- 4.8 years) with no evidence of cardiovascular disease. According to a randomized, double-blind protocol, all subjects were given natural progesterone as a vaginal cream, able to produce a rapid peak and decay of plasma hormone concentrations, or matched placebo, with crossover after a 1-week washout period. Forearm blood flow and peak flow after ischemic stress (ml/100 ml/min), local vascular resistance (mm Hg/ml/100 ml/min), venous volume (ml/100 ml), and venous compliance (ml/100 ml/mm Hg) were measured by strain-gauge venous occlusion plethysmography at baseline and after progesterone or placebo administration. Plasma norepinephrine concentrations were determined by high-performance liquid chromatography with electrochemical detection. Progesterone sharply decreased forearm blood flow (p <0.01) through an increase in local vascular resistance (p <0.01). Measures of venous function remained unchanged. Although the hormone increased circulating norepinephrine concentrations (p <0.05), there were no significant changes in mean arterial pressure or heart rate. Furthermore, progesterone reduced the local vasodilator capacity, shown by a decrease in forearm delta flow (difference between peak flow and basal flow, p <0.05). Compared with the well-known effect of estrogen, progesterone exerted an opposite action on peripheral vascular responsiveness. Peripheral circulatory changes may be attributed to a direct activity of progesterone on the arterial wall and may in part reflect a modulation of the hormone on peripheral sympathetic tone. Consideration must be given to the hypothesis that the addition of progestin may attenuate the beneficial effects of unopposed estrogen replacement therapy in postmenopausal women.

Study of myocardial contractility by pulsed wave Doppler tissue imaging does not reveal an inotropic effect of estrogen at physiologic dose

We studied myocardial contractility by pulsed wave Doppler tissue imaging in 6 postmenopausal healthy women. According to a crossover, double-blind protocol, we randomized patients to treatment with transdermal patches of estradiol-17beta or matched placebo. Estradiol-17beta did not modify local systolic and diastolic functions. Thus, at least when acutely administered, estrogen seems to be unable to determine hemodynamic changes at the myocardial level, in opposition to what occurs in the peripheral vascular system.

Impaired forearm blood flow and vasodilator reserve in healthy postmenopausal women

BACKGROUND

The natural process of cessation of ovarian estrogen production is associated with an increasing incidence of cardiovascular disease.

OBJECTIVE

We aimed to determine whether postmenopausal women had menopause-associated vasomotor disturbances develop.

METHODS

We studied the vascular forearm function using strain-gauge venous occlusion plethysmography in 12 healthy postmenopausal women (mean age +/- SD, 47 +/- 3 years; time-lapse from menopause >1 year). Twelve premenopausal subjects matched for age and biophysical characteristics were used as a control group.

RESULTS

No differences were observed in heart rate or mean blood pressure between the 2 groups of women. Forearm blood flow at supine resting was lower in postmenopausal than in premenopausal women (2.4 +/- 0.8 vs 3.1 +/- 0.5 mL/100 mL/min; P <.05). Local vascular resistance was higher in postmenopausal than in premenopausal women (43.5 +/- 17.5 vs 31.1 +/- 4.3 mm Hg/mL/100 mL/min; P <.05). Moreover, peak forearm flow in response to forearm ischemia was 20.8 +/- 7.9 mL/100 mL/min in postmenopausal women and 26.6 +/- 9.7 mL/100 mL/min in premenopausal women (P <.01). Plasma concentration of noradrenaline in the supine position was significantly higher in postmenopausal than in premenopausal women (286 +/- 22 pg/mL vs 195 +/- 33 pg/mL; P <.01). Finally, a significant positive relation was revealed in postmenopausal women between the amount of vasodilator reserve (D flow) in local peripheral circulation and levels of circulating estradiol-17beta.

CONCLUSIONS

Abnormalities observed in forearm blood flow and vasodilator capacity in postmenopausal women may be attributed to a critical loss of the vasodilating property of physiologic estrogen. Our data support the possibility that reduction in dilator capacity of the vasculature may contribute to the increase of cardiovascular disease after menopause.

Association between dopamine receptor genes and migraine without aura in a Sardinian sample

BACKGROUND

Migraine seems to be caused by a combination of environmental and genetic factors. Clinical and pharmacologic evidence supports the hypothesis that dopaminergic transmission is involved in the pathogenesis of migraine.

OBJECTIVE

The current report concerns a genetic study to test the involvement of genes for dopamine (DA) receptors D2 (DRD2), D3 (DRD3), and D4 (DRD4) in migraine without aura, particularly in a subgroup with enhanced DA sensitivity.

METHODS

For the first time, a family-based association method--the Transmission Disequilibrium Test (TDT)--was used to examine an isolated population, such as Sardinians. We studied 50 nuclear families of patients affected by migraine without aura. The subgroup of dopaminergic migraineurs was selected based on the presence of both nausea and yawning immediately before or during the pain phase of migraine.

RESULTS

No association was detected using the TDT between DRD3, DRD4, and migraine without aura either in the overall sample or in the subgroup. No difference was observed in DRD2 allelic distribution in the overall sample, although the allelic distribution at the DRD2 locus differed significantly in the subgroup of dopaminergic migraineurs (p = 0.004). Allele 1 of the TG dinucleotide intronic noncoding polymorphism of the DRD2 locus was the individual allele that appeared to be in disequilibrium with migraine without aura (p = 0.02).

CONCLUSIONS

Our data suggest that a genetic approach could be useful in providing molecular support to the hypothesis that hypersensitivity of the dopaminergic system may represent the pathophysiologic basis of migraine, at least in a subgroup of patients.

Estradiol-17beta reduces blood pressure and restores the normal amplitude of the circadian blood pressure rhythm in postmenopausal hypertension

After menopause, both systolic (SBP) and diastolic (DBP) blood pressure (BP) become higher in women than in men of the same age, suggesting that estrogen deficiency may influence the age-related increase in BP. We studied 30 postmenopausal women (mean age, 55 +/- 5.7 years; time from menopause, 2-5 years) affected by mild hypertension with no target-organ complications by means of 24-h BP monitoring. None of the group were undergoing estrogen replacement therapy or taking antihypertensive drugs. According to a randomized, double-blind protocol, subjects received patches of transdermal estradiol-17beta (E2) or a matched placebo, with crossover after a 7-day washout period. In 12 patients the 24-h peak-to-trough variation in SBP and DBP amounted to less than 10% (nondippers). Administration of E2 significantly decreased 24-h SBP and DBP in the whole cohort (P < .05). Furthermore, E2 restored the expected reduction in BP during nighttime in the nondipper subgroup. It is well known that estrogen replacement therapy protects against the development of both cardiovascular diseases and stroke. Our data suggest that this activity could be attributed, at least in part, to the activity of E2 in preserving physiologic circadian fluctuation of BP.

Effects of acute administration of transdermal estrogen on postmenopausal women with systemic hypertension

We studied 16 postmenopausal women with mild to moderate hypertension according to a randomized, double-blind protocol. They received patches of transdermal estradiol-17beta rated to deliver 100 mg/day of substance or matched placebo. A 24-hour ambulatory blood pressure (BP) monitoring was performed at baseline and after drug administrations. Our data show that estradiol-17beta exerts beneficial effects, both in lowering elevated BP levels and in maintaining a uniform BP control over 24 hours. Estrogen replacement therapy could be considered when significant changes in BP occur during the postmenopausal period.

[Does a genetic predisposition for infarction expansion exist? Evaluation of genetic polymorphisms of the renin-angiotensin system]

Aim of this study is to carry out a genetic analysis of polymorphisms of the renin-angiotensin system in a genetically homogeneous population, in patients with and without myocardial infarction (AMI) expansion and to evaluate the influence of non genetic, mechanical factors. The study was conducted on 299 patients with first AMI. Ecocardiography studies were performed on all patients on day 1 and 3 from the onset of AMI and before discharge. Eighty-four patients were excluded because of inadequate quality of echocardiograms and 215 (163 males, 52 females) were admitted. Of these, 157 had no evidence of AMI expansion (EXP-) while 58 had expansion (EXP+). DNA was extracted by standard methods from blood samples. Age and gender had no influence on AMI expansion. Anterior infarction (p < 0.000001) and Q-wave infarction (p < 0.00002) were found more frequently in EXP+. Peak of creatine phosphokinase was higher in EXP+ than in EXP- (p < 0.00001). The percent of patients treated with thrombolysis or with hypertension and/or left ventricular hypertrophy was not significantly different in the two groups. AGT MT235 polymorphism of angiotensinogen gene, I/D polymorphism of ACE gene and AT1 A1166C of AT1 receptor of angiotensin II were not significantly different in two groups. Stratified analysis showed that in patients with anterior AMI (n = 87), with a higher risk of AMI expansion, there is a significant difference (p < 0.02) in ACE genotype between EXP- and EXP+. Odds ratio assuming the dominant effect of I allele (II+ ID < DD) was 3.35 (confidence interval 1.41-7.56) with increased risk of expansion. More extension studies are need to verify if these results can contribute to early identification of patients at higher risk and to optimize therapeutic approach.

Six-year follow-up of thyroid function during lithium treatment

A cohort of patients at various stages of lithium treatment was followed up for 6 years in order to evaluate the course of thyroid abnormalities. Ultrasonography confirmed that lithium can increase thyroid size, especially in cigarette smokers, and that it can affect the texture of the gland. However, the incidence of clinical hypothyroidism or specific thyroid autoimmunity does not exceed that found in the general population. Repeated determinations of thyrotrophin (TSH) concentrations can prevent clinically relevant consequences. Addition of carbamazepine to lithium can counteract lithium-induced subclinical hypothyroidism, possibly improving prophylactic efficacy in recurrent affective disorders.

Echocardiographic assessment of aortic valve replacement with stentless porcine xenografts

Stentless porcine xenografts (SPXs) implanted in the aortic position have potential hemodynamic advantages over traditional valve prostheses because of the lack of a rigid stent. Twenty-four patients (mean age 59 years) who underwent aortic valve replacement with SPXs were studied by echocardiography early after and 26 +/- 10 months (range 8 to 40) after operation. Peak and mean gradients, as well as aortic valve area, did not change significantly from baseline (16.3 +/- 8 and 9.8 +/- 5.6 mm Hg, and 1.78 +/- 0.63 cm2, respectively) to follow-up study (12.5 +/- 5 and 7.7 +/- 3 mm Hg, and 1.8 +/- 0.65 cm2, respectively). At baseline, color flow Doppler imaging showed aortic valve regurgitation where the leaflets coapted centrally in 17 of 24 patients (trivial, n = 14; mild, n = 3). Besides the central leak, paravalvular regurgitation was seen in 4 patients (trivial, n = 3; mild, n = 1). At follow-up, 18 of 24 patients had aortic valve regurgitation (trivial, n = 11; mild, n = 6; and moderate, n = 1). New valvular regurgitation (graded as trivial, n = 2; mild, n = 2; and moderate, n = 1) was detected in 5 patients, and new paravalvular regurgitation (graded as mild) developed in 1 patient. Two patients underwent repeat operation for valve-related complications: (1) rupture of a valve cusp with acute pulmonary edema, and (2) fibrotic stenosis of the left coronary ostium with unstable angina. In conclusion, this study demonstrates good hemodynamic performance of the SPX in the aortic position.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hemodynamic assessment at rest and during dynamic physical exercise in young subjects with and without hypertensive parents]

The aim of this research was to identify any early cardiovascular changes that may be predictive of future hypertension in young subjects with family history of hypertension. The study was conducted on 25 offspring of hypertensive parents, mean age 17 years (22 with hypertension only in 1 parent and 3 with both hypertensive parents) and 20 offspring of both normotensive parents, matched by age. Subjects were divided into children (7-13 years) and young adults (19 years on). All subjects underwent three office blood pressure measurements with a mercury sphygmomanometer. On the third control, BoMed thoracic electrical bioimpedance at rest and during upright bicycle exercise was performed. Physical characteristics were similar in subjects matched by age in the two groups. Systolic blood pressure was similar in offspring of normotensives and hypertensives, both at rest and during exercise; diastolic blood pressure was greater in offspring of hypertensive parents at rest (73.1 +/- 10.5 vs 63.5 +/- 7.1 mmHg, p < 0.05), during the first minutes of exercise and during the recovery phase (p < 0.05). Moreover, at the third blood pressure measurement at rest, diastolic blood pressure decreased, with respect to the first measurement, only in children and young adult offspring of normotensive parents, while systolic blood pressure decreased in the two groups of child subjects. No differences in heart rate were observed, both at rest and during physical exercise, between offspring of normotensives and hypertensives. Left ventricular end-diastolic volume, stroke volume, ejection fraction, cardiac output and systemic vascular resistance at rest and their response to decubitus changes and exercise were normal and similar in offspring of normotensive and hypertensive parents both in children and young adults. In conclusion, a different behavior of diastolic blood pressure was found in offspring of hypertensive parents compared to that of normotensive parents, both in children and, to a higher degree, in young adults. This may be an expression of early vascular change in subjects with a genetic predisposition to hypertension.

Intracranial haemorrhage during exercise testing

We describe the occurrence of an intraparenchymal (thalamic) haemorrhage during a stress test in a hypertensive 52-year-old man who had suffered from myocardial infarction 3 months earlier. Common causes of spontaneous haemorrhage, such as arteriovenous malformation, aneurysms, neoplasm, bleeding disorders or vasculitis were excluded. This single neurological complication was observed from among 8000 exercise tests performed in our Institute from 1987 to 1993.

Regurgitant flow of mitral valve prostheses: an intraoperative transesophageal echocardiographic study

To assess the regurgitant characteristics of mitral biologic and mechanical prostheses immediately after implantation, intraoperative transesophageal echocardiography was performed in 27 patients, aged 32 to 69 years, undergoing open-heart surgery for rheumatic heart disease (n = 19), mitral valve prolapse (n = 3), malfunctioning prostheses (n = 3), or periprosthetic leaks (n = 2). The prostheses included 13 biologic (Carpentier-Edwards) and 14 mechanical valves (five Starr-Edwards, five Medtronic-Hall, and four Bjork-Shiley). Physiologic transvalvular regurgitant flow was detected in both biologic and mechanical prostheses. The spatial extent of the regurgitant jets was usually greater in the mechanical than in the biologic valves, and systolic jets, characteristic of each type of valve, were visualized consistently. Trivial periprosthetic jets (PPJs) were observed in many implanted valves (14/27). The median maximal jet area was 0.46 cm2 (range 0.1 to 1.5 cm2). Cardiopulmonary bypass was reinstituted in two patients. In one patient a PPJ was judged extensive enough (area 3.6 cm2) to warrant surgical revision of the implant, but no dehiscence was found. In the other patient a turbulent PPJ (area 5.5 cm2) was associated with a 0.5 cm dehiscence at the surgical inspection. In conclusion, (1) all mitral prostheses exhibit physiologic transvalvular regurgitation, (2) trivial mitral PPJ is a common finding in newly implanted mitral valves and does not require the revision of the implant, and (3) further experience based on larger series of patients is required to determine the maximal acceptable size of a mitral PPJ detected by intraoperative transesophageal echocardiography.

[Effects of verapamil on left ventricular mass and diastolic function in hypertensive patients]

To evaluate the effects of antihypertensive therapy with verapamil on left ventricular (LV) mass, systolic and diastolic function, 12 hypertensive patients, mean age 44 years, were studied during 12 months of treatment with verapamil, in a gradual release from (240-480 mg/day), by serial recordings of ECG, blood pressure (BP) and echocardiogram. In pretreatment conditions, 8 patients showed LV hypertrophy and 2 patients impaired LV diastolic function. Blood pressure decreased significantly after 1 month of therapy, septal and LV posterior wall thickness after 3 months and LV mass after 6 months. No significant changes were observed in LV fractional shortening and diastolic transmitral flow. At the end of the study BP normalized in 8 patients and LV mass in 1 patient. Left ventricular diastolic function was normalized in 1 patient but became worse in another, in spite of the reduction in BP and LV mass. Thus, verapamil was an effective antihypertensive drug and was able to revert hypertensive LV hypertrophy. However, the behaviour of LV diastolic function seems to be independent of the effects of the drug on BP and LV mass. Further studies are necessary to clarify this problem.

Intraoperative echocardiography by a new miniaturized epicardial probe: preliminary findings

Miniaturized probes constitute recent progress in the field of epicardial echocardiography. We recently used a new miniaturized probe, derived from a standard transesophageal probe, in a series of 12 adult patients who underwent cardiac surgery in order to test the possibility of obtaining new views for epicardial imaging. This study demonstrates the feasibility and safety of performing intraoperative echocardiography when using a miniaturized epicardial probe. This probe may be placed on a broader epicardial and vascular area, thus overcoming the size limitations of the commonly used epicardial probes. The major limitation found with the miniaturized probe, however, was the inability to obtain a true four-chamber view from the ventricular apex, due to the difficulty of holding the probe motionless between the apex and the diaphragm while the heart is beating. Although extensive experience with larger groups of patients and different pathologies will be required to define the full potential of this new probe, the advent of the miniaturized probe may further expand the applicability of epicardial echocardiography in pediatric patients during surgery for congenital heart disease.

[The effect of nifedipine in hypertensive cardiopathy. An echocardiographic and electrocardiographic study]

To assess whether antihypertensive therapy by nifedipine can reverse left ventricular (LV) hypertrophy, 15 hypertensive patients, mean age 47 years, were serially studied during 12 months of treatment with nifedipine in slow release (40-60 mg/day), by recordings of blood pressure (BP), ECG and echocardiogram. Blood pressure decreased from 161 +/- 6/104 +/- 3 mmHg to 131 +/- 3/89 +/- 1 mmHg, p < 0.001, and this fall first became statistically significant at 1 month. From the hemodynamic view point, BP decreased for a reduction in total peripheral resistance. The Sokolow-Lyon voltage decreased significantly after 6 months (from 33.5 +/- 2.7 to 28.1 +/- 2.1 mm, p < 0.01) without further changes in the subsequent months. Left ventricular mass, by echocardiography, decreased after 6 months (from 189 +/- 15 to 176 +/- 13 g/m2, p < 0.05) and further after 12 months (169 +/- 13 g/m2, p < 0.001). The reduction in LV mass was secondary to the decrease in wall thickness, particularly in posterior wall thickness. No significant changes were observed in LV fractional shortening throughout the study. Thus, nifedipine was an effective antihypertensive agent and reverted LV hypertrophy secondary to arterial hypertension without impairment of LV systolic function.

[The effect of nifedipine on arterial pressure and exercise tolerance in hypertensive patients]

The aim of this research was to assess whether the antihypertensive therapy with nifedipine, a dihydropyridine calcium-antagonist, is able to control hypertension not only at rest but also during exercise. So, 20 male hypertensive patients, mean age 48 years, were evaluated by symptom limited bicycle exercise (10 W/min) before and after 6 and 12 months of therapy with nifedipine in a slow releasing form (40-60 mg/day). Exercise tolerance significantly increased after 12 months of antihypertensive therapy with nifedipine (from 146 +/- 5 to 153 +/- 4 W, p < 0.05). Systolic and diastolic blood pressure decreased after 6 and 12 months both at rest (from 160 +/- 6/109 +/- 9 mmHg to 132 +/- 3/91 +/- 3 and 135 +/- 4/93 +/- 1 mmHg, respectively, both p < 0.001) and during exercise (at end exercise: from 238 +/- 7/121 +/- 5 mmHg to 216 +/- 6/106 +/- 3 and 213 +/- 6/107 +/- 3 mmHg, respectively, both p < 0.001). No significant changes in heart rate were observed during antihypertensive therapy both at rest and during exercise test. In conclusion, long-term antihypertensive therapy with nifedipine was effective in the control of hypertension both at rest and during physical stress. Moreover, an improvement in effort tolerance was observed in hypertensive patients.

[Nicardipine attenuates the sympathetic reflex of orthostatism: do dihydropyridine-sensitive calcium channels regulate noradrenaline release?]

Twelve hypertensive subjects were treated for 2 weeks with the dihydropyridine calcium channel antagonist nicardipine (40 mg daily) according to a double-blind, placebo-controlled study protocol. Nicardipine treatment significantly decreased systolic and diastolic blood pressure and increased plasma noradrenaline levels measured at supine rest. However, the treatment significantly inhibited the physiological increase of circulating neurotransmitter following sympathetic stimulation induced by orthostatism. These results suggest that dihydropyridine-sensitive calcium channels may modulate the noradrenaline release from nerve terminals of the peripheral sympathetic nervous system.

[The effect of antihypertensive therapy on the seasonal variations in arterial pressure in hypertensive patients]

To evaluate the influence of antihypertensive therapy (AHT) on blood pressure (BP) seasonal variations, we have analyzed the systolic and diastolic BP values in 145 hypertensives, 112 males and 33 females, aged 23-65 years, in the 10-year period 1981-1990. All patients received medical treatment and were examined for at least 5-7 consecutive years. The year was divided in 2 (cold and warm months) and 4 periods in relation to mean monthly environmental temperature (10 degrees C, 13 degrees C, 18 degrees C and 23 degrees C). Systolic and diastolic BP was higher in cold months (142/93 vs 137/88 mmHg, p less than 0.05). In cold periods AHT was increased in 11% of patients and decreased in 8%. In the warm periods AHT was decreased in 11% of patients and increased in 6%. The AHT reduction in the warm months was not significantly different in comparison to that of cold months. Vice versa, the AHT increase in cold months was greater than that of warm periods (p less than 0.001). In the 10-year period considered, 18% of patients reduced AHT in the warm period and increased it in the cold period. It was also found a small correlation between diastolic blood pressure and wind, which is, in our country, mostly the mistral. Betablockers, calcium-antagonists and the association betablocker-diuretics showed a seasonal BP variation, while patients treated by diuretic had the same BP both in winter and in summer. A small negative correlation was observed between systolic and diastolic BP and temperature in patients treated by all antihypertensive drugs except the diuretics.(ABSTRACT TRUNCATED AT 250 WORDS)

[The vascular and metabolic mechanisms of the development of the atherosclerotic plaque]

Atherosclerosis is a degenerative disease responsible for the majority of deaths in the western populations. According to the idea of the reaction to injury the endothelial cells lining the vascular wall are exposed to repeated insults to their integrity. The injury results in a loss of functional attributes of endothelium and leads to a sequence of events including platelet adherence and aggregation, release of platelet granular components, migration and proliferation of medial smooth muscle cells into the intima. Examples of types of injury include chemical injury, as in hyperlipidemia, or mechanical stress associated with critical changes in vascular flow. Atherosclerosis has been considered a disease primarily concerned with lipid metabolism by regarding the intramural caseous material of atheromatous arteries as the sine qua non of the disease. The limitation of the lipid theory is that the conventional cholesterol-fed animal does not exactly reproduces the pathology of atherosclerosis. An alternative theory suggests that atherosclerosis is induced by mechanical fatigue which produces the progressive change in structure and mechanical properties of the vessel wall. In this view the lipid accumulation is a secondary phenomenon, the consequence of concomitant biochemical alterations of mural constituents. The hypothesis of reaction to injury provides a plausible explanation for the lesion formation and the different theories of atherogenesis are not mutually exclusive.

[What have we learned from large trials?]

Clinical trials, during myocardial infarction, showed the importance of thrombolytic therapy on coronary patency, to improve left ventricular function, to reduce early and late mortality. Since the efficacy of thrombolytic therapy is now well established, most clinical trials were made to compare the efficacy of SK, rt-PA and APSAC and to evaluate concomitant drugs. Recanalization and coronary patency, reocclusion and incidence of side effects, left ventricle function's improvement and lowered mortality have been used to assess drugs' activity. At the moment the efficacy of three thrombolytic drugs seems to be the same. So the drug's choice is related not to drug's efficacy but to side effects of the drugs. Concomitant intravenous heparin therapy is now under study; utility of this therapy is shown by its theoretical assumptions and by clinical trials results. Large clinical trials are working to extend our knowledge, improving the patients' management in our every day clinical practice. Furthermore, large trials do not replace but go together with studies performed on few patients, whose results often give advance notice of those of large ones.

[Arterial blood pressure behavior during progressive muscular exercise in subjects with stable arterial hypertension]

To assess the behaviour of blood pressure (BP) during exercise in hypertensive patients (H), 103 males aged 21 to 59 years (mean 43 years) with essential hypertension WHO class I-II were studied. All H, without antihypertensive therapy for at least 15 days, underwent sitting bicycle exercise (10 W/min). BP was measured on the left arm by a standard mercury sphygmomanometer. The fifth Korotkoff phase was taken as the diastolic pressure. Heart rate was measured by electrocardiogram. Subjects were studied at rest in sitting position, during exercise every 3 min and during recovery at 1, 3 and 5 min. As controls we took 100 normotensive (N) males aged 20 to 59 years (mean 39 years). The results were analyzed also by decades. Systolic (S) and diastolic (D) blood pressure were higher in H in comparison with N at rest, in sitting position, (N 119 +/- 10/79 +/- 7 mmHg; H 162 +/- 21/112 +/- 11 mmHg; p less than 0.01), during exercise and recovery. SBP and, to a lesser extent DBP, progressively increased during exercise both in N and in H patients (at peak exercise: N 192 +/- 20/85 +/- 13 mmHg; H 239 +/- 25/121 +/- 13 mmHg, p less than 0.01). The mean increase of SBP during exercise was 77 mmHg in H and 73 mmHg in N (NS). DBP increment was about 6 mmHg in N and 9 mmHg in H (NS). Within the age decades, SBP during exercise was higher in the age group of 50 to 59 in comparison with 20 to 29 in N and H (p less than 0.05) and DBP in the age group of 40 to 49 and 50 to 59 in comparison with 20 to 29 and 30 to 39 (p less than 0.01). The fall of SBP and DBP was greater at 1 min of recovery both in H and N and became progressively smaller thereafter. At a same workload (90 and 120 W) 60% of H had SBP and 85% had DBP higher than BP in N (above 200/104 mmHg--mean + 2 SD--at 90 W and 215/106 mmHg at 120 W). No difference was observed in heart rate at rest and during exercise between N and H. In conclusion, H had SBP and DBP higher at rest, during exercise and recovery in comparison with N. However, a parallel increase of BP was found in the 2 groups during exercise. Ergometric test showed that 60-85% of H had also excessive increase of systolic and diastolic blood pressure during exercise.

[A new anti-ischemic drug for the treatment of stable effort angina pectoris: nicorandil. Comparison with placebo and isosorbide-5-mononitrate]

The aim of this study was to investigate antianginal and antiischemic activity and tolerance of a new nitrate derivative, nicorandil (N). This research has been carried out in 18 patients, aged 47-70 years, suffering from stable effort angina with fixed ischemic threshold. The study started with 10 days of washout, during which the patients exercised twice on bicycle to verify the reproducibility of the test. Then, they took N or isosorbide-5-mononitrate (ISM) for 14 days according to a double blinded cross-over balanced study. Between the 2 periods patients took placebo (PL) for 14 days. In the first day and in the last day of each period, 2 hours after the last drug intake, patients performed a stress test on bicycle. Like ISM, N significantly increased, versus PL, 1 mm of ST depression time (ischemic threshold) in the first and in the last day, without differences between the 2 drugs and between the days. Moreover, ST depression was significantly lower at maximal common work (MCW) versus PL. The rate-pressure product was not different from PL after N and ISM at maximal common work, but is was increased at the ischemic threshold. In conclusion, like ISM, N has shown antiischemic activity in patients suffering from stable angina pectoris on effort with fixed ischemic threshold. After 14 days of treatment there was no evidence of tolerance. The activity of N seems essentially due to an increase of coronary blood flow to ischemic zones.

[Effects of antihypertensive therapy with selective and non-selective beta blocking agents on dimensions and function of the left ventricle]

The influence of cardioselectivity and/or intrinsic sympathomimetic activity (ISA) of betablockers on hemodynamic antihypertensive effect and on left ventricular (LV) dimensions and function was studied by echocardiography in 72 hypertensive patients, mean age 43 years. After 15 days of placebo, active therapy was given for 1 month: acebutolol (ACEB, n: 16, 400-800 mg/day), atenolol (ATEN, n: 16, 50-100 mg/day), pindolol (PIND, n: 13, 15-30 mg/day), timolol (TIMO, n: 15, 10-20 mg/day) and nadolol (NADO, n: 12, 80-160 mg/day). All betablockers showed effective antihypertensive activity. Betablockers without ISA (ATEN, TIMO, NADO) reduced cardiac output (p less than 0.05), those with ISA (ACEB, PIND) decreased total peripheral resistance (p less than 0.01 and p less than 0.05 respectively). Independently from ISA, cardioselective betablockers (ATEN, ACEB) increased LV end diastolic dimension and stroke volume (p less than 0.05). LV mass was not changed, although interventricular septum thickness decreased after TIMO and NADO (p less than 0.05). LV function, as assessed by fractional shortening, was not impaired by any betablocker.

[Electrocardiographic and echocardiographic changes during antihypertensive therapy]

To investigate the changes of electrocardiographic and echocardiographic indexes of left ventricular hypertrophy (LVH) during antihypertensive therapy, 100 hypertensive patients, mean age 46 years, were studied in pretreatment condition and during 12 months of antihypertensive therapy. In pretreatment condition, 83 patients showed LVH by echocardiography (echo; left ventricular mass index greater than 130 g/m2) and 30 patients had LVH by electrocardiography (ECG) (Sokolow index greater than 35 mm). In comparison to echo index of LVH, Sokolow index showed a sensibility of 34% and a specificity of 88%. Both LV mass echo index and ECG index significantly decreased after 3 months but in different way. LV mass index mainly decreased after 12 months, whereas Sokolow index particularly decreased after 6 months, with no further changes in the subsequent months. After 12 months of therapy, the LV mass echo index normalized in 19% of the patients (16/83) and Sokolow index normalized in 57% (17/30). ECG sensibility and specificity, in comparison to LV mass echo, was 20% and 100%, respectively. Thus, ECG appears less sensitive than echo in the detection of LVH. During antihypertensive therapy ECG index of LVH normalized more precociously and to a greater extent than the echo index. However, the normalization of LVH by ECG does not necessarily mean that a complete anatomic regression of LVH has occurred.

Catecholamine injections in canine paravertebral ganglia produce hypotension by neurogenic vasodilatation

In the present study the alpha 1 selective agonist phenylephrine (PE), the alpha 2 selective agonist clonidine (CLO) and the non-selective endogenous catecholamine norepinephrine (NE) and dopamine (DA) were injected directly into the blood supply of the paravertebral sympathetic ganglia (PSG) of anesthetized open-chest dogs. Intra-arterial injection of all agonists produced dose-dependent decreases in mean arterial pressure (MAP) and femoral vascular resistance (FVR) but had no effect on heart rate. Their potency order was CLO greater than NE greater than PE greater than DA. Intravenous injections of the medium dose for NE and PE produced significant increases in MAP, while the medium dose of CLO injected iv produced a small decrease in MAP. The ganglionic blocking agent, hexamethonium (10 mg/kg iv) completely eliminated the hypotensive response to all agonists. Intra-arterial administration of the alpha 1 selective antagonist terazosin (0.5 mg) significantly reduced the decrease in MAP produced by the ganglionic actions of PE, but had no significant effect on the response to CLO. In contrast, the alpha 2 selective antagonist rauwolscine (100 micrograms) significantly reduced the decreases in MAP produced by ia CLO, but not that produced by ia PE. However, both antagonists inhibited the hypotensive effect of NE and DA. These findings suggest that both subtypes of alpha-adrenoceptors, alpha 1 and alpha 2, are present in the PSG and that both subtypes are inhibitory since their activation results in reduced transmission of impulses through the ganglia.

[Effects of indenolol on left ventricular mass in patients with essential arterial hypertension]

This study evaluated the effect of long-term antihypertensive therapy with indenolol, a beta blocking agent with beta 2 stimulating activity, its antihypertensive hemodynamic mechanism and its effect on hypertensive left ventricular (LV) hypertrophy. Fourteen hypertensive patients, mean age of 48 years, were serially studied during 12- month therapy with indenolol (60-120 mg daily), by recording blood pressure, electrocardiogram and echocardiogram. Blood pressure, heart rate and cardiac output significantly decreased after 1 months of therapy, LV posterior wall thickness decreased after 6 months, interventricular septum thickness and LV mass decreased after 12 months. LV fractional shortening did not change throughout the study. Blood pressure normalized (less than or equal to 140/90 mmHg) in 50% of the patients; LV mass normalized in 40% of the patients. In conclusion, indenolol was an effective antihypertensive agent, also in the long-term treatment. Its antihypertensive hemodynamic effect seems to be due mainly to a reduction in cardiac output. Indenolol caused a regression of LV hypertensive hypertrophy without impairment of LV systolic function.

[Cardiovascular response to dynamic physical exercise in adolescents with casual raised values of arterial blood pressure]

The blood pressure response to dynamic exercise was studied in 90 adolescents (45 males and 45 females) mean age 15 years (range 13-16 years) with casual systolic and/or diastolic hypertension (H) and in 50 matched for age adolescents (26 males and 24 females) with casual blood pressure about the fiftieth percentile for age and sex (N). During the third blood pressure control they underwent a maximal bicycle exercise test in sitting position (10 W/min). During exercise and recovery ECG was recorded every 30 s and blood pressure, with a mercury sphygmomanometer, every 3 min. Adolescents with casual hypertension at rest showed, in comparison to normotensives, an increase in blood pressure (H: 176.1 +/- 18.8 mmHg; N: 167.4 +/- 14.2 mmHg, p less than 0.01 at peak of exercise) and in rate-pressure product (H: 326.8 +/- 40.9 X 10(-2); N: 308.7 +/- 29.4 X 10(-2); p less than 0.01 at peak of exercise) during exercise and recovery. Heart rate was greater at rest in hypertensive adolescents, but there was no difference between the 2 groups during exercise. Exercise tolerance was similar in the 2 groups. Casual transient hypertension at rest and excessive increase of systolic blood pressure during exercise could be expression of early cardiovascular changes preceding sustained hypertension.

Different patterns of left ventricular filling in arterial hypertension

To determine whether left ventricular (LV) filling dynamics may be influenced by the type of LV morphological adaptation to arterial hypertension, pulsed Doppler mitral flow velocity recordings were performed in 30 hypertensive patients and in 18 normotensive subjects matched for age, body surface and heart rate. Peak early (E) and late (A) mitral flow velocity, A/E ratio (A/E), time to peak E (TP), acceleration (AHT) and deceleration half-time (DHT) of early mitral flow and isovolumic relaxation time (IRT) were measured. Compared with the control group, hypertensive patients showed prolonged IRT and DHT, increased A and A/E, whereas TP, AHT and E were unchanged. Hypertensive patients were classified into two subgroups on the basis of h/r ratio (h/r). Subgroup 1: 16 patients with normal h/r, less than 0.42, (five patients with increased LV mass index, greater than 129.2 g m-2, and 11 patients with normal LV mass index, less than 129.2 g m-2). Subgroup 2: 14 patients with increased h/r, greater than 0.42, (nine patients with increased LV mass index, greater than 129.2 g m-2 and five patients with normal LV mass index, less than 129.2 g m-2). In Subgroup 1 the cardiac output (CO) was increased and the total peripheral resistance (TPR) was unchanged in comparison with the control group. In Subgroup 2 the opposite haemodynamic profile was detected: normal CO and increased TPR.(ABSTRACT TRUNCATED AT 250 WORDS)

Propionyl carnitine in stable effort angina

The aim of this study was to investigate the anti-ischemic activity of propionyl carnitine (PC) in 18 informed, volunteer male patients, aged 37-70, suffering from a typical stable effort angina. The study design was randomized, balanced, crossover, and double blinded. The study lasted 75 days. In the first 15 days of washout the patients performed two maximal symptom-limited bicycle tests to verify the repeatability of the parameters examined. Then one group received PC for 30 days 500 mg three times a day, and the other group received placebo (PL) three times a day. At the end of 30 days the groups exchanged treatments. At the end of each period, 2 hours after the last oral administration, the patients performed a maximal symptom-limited bicycle exercise test with increased loads of 10 watts/min. No significant differences were observed between the two tests performed during the wash-out period, for a 1 mm ST-segment depression time, for the time to the end of exercise, and for the rate x pressure product at the same experimental time. The oral administration of PC in coronary patients increased both the 1 mm ST-segment depression time and the time to the end of exercise. Furthermore, the drug reduced the ischemic depression of ST at maximal common work and at maximal work. After PC, the rate x pressure product was not significantly different in relation to placebo at submaximal and maximal exercise. Thus PC seems to have an antiischemiclike effect, probably related to its metabolic activity.

[Echocardiographic study at rest and during effort in adult asymptomatic thalassemic patients]

An echocardiographic study was performed in 21 young patients with thalassemia major (TM, age 16-22 years), with no cardiac symptoms, and in 24 age-matched normals (N) at rest and during sitting bicycle exercise (EX). All TM were receiving blood transfusions regularly to maintain hemoglobin level above 11 g/dl and subcutaneous infusion of desferrioxamine (40 mg/Kg/day) to reduce hemosiderosis. At rest, in comparison to N, TM showed a significant increase in LV end-diastolic dimension (EDD), septal, posterior wall thickness and mass, whereas wall thickness to EDD ratio and LV fractional shortening (FS) were not different. Stress echocardiography was recorded with success in 90% of TM and 83% of N. During EX, FS increased progressively with increase of heart rate in both groups, though the increase of FS was lower in TM. Thus, asymptomatic young patients with thalassemia major, under well transfusion-chelation therapy, showed cardiac changes from volume overload. LV systolic function, normal at rest, was moderately impaired during exercise test.

Diagnosis of amiodarone-iodine-induced thyrotoxicosis(AIIT) associated with severe nonthyroidal illness

A rare case of amiodarone-iodine-induced thyrotoxicosis (AIIT) associated with nonthyroidal illness is reported. Serum total thyroxine (TT4) and free T4 (FT4) concentrations were elevated and serum TSH was undetectable as frequently observed also in euthyroid amiodarone-treated patients. At variance with common forms of AIIT, serum total triiodothyronine (TT3) was reduced due to low-T3 syndrome. The laboratory diagnosis was made on the basis of elevated free T3 (FT3) levels. Thus, in patients with severe nonthyroidal illness submitted to chronic amiodarone treatment, thyroid status can only be determined by free hormone measurement, particularly FT3 in the case of thyrotoxicosis.