Precipitating factors in patients with spontaneous coronary artery dissection: Clinical, laboratoristic and prognostic implications

BACKGROUND

Spontaneous coronary artery dissection (SCAD) often presents with acute coronary syndrome and underlying pathophysiology involves the interplay between predisposing factors and precipitating stressors, such as emotional and physical triggers. In our study we sought to compare clinical, angiographic and prognostic features in a cohort of patients with SCAD according to the presence and type of precipitating stressors.

METHODS

Consecutive patients with angiographic evidence of SCAD were divided into three groups: patients with emotional stressors, patients with physical stressors and those without any stressor. Clinical, laboratoristic and angiographic features were collected for each patient. The incidence of major adverse cardiovascular events, recurrent SCAD and recurrent angina was assessed at follow-up.

RESULTS

Among the total population (64 subjects), 41 [64.0%] patients presented with precipitating stressors, including emotional triggers (31 [48.4%] subjects) and physical efforts (10 [15.6%] subjects). As compared with the other groups, patients with emotional triggers were more frequently female (p = 0.009), had a lower prevalence of hypertension (p = 0.039] and dyslipidemia (p = 0.039), were more likely to suffer from chronic stress (p = 0.022) and presented with higher levels of C-reactive protein (p = 0.037) and circulating eosinophils cells (p = 0.012). At a median follow-up of 21 [7; 44] months, patients with emotional stressors experienced higher prevalence of recurrent angina (p = 0.025), as compared to the other groups.

CONCLUSIONS

Our study shows that emotional stressors leading to SCAD may identify a SCAD subtype with specific features and a trend towards a worse clinical outcome.

Detection of Small Airway Dysfunction in Asthmatic Patients by Spirometry and Impulse Oscillometry System

BACKGROUND

There is no gold standard in diagnosing SAD. Indicators of SAD are considered: (a) a value <65% of predicted values of two of three measures, FEF25-75, FEF50 e FEF75 (FEF+); (b) a value of FEV3/FEV6 < LLN (FEV3/FEV6+); (c) an IOS value of R5-R20 >0.07 kPa·s·L-1 (R5-R20+).

AIM AND OBJECTIVES

The aim of the study was to ascertain, in asthmatic patients, whether spirometry and IOS indicators agree in detecting SAD. We also assessed the relationship between spirometry and IOS indicators and clinical features of asthma.

METHODS

We prospectively recruited adult asthmatic patients. Anthropometric and clinical characteristics were recorded. All patients performed spirometry and IOS tests.

RESULTS

We enrolled 301 asthmatic patients (179 females; mean age 50 ± 16 years) with normal to moderately severe degree of airway obstruction; 91% were non-smokers, 74% were atopic, 28% had an exacerbation in the previous year, and 18% had a poor asthma control by ACT. SAD was diagnosed in 62% of patients through FEF+, in 40% through FEV3/FEV6+ and in 41% through R5-R20+. κ values were 0.49 between FEF+ and FEV3/FEV6+, 0.20 between FEF+ and R5-R20+, 0.07 between FEV3/FEV6+ and R5-R20+. R5-R20+ but not FEF+ and FEV3/FEV6+ was significantly associated with ACT score (p < 0.05).

CONCLUSIONS

Our study shows that in mild to moderately severe asthmatic patients, spirometry and IOS indicators are complementary in diagnosing SAD. Additionally, IOS indicator, but not spirometry ones, was related to asthma control.

Age-related increases in cardiac excitability, refractoriness and impulse conduction favor arrhythmogenesis in male rats

The effects of excitability, refractoriness, and impulse conduction have been independently related to enhanced arrhythmias in the aged myocardium in experimental and clinical studies. However, their combined arrhythmic effects in the elderly are not yet completely understood. Hence, the aim of the present work is to relate relevant cardiac electrophysiological parameters to enhanced arrhythmia vulnerability in the in vivo senescent heart. We used multiple-lead epicardial potential mapping in control (9-month-old) and aged (24-month-old) rat hearts. Cardiac excitability and refractoriness were evaluated at numerous epicardial test sites by means of the strength-duration curve and effective refractory period, respectively. During sinus rhythm, durations of electrogram intervals and waves were prolonged in the senescent heart, compared with control, demonstrating a latency in tissue activation and recovery. During ventricular pacing, cardiac excitability, effective refractory period, and dispersion of refractoriness increased in the aged animal. This scenario was accompanied by impairment of impulse propagation. Moreover, both spontaneous and induced arrhythmias were increased in senescent cardiac tissue. Histopathological evaluation of aged heart specimens revealed connective tissue deposition and perinuclear myocytolysis in the atria, while scattered microfoci of interstitial fibrosis were mostly present in the ventricular subendocardium. This work suggests that enhanced arrhythmogenesis in the elderly is a multifactorial process due to the joint increase in excitability and dispersion of refractoriness in association with enhanced conduction inhomogeneity. The knowledge of these electrophysiological changes will possibly contribute to improved prevention of the age-associated increase in cardiac arrhythmias.

Impact of COVID-19 on the cardiovascular health of women: a review by the Italian Society of Cardiology Working Group on 'gender cardiovascular diseases'

The coronavirus disease 19 (COVID-19), due to coronavirus 2 (SARS-CoV-2) infection, presents with an extremely heterogeneous spectrum of symptoms and signs. COVID-19 susceptibility and mortality show a significant sex imbalance, with men being more prone to infection and showing a higher rate of hospitalization and mortality than women. In particular, cardiovascular diseases (preexistent or arising upon infection) play a central role in COVID-19 outcomes, differently in men and women. This review will discuss the potential mechanisms accounting for sex/gender influence in vulnerability to COVID-19. Such variability can be ascribed to both sex-related biological factors and sex-related behavioural traits. Sex differences in cardiovascular disease and COVID-19 involve the endothelial dysfunction, the innate immune system and the renin-angiotensin system (RAS). Furthermore, the angiotensin-converting enzyme 2 (ACE2) is involved in disease pathogenesis in cardiovascular disease and COVID-19 and it shows hormone-dependent actions. The incidence of myocardial injury during COVID-19 is sex-dependent, predominantly in association with a greater degree of inflammation and coagulation disorders among men. Its pathogenesis is not fully elucidated, but the main theories foresee a direct role for the ACE2 receptor, the hyperimmune response and the RAS imbalance, which may also lead to isolated presentation of COVID-19-mediated myopericarditis. Moreover, the latest evidence on cardiovascular diseases and their relationship with COVID-19 during pregnancy will be discussed. Finally, authors will analyse the prevalence of the long-covid syndrome between the two sexes and its impact on the quality of life and cardiovascular health.

220 MANAGING CARDIAC ARREST SECONDARY TO SPONTANEOUS CORONARY ARTERY DISSECTION: SHOULD WE ROUTINELY CONSIDER ICD IMPLANTATION?

Introduction

Cardiac arrest secondary to a spontaneous coronary artery dissection (SCAD) represents a challenging scenario. It deserves specific considerations due to the dramatic presentation and the need for secondary sudden cardiac death prevention.

Methods

We collected clinical data of four women admitted during the last two years in the Coronary Care Unit of Parma University Hospital, whose presentation of SCAD were cardiac arrest due to ventricular fibrillation.

Results

Three patients survived the acute phases. One patient, being considered at high risk of SCAD recurrence, received a subcutaneous implantable cardioverter-defibrillator (S-ICD). Acute management of cardiac arrest related to SCAD deserves specific considerations. Our case series illustrates the importance of prompt resuscitation manoeuvres and early defibrillation. We propose a flow chart of management of cardiac arrest in patient with suspect of SCAD. Evaluating risk of SCAD recurrence and sudden cardiac death The management of SCAD patients complicated by malignant ventricular arrhythmias and cardiac arrest is challenging. Looking at published registries, it appears that SCAD patients are more likely to suffer from ventricular arrythmia or sudden cardiac death than non-SCAD MI patients. The risk-benefit ratio of ICD implantation in these patients remain uncertain . Evaluation of scar burden with CMR can help stratify the global arrhythmic risk, especially as extensive myocardial scar with a residual impaired LVEF increases the risk of future arrhythmic events. In our series, only one patient underwent S-ICD implantation, and the decision was mainly driven by the finding of underlying arteriopathy affecting other vascular territories, suggesting a potentially higher rate of SCAD recurrence. For this particular subset of patients, we propose an algorithm that combines predisposing factors and myocardia injury quantification data that could be useful for the estimate of the risk of malignant arrythmias, as well as the risk of recurrence of SCAD, but needs to be validated in larger case studies.

Conclusions

The acute management of cardiac arrest related to SCAD deserves specific consideration. The residual myocardial damage, predisposing and precipitants factors should be evaluated in order to estimate the SCAD recurrence and sudden cardiac death risks.

An Impairment in Resting and Exertional Breathing Pattern May Occur in Long-COVID Patients with Normal Spirometry and Unexplained Dyspnoea

Background: Long-term sequelae, called Long-COVID (LC), may occur after SARS-CoV-2 infection, with unexplained dyspnoea as the most common symptom. The breathing pattern (BP) analysis, by means of the ratio of the inspiratory time (TI) during the tidal volume (VT) to the total breath duration (TI/TTOT) and by the VT/TI ratio, could further elucidate the underlying mechanisms of the unexplained dyspnoea in LC patients. Therefore, we analysed TI/TTOT and VT/TI at rest and during maximal exercise in LC patients with unexplained dyspnoea, compared to a control group. Methods: In this cross-sectional study, we enrolled LC patients with normal spirometry, who were required to perform a cardio-pulmonary exercise test (CPET) for unexplained dyspnoea, lasting at least 3 months after SARS-CoV-2 infection. As a control group, we recruited healthy age and sex-matched subjects (HS). All subjects performed spirometry and CPET, according to standardized procedures. Results: We found that 42 LC patients (23 females) had lower maximal exercise capacity, both in terms of maximal O2 uptake (VO2peak) and workload, compared to 40 HS (22 females) (p < 0.05). LC patients also showed significantly higher values of TI/TTOT at rest and at peak, and lower values in VT/TI at peak (p < 0.05). In LC patients, values of TI/TTOT at peak were significantly related to ∆PETCO2, i.e., the end-tidal pressure of CO2 at peak minus the one at rest (p < 0.05). When LC patients were categorized by the TI/TTOT 0.38 cut-off value, patients with TI/TTOT > 0.38 showed lower values in VO2peak and maximal workload, and greater values in the ventilation/CO2 linear relationship slope than patients with TI/TTOT ≤ 0.38 (p < 0.05). Conclusions: Our findings show that LC patients with unexplained dyspnoea have resting and exertional BP more prone to diaphragmatic fatigue, and less effective than controls. Pulmonary rehabilitation might be useful to revert this unpleasant condition.

Distribution of the Clinical Manifestations of Alpha 1 Antitrypsin Deficiency in Respiratory Outpatients from an Area of Northern Italy

BACKGROUND

Alpha 1 antitrypsin deficiency (AATD) is an autosomal codominant genetic condition that affects Caucasians of the European population due to the presence of a deficient allele of the SERPINA1 gene. A frequency of about 1/5,000 individuals has been estimated in Italy.

OBJECTIVES

The aim of the study was to evaluate the distribution of the clinical manifestations of severe and intermediate genetic AATD in the geographic area around Parma in Northern Italy.

METHOD

238 subjects were submitted to molecular analysis of the SERPINA1 gene, and data on anthropometric variables, smoking habits, number of packs per year, AAT serum concentration, and clinical manifestations were recorded and presented as mean ± SD or median values (1st quartile; 3rd quartile).

RESULTS

The results show a distribution of genetic AATD of 4.1% of the screened population in the area encompassing the city of Parma. PI*MS and PI*MZ were the most common genotypes at 40.9% and 28.2% of the population with genetic AATD, and asthma and emphysema were the most represented clinical manifestations.

CONCLUSION

Our study allowed to increase the knowledge of the distribution of genetic AATD in Northern Italy providing information regarding frequencies of genotypes and clinical manifestations of the disorder.

C69 EFFECTIVENESS AND SAFETY OF DISTINCT ANTIPLATELET REGIMENS AFTER TRANSCATHETER LEFT ATRIALE APPENDAGE OCCLUSION: A SINGLE CENTER REAL–WORLD EXPERIENCE

Transcatheter left atrial appendage occlusion (LAAO) has emerged as a reliable tool to prevent thromboembolic events, in particular ischemic stroke, in patients with atrial fibrillation (AF) in the absence of mitral stenosis/valve prosthesis and contraindication to oral anticoagulation (OAC). Antiplatelet therapy (APT) is required after device implantation to prevent device–related thrombus (DRT). Previous studies provided conflicting results on the optimal APT regimen after LAAO. Thus, herein we aimed at assessing the comparative effectiveness and safety of distinct APT regimens. We conducted a real–world single–center observational study including consecutive AF patients that underwent LAAO at the University Hospital of Parma between October 2010 and June 2021. Clinical follow–up included all successfully implanted patients. Primary endpoint was net efficacy outcome, a composite of any ischemic or hemorrhagic event. Secondary endpoints were ischemic (any of the following: ischemic stroke, transient ischemic attack [TIA], DRT, systemic embolism) and hemorrhagic (major [≥3] bleedings according to Bleeding Academic Research Consortium [BARC] classification) complications alone. We enrolled a total of 130 patients (median age 77.0 [72.7;81.0] years; 78 [60.0%] men). History of hemorrhagic stroke in OAC (74 [56.9%]) was the main indication for LAAO. Technical procedure success was achieved in 123 (94.6%) patients. According to multidisciplinary team evaluation, immediately after LAAO, 39 (31.7%) patients received short (≤ 1 month)–dual APT (DAPT) consisting of cardioaspirin and clopidogrel, 35 (28.5%) long (&gt;1, ≤12 months)–DAPT and 49 (39.8%) single APT (SAPT). At a median follow–up of 32 months, the incidence of primary endpoint was significantly lower in short–DAPT group (3 [7.7%] vs. 7 [20.0%] in long–DAPT vs. 14 [28.6%] in SAPT, p = 0.049], mainly driven by a lower occurrence of bleeding endpoint (0 [0.0] vs. 4 [11.4%] in long–DAPT vs. 9 [18.4%] in SAPT, p = 0.020) without differences in the incidence of ischemic endpoint (p = 0.916). Finally, comparison of the Kaplan–Meier curves showed that short–DAPT group had a higher primary endpoint–free survival (p = 0.015) compared to the others. In summary, our study highlighted that short (≤ 1 month)–DAPT regimen after LAAO is associated with better outcomes, mainly driven by reduction of major bleedings. Strong evidences arising from randomized trials are warranted to support these findings.

P56 SPONTANEOUS CORONARY ARTERY DISSECTIONS: ANALYSIS OF NON TRADITIONAL RISK FACTORS

 

The etiology of spontaneous coronary dissection (SCAD) is not well defined and Non traditional risk factors (NT–RF) have assumed increasing interest, but few data are available. NT–RF include three categories: Sex–related (SR–NT–FR), Sex–predominant (SP–NT–RF) and Gender–related (GR–NT–RF). (Table 1)

Aim of the Study

The objective of our analysis was to evaluate the incidence of NT–RF in Parma SCAD registry population.

Material and methods

We reviewed 62 patients with SCAD enrolled between January 2013 through November 2021

Results

Traditional risk factors were less common: hypertension was the most prevalent (39 pts, 62.9%). When considering NT–RF, 51 patients (82%) had at least one of all, with at least one SR–RF (66%) or GR–RF (64,5%). Patients with NT–RF were younger at time of SCAD (mean age 53 vs 66; p = 0.027) and they were predominantly females (48 vs 7 pts, p = 0.004) (Table 2). No differences were found among NT–RF SCAD and nNT–RF SCAD patients by fibromuscular dysplasia, peripheral arterial disease and chronic kidney disease. Patients with SCAD more often presented with non ST–segment elevation myocardial infarction (43 pts, 72.6%) vs ST–segment elevation (17 pts, 27.4%). No differences in clinical presentation and angiographic characteristics were found among NT–RF and nNT–RF patients group. MACE occurred in 17.7% of patients of the overall study population, at a median follow–up of 23 (interquartile range: 11;57) months. When comparing the incidence of cardiovascular events in the 2 study groups there was a trend toward a higher prevalence of MACE in NT–RF group without statistical significance (NT–RF SCAD 19.6% – nNT–RF SCAD 9.1%; p = 0.4). (Table 3)

Conclusion

SCAD is an emerging cause of myocardial infarction in young and middle–aged women without the traditional cardiovascular risk profile. Although overall survival seems good, SCAD is a potentially malignant disease which can present with ventricular arrhythmias and sudden cardiac death. Risk estimation is difficult in women, due to the scarce validity of prediction models, therefore a great effort must be made by the clinical community for the widespread diffusion and use of models incorporating NT–RF. Acknowledgement of peculiar features of this disease could help clinicians and researchers to establish targeted interventions for cardiovascular primary prevention, early diagnosis and secondary prevention in women, including rehabilitation and stress management programmes.

Clinical manifestations of a new alpha‐1 antitrypsin genetic variant: Q0parma

Alpha‐1 antitrypsin deficiency is an autosomal, codominant disorder caused by mutations of the SERPINA1 gene. Several mutations of SERPINA1 have been described associated with the development of pulmonary emphysema and/or chronic liver disease and cirrhosis. Here, we report a very rare PI*Q0parma variant identified for the first time in an Italian family originally from the city of Parma in Northern Italy

Sex-Related Differences in Long-COVID-19 Syndrome

Background: Sex differences have been demonstrated in the acute phase of COVID-19. Women (F) were found to be less prone to develop a severe disease than men (M), but few studies have assessed sex-differences in Long-COVID-19 syndrome. Methods: The aim of this prospective/retrospective study was to characterize the long-term consequences of this infection based on sex. For this purpose, we enrolled 223 patients (89 F and 134 M) who were infected by SARS-CoV-2. In the acute phase of the illness, F reported the following symptoms more frequently than M: weakness, dysgeusia, anosmia, thoracic pain, palpitations, diarrhea, and myalgia-all without significant differences in breathlessness, cough, and sleep disturbance. Results: After a mean follow-up time of 5 months after the acute phase, F were significantly more likely than M to report dyspnea, weakness, thoracic pain, palpitations, and sleep disturbance but not myalgia and cough. At the multivariate logistic regression, women were statistically significantly likely to experience persistent symptoms such as dyspnea, fatigue, chest pain, and palpitations. On the contrary, myalgia, cough, and sleep disturbance were not influenced by sex. Conclusion: We demonstrated that F were more symptomatic than M not only in the acute phase but also at follow-up. Sex was found to be an important determinant of Long-COVID-19 syndrome because it is a significant predictor of persistent symptoms in F, such as dyspnea, fatigue, chest pain, and palpitations. Our results suggest the need for long-term follow-up of these patients from a sex perspective to implement early preventive and personalized therapeutic strategies.

308 Sex-related differences in long COVID-19 syndrome

Aims

Sex-differences have been demonstrated in the acute phase of COVID-19 infection; females (f) were found to be less prone to develop a severe disease than males (M), but few studies have assessed sex-differences in Long-COVID-19 syndrome.

Methods and results

The aim of this prospective/retrospective study was to characterize the long-term consequences of this infection from a sex-perspective. For this purpose, we enrolled 223 patients (89 F and 134 M) who experienced a SARS-CoV-2 infection. In the acute phase of the illness, females reported more frequently than males: weakness, dysgeusia, anosmia, thoracic pain, palpitations, diarrhoea, and myalgia without significant differences in breathlessness, cough, and sleep disturbance. After a mean follow-up time of 5 months after the acute phase, females were significantly more likely than males to report weakness, thoracic pain, palpitations, and sleep disturbance but not myalgia and cough. At the multivariate logistic regression, women were statistically significantly likely to experience persistent symptoms such as dyspnoea, fatigue, chest pain, and palpitations. On the contrary, myalgia, cough and sleep disturbance were not influenced by sex.

Conclusions

We demonstrated that females were more symptomatic than males not only in the acute phase but also at follow-up. Sex was found to be an important determinant of Long-COVID syndrome because it is a significant predictor of persistent symptoms in females, such as dyspnoea, fatigue, chest pain, and palpitations. Our results suggest the need for long-term follow-up of these patients from a sex-perspective in order to implement early preventive and personalized therapeutic strategies.

301 Long term sequelae after COVID-19: the different impact on the right and left ventricles

Aims

Most patients who had COVID-19 are still symptomatic after many months post infection, but the long-term outcomes are not yet well-defined. The aim of our prospective/retrospective study was to define the cardiac sequelae of COVID-19 infection.

Methods and results

This monocentric cohort study included 160 consecutive patients (64 females, 60 + 12 years) who had been discharged from the ward or from the outpatient clinic after a diagnosis of COVID-19 and subsequently referred for a follow-up visit. Clinical features as well as lab and instrumental data about the acute phase of the disease, such as haemodynamic instability (HI), cardiac biomarkers, d-dimer, C-reactive protein (CRP), high resolution CT (HRCT) score along with information about the follow-up visit, including ECG and Conventional and Doppler Tissue Echocardiographic (DTE) parameters, were recorded. The median follow-up time after symptom onset was 5 months. At follow-up visit, the majority of the patients reported dyspnoea and asthenia. Moreover, echocardiography showed morpho-functional changes of both right (RV) and left (LV) ventricles, such as RV dilation, increased pressure in the pulmonary circulation, and by-ventricular systolic–diastolic dysfunction. When examined using multivariate analysis, independent of age, sex, and co-morbidities, RV and LV changes were significantly associated (P &lt; 0.05) with HRCT score and HI and with CRP, respectively.

Conclusions

Our results suggest that COVID-19 may impact RV and LV differently. Notably, the extent of the pneumonia and HI may affect RV, whereas the inflammatory status may influence LV. A long-term follow-up is warranted to refine and customize the most appropriate therapeutic strategies.

Coronavirus Disease 2019: COSeSco - A Risk Assessment Score to Predict the Risk of Pulmonary Sequelae in COVID-19 Patients

BACKGROUND

The presence of interstitial pneumonia in coronavirus disease 2019 (COVID-19) patients, as diagnosed through laboratory, functional, and radiological data, provides potential predicting factors of pulmonary sequelae.

OBJECTIVES

The objectives were the creation of a risk assessment score for pulmonary sequelae at high-resolution computed tomography (HRCT) through the assessment of laboratory data, lung function, and radiological changes in patients after the onset of COVID-19 interstitial pneumonia and the identification of predictive factors.

METHODS

We enrolled 121 subjects hospitalized due to COVID-19 pneumonia in our study. Clinical features, Charlson Comorbidity Index (CCI) score, HRCT score, and blood chemistry data at hospital admission, as well as HRCT score, pulmonary function testing values, exercise capacity by means of a 6-Minute Walk Test (6MWT), and dyspnea perception by the modified Medical Research Council (mMRC) at 4-month follow-up, were all recorded. The variables were elaborated in order to create a predictive model to identify patients at high risk of pulmonary sequelae at HRCT.

RESULTS

At the time of follow-up visit, 63% of patients had functional abnormality (diffusion lung capacity and/or total lung capacity <80% of predicted). Age, BMI, CCI, D-dimer, 6MWT, and mMRC were included in the COVID-19 Sequelae Score (COSeSco, ranging 0-15), which was able to individuate COVID-19 patients with radiologic sequelae (HRCT score >10%) at follow-up. The most revelatory COSeSco value that was found to intercept the highest sensitivity (100%) and specificity (77%) was 2.

CONCLUSION

The COSeSco - comprising age, BMI, comorbidities, D-dimer, walking distance, and dyspnea perception - makes it possible to identify particularly at-risk COVID-19 patients who are likely to develop pulmonary sequelae assessed by HRCT.

Determinants of cardiac structure in frail and sarcopenic elderly adults

BACKGROUND

Cardiac structure and function change with age. The higher prevalence of left ventricular hypertrophy (LVH) with concentric remodeling is indicative of a typical geometric pattern of aging associated with a higher cardiovascular (CV) risk and diseases. The recent associations found between low left ventricular and skeletal mass in older patients with frailty and sarcopenia have raised great interest in investigating cardiac characteristics and determinants of left ventricular mass (LVM) in this population.

DESIGN

Cross-sectional study.

METHODS

We evaluated 100 sarcopenic and physically frail outpatients, 33 men (M), 67 women (F), aged ≥70 years (mean age 79 ± 5) and enrolled in the Parma site of European multicenter SPRINTT population.

RESULTS

All male and female participants showed LVH, assessed as indexed LVM to body surface area (LVM/BSA) (M = 128 ± 39 g/m²; F = 104 ± 26 g/m²), and were more prone to have concentric geometry, as demonstrated by relative wall thickness value (0.41 in both sexes). After backward regression analysis, including covariates such as age, sex, office or ABPM systolic blood pressure (SBP), heart rate, BSA, use of β blockers, ACE-inhibitors, angiotensin receptor blockers, calcium channel blockers, diuretics, physical activity, hemoglobin level, and Mini Mental State examination - the most powerful determinants of LVM were clinical SBP (β = 1.51 ± 0.31, p = 0.0005), BSA (β = 165.9 ± 41.4, p = 0.0001), while less powerful determinants were 24 h, daily and nightly SBP (p = 0.02, p = 0.002, p = 0.004 respectively).

CONCLUSIONS

Older sarcopenic and physically frail patients showed LVH with a tendency towards concentric geometry. The main determinant of LVM was SBP, highlighting the key role that hemodynamic condition plays in determining LVH in this population.

Comprehensive Model for Physical and Cognitive Frailty: Current Organization and Unmet Needs

Aging is characterized by the decline and deterioration of functional cells and results in a wide variety of molecular damages and reduced physical and mental capacity. The knowledge on aging process is important because life expectancy is expected to rise until 2050. Aging cannot be considered a homogeneous process and includes different trajectories characterized by states of fitness, frailty, and disability. Frailty is a dynamic condition put between a normal functional state and disability, with reduced capacity to cope with stressors. This geriatric syndrome affects physical, neuropsychological, and social domains and is driven by emotional and spiritual components. Sarcopenia is considered one of the determinants and the biological substrates of physical frailty. Physical and cognitive frailty are separately approached during daily clinical practice. The concept of motoric cognitive syndrome has partially changed this scenario, opening interesting windows toward future approaches. Thus, the purpose of this manuscript is to provide an excursus on current clinical practice, enforced by aneddoctical cases. The analysis of the current state of the art seems to support the urgent need of comprehensive organizational model incorporating physical and cognitive spheres in the same umbrella.

Interaction of Skeletal and Left Ventricular Mass in Older Adults with Low Muscle Performance

BACKGROUND

It was recently hypothesized the existence of "cardiac-skeletal muscle axis." However, the relationship between skeletal muscle mass (SMM) and left ventricular mass (LVM) has never been investigated in the specific group of older individuals with low skeletal mass and physical performance. We tested this hypothesis in the SPRINT-T (Sarcopenia and Physical Frailty IN older people: multicomponenT Treatment strategies Trial) population using LVM as independent variable and SMM as dependent variable.

METHODS

SMM was assessed by dual-energy X-ray absorptiometry scan and expressed as appendicular lean mass (ALM), and LVM was estimated through echocardiography. Low ALM was defined according to Foundation for the National Institutes of Health Sarcopenia Project criteria, and Short Physical Performance Battery (SPPB) was used to assess physical performance.

RESULTS

The population consisted of 100 persons (33 men and 67 women), aged 70 years or older (mean age = 79 ± 5 years) with low ALM and SPPB ranged between 3 and 9, suggestive of physical frailty. Charlson Comorbidity Index median score was 0. Mean value of LVM was 193 ± 67 g, indexed LVM/body surface area (LVM/BSA) was 112 ± 33 g/m2, and cardiac output (CO) was 65 ± 19 L/min. ALM was strongly and positively correlated with LVM (r = 0.54602; P < .0001), LVM/BSA (r = 0.30761; P < .002), CO (r = 0.49621; P < .0001), body mass index (BMI) (r = 0.52461; P < .0001), sex (r = 0.77; P < .001), fat mass (r = 0.38977; P < .0001), and hemoglobin (Hb) (r = 0.26001; P < .01). In the multivariate analysis, LVM (β = .019 ± .005; P < .0001), CO (β = .038 ± .016; P = .019), BMI (β = .286 ± .051; P < .0001), and Hb (β = .544 ± .175; P = .0025) remained associated to ALM.

CONCLUSIONS

In a sample of older persons with low muscle mass and physical performance, LVM was positively and significantly correlated with ALM, independently from blood pressure, physical activity, and other potential confounders. Future studies are needed to address the effect of interventions targeting LVM and SMM.

Left atrial appendage occlusion in patients with atrial fibrillation and large prevalence of prior intracranial bleeding

BACKGROUND

Left atrial appendage occlusion (LAAO) represents an alternative approach for the prevention of cardioembolic stroke in patients with nonvalvular atrial fibrillation (NVAF) and contraindication for oral anticoagulation (OAC). The aim of our study was to analyse the outcomes in patients treated with LAAO, with a focus on cases with previous intracranial bleeding.

METHODS

Sixty patients with NVAF underwent LAAO (75.4 ± 9 years); mean CHA2DS2-VASc was 4.4 ± 1.7, mean HAS-BLED 3.2 ± 0.9. Thirty-two patients (53.3%) reported previous intracranial bleeding. Ischaemic and bleeding events recorded during follow-up were compared with expected event rates according to CHA2DS2-VASc and HAS-BLED scores.

RESULTS

Device implantation was successful in 58 patients (96.7%). The antiplatelet therapy was tailored according to patients' bleeding risk. During follow-up (2.32 ± 1.5 years) 3 ischaemic strokes and 1 transient ischaemic attack occurred, versus 13 total expected thromboembolic events (P = 0.033); 5 major bleedings were observed, versus 7 expected ones, if the patients were under OAC. Considering the combined endpoint (thromboembolic and major bleeding events) 9 events were observed versus 20 expected major events (P = 0.031). In the prespecified subgroup of patients with previous intracranial bleeding, two ischaemic strokes and one transient ischaemic attack were observed during follow-up versus six total expected thromboembolic events; no intracranial bleeding recurrence was recorded. Regarding the combined endpoint four major events were recorded versus nine expected ones.

CONCLUSION

LAAO is an efficient and safe option for the prevention of cardioembolic stroke in patients with NVAF, high thromboembolic risk and contraindication to OAC, particularly in patients with previous intracranial bleeding.

Treatment of Delirium in Older Persons: What We Should Not Do!

The presentation of common acute diseases in older age is often referred to as “atypical”. Frequently, the symptoms are neither single nor tissue related. In most cases, the onset of symptoms and diseases is the expression of a diminished reserve with a failure of the body system and imbalance of brain function. Delirium is one of the main devastating and prevalent atypical symptoms and could be considered as a geriatric syndrome. It encompasses an array of neuropsychiatric symptoms and represents a disarrangement of the cerebral function in response to one or more stressors. The most recent definition, reported in the DSM-V, depicts delirium as a clear disturbance in attention and awareness. The deficit is to be developed in a relatively short time period (usually hours or days). The attention disorder must be associated with another cognitive impairment in memory, orientation, language, visual-spatial or perception abilities. For the treatment, it is imperative to remove the potential causes of delirium before prescribing drugs. Even a non-pharmacological approach to reducing the precipitating causes should be identified and planned. When we are forced to approach the pharmacological treatment of hyperactive delirium in older persons, we should select highly cost-effective drugs. High attention should be devoted to the correct balance between improvement of psychiatric symptoms and occurrence of side effects. Clinicians should be guided in the correct choice of drugs following cluster symptoms presentation, excluding drugs that could potentially produce complications rather than advantages. In this brief point-of-view, we propose a novel pharmacological flow-chart of treatment in relation to the basic clusters of diseases of an older patient acutely admitted to the hospital and, in particular, we emphasize “What We Should Not Do!”, with the intention of avoiding possible side effects of drugs used.

The Relationship Between Widespread Pollution Exposure and Oxidized Products of Nucleic Acids in Seminal Plasma and Urine in Males Attending a Fertility Center

Background: In recent decades, there has been an increase in male infertility, and in many cases, the etiology remains unclear. Several studies relate male hypo-fertility to xenobiotic exposure, even if no data exist about multiple exposure at the environmental level. Methods: The study involved 86 males with diagnosis of idiopathic male infertility (IMI), and 46 controls with no alteration in sperm characteristics. Seminal plasma (SP) and urine samples were analyzed by liquid chromatography tandem mass spectrometry (LC-MS/MS) to quantify biomarkers of exposure (the main metabolites of benzene, toluene, 1,3-butadiene, 3-monochloropropanediol, styrene, and naphthol) and effect (oxidized products of nucleic acids).Results: Biomarker concentrations were similar in subjects with IMI and controls even if a stronger correlation between biomarkers of exposure and effects were observed in SP. Data show that, both in SP and urine, most metabolites were inter-correlated, indicating a simultaneous co-exposure to the selected substances at the environmental level. Principal component analysis showed in SP the clustering of mercapturic acids indicating a preferential metabolic pathway with Glutathione (GSH) depletion and, consequently, an increase of oxidative stress. This result was also confirmed by multivariable analysis through the development of explanatory models for oxidized products of nucleic acids. Conclusions: This study highlights how oxidative stress on the male reproductive tract can be associated with a different representation of metabolic pathways making the reproductive tract itself a target organ for different environmental pollutants. Our results demonstrate that SP is a suitable matrix to assess the exposure and evaluate the effects of reproductive toxicants in environmental/occupational medicine. The statistical approach proposed in this work represents a model appropriate to study the relationship between multiple exposure and effect, applicable even to a wider variety of chemicals.

Idiopathic pulmonary fibrosis and occupational risk factors

Idiopathic pulmonary fibrosis (IPF) is a rare lung disease of unknown origin that rapidly leads to death. However, the rate of disease progression varies from one individual to another and is still difficult to predict. The prognosis of IPF is poor, with a median survival of three to five years after diagnosis, without curative therapies other than lung transplantation. The factors leading to disease onset and progression are not yet completely known. The current disease paradigm is that sustained alveolar epithelial micro-injury caused by environmental triggers (e.g., cigarette smoke, microaspiration of gastric content, particulate dust, viral infections or lung microbial composition) leads to alveolar damage resulting in fibrosis in genetically susceptible individuals. Numerous epidemiological studies and case reports have shown that occupational factors contribute to the risk of developing IPF. In this perspective, we briefly review the current understanding of the pathophysiology of IPF and the importance of occupational factors in the pathogenesis and prognosis of the disease. Prompt identification and elimination of occult exposure may represent a novel treatment approach in patients with IPF.

[Laboratory animal allergy.]

Laboratory animal allergy (LAA) is caused by an immunological hypersensitivity reaction to highmolecular- weight antigens that are present in laboratory animals' urine, dander and saliva. All laboratory animal facility personnel who regularly come in contact with laboratory animals, such as technicians, researchers, cleaning staff, veterinarians and even administrative staff, are at risk of developing LAA. Generally, most epidemiological studies indicate a LAA prevalence ranging from 6% to 44% and an incidence ranging from 9% to 30%. Prevalence and incidence data vary widely because the diagnosis is not uniformly defined: some diagnoses are made solely on the basis of symptoms, whereas others also require a positive skin test or confirmation of the presence of laboratory animal allergen-specific IgE antibodies.

Left Ventricular Myocardial Performance in Normotensive Offspring of Hypertensive Parents

INTRODUCTION

Early alterations in the cardiovascular system have been described in offspring of hypertensive parents, but with conflicting results.

AIM

To evaluate the influence of genetic predisposition to hypertension on left ventricular (LV) geometry and function, 30 normotensive male offspring of hypertensive parents (EH+) and 30 matched offspring of normotensive families (EH-), were studied.

METHODS

All subjects underwent office and 24-h ambulatory blood pressure monitoring (ABPM), conventional and Tissue Doppler Echocardiography (TDE), including assessment of myocardial performance index (MPI).

RESULTS

EH+ showed an increase in office BP with statistical significance in diastolic BP (84 ± 7 vs 73 ± 6 mmHg; p < 0.05). Relative wall thickness (RWT) was greater in EH+ (0.37 ± 0.05 vs 0.31 ± 0.03; p < 0.05) and significantly related to the EH+ condition at the univariate analysis (p < 0.003), whilst the LV mass index was unchanged (84.3 ± 14 vs 80 ± 17 g/m²; p = NS), suggesting a trend towards concentric remodeling. Systolic and diastolic function, in both ventricles, were superimposable in the two groups. The MPI was higher in EH+ (0.49 ± 0.10 vs 0.45 ± 0.08; p = NS) and significantly correlated to RWT (r = 0.47, p < 0.01). However, at the stepwise multiple regression analysis, only the condition of EH + was independently associated with RWT (p <0.006). RWT, according to ROC curves analysis, predicted the condition of EH+ (cutoff 0.359, specificity 89%, sensitivity 82%).

CONCLUSION

Current results provide information about LV myocardial performance in EH+ subjects, related to a LV concentric remodeling and to endothelial dysfunction.

In-situ optical assessment of rat epicardial kinematic parameters reveals frequency-dependent mechanic heterogeneity related to gender

BACKGROUND

Gender-related cardiac mechanics following the electrical activity has been investigated from basic to clinical research, but results are still controversial. The aim of this work is to study the gender related cardiac mechanics and to focus on its heart rate dependency.

METHODS

We employed 12 Sprague Dawley rats (5 males and 7 females) of the same age and, through a novel high resolution artificial vision contactless approach, we evaluated in-situ cardiac kinematic. The hearts were paced on the right atria appendage via cathodal stimuli at rising frequency.

RESULTS

Kinematic data obtained at rising pacing rates are different between male and female rat hearts: male tended to maintain the same level of cardiac force, energy and contractility, while female responded with an increment of such parameters at increasing heart rate. Female hearts preserved their pattern of contraction and epicardial torsion (vorticity) at rising pacing rates compared to male. Furthermore, we observed a difference in the mechanical restitution: systolic time vs. diastolic time, as an index of cardiac performance, reached higher value in male compared to female hearts.

CONCLUSION

Our innovative technology was capable to evaluate in-situ rat epicardial kinematic at high stimulation frequency, revealing that male preserved kinematic parameters but varying the pattern of contraction/relaxation. On the contrary, female preserved the pattern of contraction/relaxation increasing kinematic parameters.

Proactive interception and care of Frailty and Multimorbidity in older persons: the experience of the European Innovation Partnership on Active and Healthy Ageing and the response of Parma Local Health Trust and Lab through European Projects

According to the 2018 European Union Ageing Report, the demographic profile of the European population is projected to be older. Aging cannot be considered a homogeneous process, and only in certain cases is “successful”, with maintained functional ability, which is determined by intrinsic capacity, the environment, and their interaction. When intrinsic capacity is lost, elders with chronic diseases develop frailty, a condition with high-risk of disability. Old-age dependency-ratio is projected to increase from 29.6% to 51.2% in the EU in 2070: thus, the need of new approaches targeting the prevention of disability. Numerous studies are conducted in the European Innovation Partnership on Active and Healthy Ageing and addressing identification, treatment, coordination and integration of care in frail older subjects. SUNFRAIL is aimed at developing a model, good practices and tools to improve the identification, prevention and care of frailty and management of multimorbidity. SPRINTT is testing the effectiveness of a multi-component treatment able to treat frailty and sarcopenia. VIGOUR, a project aimed at strengthening integrated-care in different contexts of European Countries, verifies enablers and obstacles encountered in the real world by these good practices. Through the creation of Parma-Lab and Frailty-Team in the Academic-Hospital of Parma combined with the contribution of Parma Health-Trust in the “Community Health-Centers”, the Projects were translated into Health Services Arena. This response bridging European Studies and clinical practice, aims to early detecting and caring 75-year older citizens with frailty and multimorbidity, living in the community, not institutionalized and at risk of hospitalization and mobility ADL-disability. (www.actabiomedica.it)

Hemodynamic and ECG responses to stress test in early adolescent athletes explain ethnicity-related cardiac differences

BACKGROUND

Ethnicity is an important determinant of athletes' cardiovascular adaptation. Black adolescent and adult athletes exhibit a left ventricular (LV) hypertrophy with a concentric remodelling higher than their Caucasian counterparts. Scant data, however, are available on race-related differences in hemodynamic response of adolescent athletes to exercise and its relation with heart remodelling. We evaluated if race-specific, sport-related structural and electrical remodelling in adolescent athletes of Caucasian and African ethnicity exclusively depends on race itself rather than on different cardiovascular responses to physical exercise.

METHODS

We examined 90 adolescent athletes, 60 Caucasian (WA) and 30 Black (BA). All participants underwent thorough clinical, echocardiographic and stress test evaluations.

RESULTS

BA had greater indexed LV mass (LVM/BSA) with increased relative wall thickness (RWT) implying a concentric remodelling. BA showed higher systolic blood pressure (SBP) compared to WA during the whole exercise test. ECG data showed that BA vs WA had a significant shorter QRS duration in each step considered with a significant greater QT dispersion. BA reached a higher relative pressure peak as compared to WA. RWT was strongly influenced by ethnicity and less by SBP at peak of exercise (PE), although LVM/BSA was significantly related to SBP at PE and just marginally to age and not significantly to race.

CONCLUSIONS

Black adolescent athletes showed higher SBP during all steps of exercise associated to a different trend. Ethnicity was the main determinant of RWT, suggesting that LV geometry is principally race-related rather than influenced by a different hemodynamic profile to physical activity.

Resolution of late-onset heart and liver failures after reversion of jejuno-ileal bypass: a case report

OBJECTIVES

Jejuno-ileal bypass (JIB) was a kind of bariatric surgery performed from 1960s to 1980s, able to induce sustainable weight loss by creating a surgical short bowel syndrome.

MATERIALS AND METHODS

We report a case of an octogenarian woman who underwent in the early eighties this kind of surgery with consequent 40 kg weight loss. After 27 years, she first developed a reversible metabolic cardiomyopathy that began with signs and symptoms of heart failure. Thereafter, she was diagnosed with severe intractable liver insufficiency.

RESULTS

Despite her old age, the patient underwent reversal of JIB with consequent early improvement of hepatic function.

CONCLUSIONS

This case demonstrate that in case of long-term and life-threatening complications, it is possible to successfully reverse JIB surgery after upto 30 years. The hypothesis on pathophysiology of heart and liver insufficiency are discussed.

ALLiance for sEcondary PREvention after an acute coronary syndrome. The ALLEPRE trial: A multicenter fully nurse-coordinated intensive intervention program

The main objective of cardiovascular disease prevention is to reduce morbidity and mortality by promoting a healthy lifestyle, reducing risk factors, and improving adherence to medications. Secondary prevention after an acute coronary syndrome has proved to be effective in reducing new cardiovascular events, but its limited use in everyday clinical practice suggests that there is considerable room for improvement. The short-term results of evidence-based studies of nurse-coordinated secondary prevention programs have been positive, but there is a lack of long-term outcome data. The Alliance for the Secondary Prevention of Cardiovascular Disease in the Emilia-Romagna region (ALLEPRE) is a multicenter, randomized, controlled trial designed to compare the effects of a structured nurse-coordinated intensive intervention on long-term outcomes and risk profiles after an acute coronary syndrome with those of the standard of care. All of the patients randomized to the intervention group take part in 9 one-to-one sessions with an experienced nurse from the participating centers with the aim at promoting healthy lifestyles, reducing risk factors, and increasing adherence to medication over a mean period of 5 years. The primary clinical end point is the reduction in the risk of the 5-year occurrence of major adverse events (a composite of cardiovascular mortality, nonfatal reinfarction, and nonfatal stroke). The primary surrogate end point is the achievement of prespecified targets relating to classical risk factors, lifestyle modifications, and adherence to pharmacological therapy after 2 years of follow-up. Coronary heart disease is a chronic degenerative disease, and patients who recover from an acute coronary syndrome (ACS) are at high risk of developing recurrent events.1 Although secondary prevention measures have proved to be effective and are strongly recommended by all of the international guidelines,2., 3. the 4 EUROASPIRE surveys4., 5., 6., 7., 8. showed that there was still a high prevalence of conventional risk factors, that secondary prevention measures were inadequately implemented, and that their main goals were often not reached. In addition, there were considerable discrepancy in secondary prevention practices between centers and countries, and a widespread underuse of cardiac prevention and rehabilitation programs despite their demonstrated effectiveness in reducing cardiovascular risk over time.9., 10. Over the last 10 years, nurses have been increasingly involved in successful cardiovascular risk management,11., 12., 13. but although this has improved levels of cardiovascular risk, no clear reduction in hard end points such as major cardiovascular adverse events and mortality has been demonstrated.10 The aim of the ALLEPRE trial is to evaluate the benefit of a homogeneous, structured, secondary prevention intervention program, fully coordinated by nurses from in- and outpatient clinics, in terms of cardiovascular risk profiles and major clinical events in ACS patients living in the large Emilia-Romagna region of Italy.

Calcium channel blockade blunts the renal effects of acute nitric oxide synthase inhibition in healthy humans

Our aim was to investigate whether blockade of calcium channels (CCs) or angiotensin II type 1 receptors (AT1R) modulates renal responses to nitric oxide synthesis inhibition (NOSI) in humans. Fourteen sodium-replete, healthy volunteers underwent 90-min infusions of 3.0 μg·kg−1·min−1 NG-nitro-l-arginine methyl ester (l-NAME) on 3 occasions, preceded by 3 days of either placebo (PL), 10 mg of manidipine (MANI), or 50 mg of losartan (LOS). At each phase, mean arterial pressure (MAP), glomerular filtration rate (GFR; inulin), renal blood flow (RBF; p-aminohippurate), urinary sodium (UNaV), and 8-isoprostane (U8-iso-PGF2αV; an oxidative stress marker) were measured. With PL + l -NAME, the following changes were observed: +6% MAP ( P < 0.005 vs. baseline), −10% GFR, −20% RBF, −49% UNaV ( P < 0.001), and +120% U8-iso-PGF2αV ( P < 0.01). In contrast, MAP did not increase during LOS + l-NAME or MANI + l-NAME ( P > 0.05 vs. baseline), whereas renal changes were the same during LOS + l-NAME vs. PL + l-NAME (ANOVA, P > 0.05). However, during MANI + l-NAME, changes vs. baseline in GFR (−6%), RBF (−12%), and UNaV (−34%) were blunted vs. PL + l-NAME and LOS + l-NAME ( P < 0.005), and the rise in U8-iso-PGF2αV was almost abolished (+37%, P > 0.05 vs. baseline; P < 0.01 vs. PL + l-NAME or LOS + l-NAME). We conclude that, since MANI blunted l-NAME-induced renal hemodynamic changes, CCs participate in the renal responses to NOSI in healthy, sodium-replete humans independent of changes in MAP and without the apparent contribution of the AT1R. Because the rise in U8-iso-PGF2αV was essentially prevented during MANI + l-NAME, CC blockade may oppose the renal effects of NOSI in part by counteracting oxidative stress responses to acutely impaired renal NO bioavailability.

Left ventricular structure and remodeling in patients with COPD

Background

Data on cardiac alterations such as left ventricular (LV) hypertrophy, diastolic dysfunction, and lower stroke volume in patients with COPD are discordant. In this study, we investigated whether early structural and functional cardiac changes occur in patients with COPD devoid of manifest cardiovascular disease, and we assessed their associations with clinical and functional features.

Methods

Forty-nine patients with COPD belonging to all Global Initiative for Chronic Obstructive Lung Disease (GOLD) classes were enrolled and compared with 36 controls. All subjects underwent clinical history assessment, lung function testing, blood pressure measurement, electrocardiography, and conventional and Doppler tissue echocardiography. Patients were also subjected to computed tomography to quantify emphysema score.

Results

Patients with COPD had lower LV cavity associated with a marked increase in relative wall thickness (RWT), suggesting concentric remodeling without significant changes in LV mass. RWT was significantly associated with ratio of the forced expiratory volume in 1 second to the forced vital capacity and emphysema score and was the only cardiac parameter that – after multivariate analysis – significantly correlated with COPD conditions in all individuals. Receiver operating characteristic curve analysis showed that RWT (with a cutoff point of 0.42) predicted the severity of COPD with 83% specificity and 56% sensitivity (area under the curve =0.69, 95% confidence interval =0.59–0.81). Patients with COPD showed right ventricular to be functional but no structural changes.

Conclusion

Patients with COPD without evident cardiovascular disease exhibit significant changes in LV geometry, resulting in concentric remodeling. In all individuals, RWT was significantly and independently related to COPD. However, its prognostic role should be determined in future studies.

Nitric oxide-angiotensin II interactions and renal hemodynamic function in patients with uncomplicated type 1 diabetes

The objective is to elucidate the effect of nitric oxide (NO)-renin-angiotensin system (RAS) interactions on renal hemodynamic function in uncomplicated, type 1 diabetes mellitus (DM). In 14 salt-replete, male healthy volunteers (C) and 9 male DM patients on euglycemia, glomerular filtration rate (GFR), renal blood flow (RBF), filtration fraction (FF), and sodium excretion (UNaV) were measured at baseline and during a 90-min infusion of 3.0 μg·kg−1·min−1 NG-nitro-l-arginine-methyl-ester (l-NAME) after 3 days of pretreatment with either placebo (PL) or 50 mg losartan (LOS). Baseline GFR, RBF, and FF were higher in DM ( P < 0.005). In the C group, PL + l-NAME caused declines in GFR (101 ± 3 to 90 ± 3 ml·min−1·1.73 m−2), RBF (931 ± 22 to 754 ± 31 ml·min−1·1.73 m−2), and UNaV (158 ± 12 to 82 ± 18 μmol/min) and an increase in FF (0.19 ± 0.02 to 0.21 ± 02; P < 0.001), which were not influenced by LOS pretreatment ( P > 0.05 for LOS + l-NAME-C vs. PL + l-NAME-C). In DM, PL + l-NAME resulted in exaggerated renal effects, with changes in GFR (128 ± 3 to 104 ± 3 ml·min−1·1.73 m−2), RBF (1,019 ± 27 to 699 ± 34 ml·min−1·1.73 m−2), UNaV (150 ± 13 to 39 ± 14 μmol/min), and FF (0.22 ± 0.03 to 0.26 ± 0.02) that were significantly greater vs. PL + l-NAME-C ( P < 0.005). LOS pretreatment blunted GFR, RBF, FF, and UNaV responses to l-NAME in DM ( P < 0.005 vs. PL + l-NAME-DM), resulting in a response profile that was similar to PL + l-NAME and LOS + l-NAME in C ( P > 0.05). Renal responses to l-NAME in uncomplicated, type 1 DM are exaggerated vs. C, consistent with an upregulation of NO bioactivity. LOS, without effects in C, prevents the accentuated actions of l-NAME in DM, thus indicating an augmented role for NO-RAS interactions in renal hemodynamic function in DM.

Renal hemodynamic response to L-arginine in uncomplicated, type 1 diabetes mellitus: the role of buffering anions and tubuloglomerular feedback

According to the "tubulocentric" hypothesis of the glomerular hyperfiltration of diabetes mellitus (DM), tubuloglomerular feedback (TGF) is the critical determinant of the related renal hemodynamic dysfunction. To examine the role of TGF in human type 1 DM, 12 salt-replete healthy (C) and 11 uncomplicated DM individuals underwent measurements of glomerular filtration rate (GFR), renal blood flow (RBF), and lithium-derived absolute "distal" sodium delivery (DDNa). Measurements were made during two 3-h infusions of 0.012 mmol·kg(-1)·min(-1) l-arginine (ARG) buffered with either equimolar HCl (ARG.HCl) or citric acid (ARG.CITR). Our hypothesis was that changes in TGF signaling would be directionally opposite ARG.HCl vs. ARG.CITR according to the effects of the ARG-buffering anion on DDNa. Similar changes in C and DM followed ARG.CITR, with declines in DDNa (-0.26 ± 0.07 mmol/min C vs. -0.31 ± 0.07 mmol/min DM) and increases in RBF (+299 ± 25 vs. +319 ± 29 ml·min(-1)·1.73 m(-2)) and GFR (+6.6 ± 0.8 vs. +11.6 ± 1.2 ml·min(-1)·1.73 m(-2)). In contrast, with ARG.HCl, DDNa rose in both groups (P = 0.001), but the response was 73% greater in DM (+1.50 ± 0.15 mmol/min C vs. +2.59 ± 0.22 mmol/min DM, P = 0.001). RBF also increased (P = 0.001, +219 ± 20 ml·min(-1)·1.73 m(-2) C, +105 ± 14 DM), but ΔRBF after ARG.HCl was lower vs. ARG.CITR in both groups (P = 0.001). After ARG.HCl, ΔRBF also was 50% lower in DM vs. C (P = 0.001) and GFR, unchanged in C, declined in DM (-7.4 ± 0.9 ml·min(-1)·1.73 m(-2), P = 0.02 vs. C). After ARG.HCl, unlike ARG.CITR, DDNa increased in C and DM, associated with less ΔRBF and ΔGFR vs. ARG.CITR. This suggests that the renal hemodynamic response to ARG is influenced substantially by the opposite actions of HCl vs. CITR on DDNa and TGF. In DM, the association of ARG.HCl-induced exaggerated ΔDDNa, blunted ΔRBF, and the decline in GFR vs. C shows an enhanced TGF dependence of renal vasodilatation to ARG, in agreement with a critical role of TGF in DM-related renal hemodynamic dysfunction.

[Echocardiography in internal medicine: usefulness of Doppler tissue analysis]

The Doppler echocardiographic examination is the most important and common method used for cardiac imaging due to its safety, its relatively low cost and the great amount of morphofunctional information it can provide. It also plays a relevant role in the assessment of cardiac involvement underlying systemic diseases, in most of which the complication rate is often subclinical and represents one of the main causes of mortality. Advances in technology have lead to an increase in diagnostic accuracy and the range of applications of echocardiography. Among the new techniques, tissue Doppler echocardiography has been shown to identify early ventricular changes in both diastolic and systolic phases and in the preclinical stage of systemic diseases such as amyloidosis, systemic lupus erythematosus, vasculitis, with possible cardiac involvement. The increased sensitivity derives from the possibility of assessing longitudinal mechanics, which seems affected earlier than the circumferential one by pathological processes. Tissue Doppler echocardiography analysis, associated with a complete clinical history, can make an early diagnosis or arise a diagnostic suspicion to the physician, allowing early detection and rapid implementation of diagnostic and therapeutic measures able to improve patient prognosis.

Impact of myocardial geometry on left ventricular performance in healthy black and white young adults

Racial differences in left ventricular (LV) structure are suggested by clinical and experimental studies. This study evaluates if racial differences in LV performance exist comparing black to white young males, by tissue Doppler echocardiography and myocardial performance index (MPI). We examined 40 healthy males, 20 blacks (mean age 27.6 +/- 4.4 years) and 20 whites (mean age 26.5 +/- 6.7 years). All subjects underwent conventional echocardiography, tissue Doppler echocardiography, and MPI assessment. No differences were found in LV diameters, volumes, mass, and hemodynamic measurements. Septal and posterior wall thicknesses were significantly increased in black subjects as well as the relative wall thickness. Systolic and diastolic functions estimated by conventional parameters were superimposable in the two groups. In black subjects, a significant increase of septal S-wave, peak velocity, and time-velocity integral were found. MPI was significantly higher in black compared to white subjects (0.46 +/- 0.05 vs 0.40 +/- 0.06, P < 0.002). A significant correlation between MPI and relative wall thickness (r = 0.54) was demonstrated. Besides, MPI correlated with S(pv) (r = 0.55) and S(tvi) (r = 0.38) at the septal site. In conclusion our data show a higher MPI in black subjects that seems to be geometry-dependent. Correlations between MPI and tissue Doppler echocardiography systolic indexes were found. Our findings suggest that racial differences in LV performance exist, especially, in the systolic function, even in the absence of other conventional echocardiographic changes.

Cardiac involvement in the Churg-Strauss syndrome

Churg-Strauss syndrome (CSS) is a rare systemic disease characterized by necrotizing vasculitis and peripheral eosinophilia. Cardiac involvement is considered common and is given a high rank among the causes of morbidity and mortality. The aim of this study was an update on the cardiac manifestations of this syndrome using a noninvasive approach. Sixteen patients with CSS were compared with a gender- and age-matched group of 20 healthy subjects. All patients but 1 were receiving treatment (steroids and/or immunosuppressive drugs). According to the Birmingham vasculitis activity score, 12 patients were in an active phase, and 4 were in drug-induced remission. All subjects underwent M-B-mode echocardiography and Doppler tissue echocardiography. Heart failure, life-threatening arrhythmias, and other prominent manifestations of heart disease were not observed. No differences were found in left ventricular diameter, volume, mass, or ejection fraction. The 2 groups did not differ in right ventricular diameter and pulmonary pressure. Few and nonspecific changes were detected by 2-dimensional echocardiography, including subclinical pericardial effusion and mitral regurgitation, in fewer than half the subjects. Subjects with CSS showed an impairment of ventricular relaxation. Changes were more prominent in the right ventricle. The peak velocity (PV) of early diastolic tricuspid inflow (E) was about 8% less than in controls, and the velocity of late diastolic inflow (A) was 35% greater. The E/A(PV) ratio was, on average, 33% less. In the left ventricle, E(PV) was 11% less and A(PV) 11% greater. The E/A ratio was decreased by 22%. Doppler analysis of tissue kinetics confirmed these indications. In the right ventricle, E(PV) was decreased by 10% and A(PV) was increased by 20% in the patient group. The E/A(PV) ratio was decreased by 29%. In the left ventricle, in which different sites were sampled, the average changes were -15%, +1%, and -23%, respectively. In the left ventricle, the velocity of systolic contraction was also decreased by 12%. Because of the small group size, only some of these differences were statistically significant. In conclusion, these moderate changes, devoid of clinical correlates, contrast with early reports emphasizing cardiac morbidity and poor prognosis in this syndrome.

Evaluation of the myocardial performance index for early detection of mitoxantrone-induced cardiotoxicity in patients with multiple sclerosis

AIMS

Multiple sclerosis is the most common cause of neurological disability in young adults. Mitoxantrone is a synthetic anthracenedione, recently approved for the treatment of worsening multiple sclerosis, which is known to induce cardiotoxicity. This study was designed to evaluate the early alterations in left ventricular function in patients with multiple sclerosis receiving mitoxantrone, by the use of the myocardial performance index, a new parameter of global (systolic and diastolic) ventricular function.

METHODS AND RESULTS

The study included 29 Caucasian patients with multiple sclerosis (mean age 41.8+/-9.3 years, 12 males and 17 females) treated with mitoxantrone (mean cumulative dose 30.8+/-18.2 mg/m(2)) who were compared with 28 healthy subjects (mean age 37.8+/-11.8 years, 13 males and 15 females). Both groups underwent a complete two-dimensional and Doppler echocardiography including assessment of the mitral inflow and left ventricular outflow patterns for estimation of the Doppler-derived myocardial performance index. This parameter is defined as the sum of isovolumic contraction time and isovolumic relaxation time, divided by ventricular ejection time. No differences were observed in blood pressure, heart rate, left ventricular diameters, mass and ejection fraction in multiple sclerosis patients compared to the controls. The mitral flow pattern showed a significant decrease of E wave calculated as peak velocity (E(pv)) (63.3+/-13.4 vs. 77.2+/-17.2, P<0.002) and time velocity integral (E(tvi)) (8.8+/-1.9 vs. 10.3+/-2.4, P<0.02), with a significant decrease of E(pv)/A(pv) ratio and a non-significant decrease of E(tvi)/A(tvi) ratio in the patients. In addition, E-wave deceleration time was significantly increased in multiple sclerosis patients compared to controls (178.2+/-30.2 vs. 137.9+/-14.7, P<0.0001). The mean value of myocardial performance index was 0.55+/-0.1 in patients compared to 0.37+/-0.06 in the controls (P<0.0001). A significant correlation between the given cumulative dose of mitoxantrone and myocardial performance index (r=0.67, P<0.001) and E-wave deceleration time (r=0.45, P<0.001) respectively were demonstrated.

CONCLUSION

The myocardial performance index represents a parameter of combined systolic and diastolic myocardial performance strongly correlated with the given cumulative dose of mitoxantrone. The myocardial performance index may be an adjunctive parameter to conventional echocardiography for detecting sub-clinical cardiotoxicity of mitoxantrone in the clinical management of the multiple sclerosis patients.

Apical hypertrophic cardiomyopathy and atrial septal defect: part of a multi-organ syndrome?

AIM

We describe a case of non-obstructive apical hypertrophic cardiomyopathy with atrial septal defect, in a 48-year-old caucasian female patient with chronic renal failure, hypothyroidism and primary amenorrhea, referred to our hospital for syncope, palpitation and shortness of breath.

METHODS AND RESULTS

Electrocardiogram, transthoracic echocardiogram and cardiac magnetic resonance showed classical features of apical hypertrophic cardiomyopathy. Apical hypertrophic cardiomyopathy is morphologically characterized by apical ventricular hypertrophy, and is reported to be a relatively benign prognosis compared with the other type of hypertrophic cardiomyopathy.

CONCLUSION

Apical hypertrophic cardiomyopathy is very rare in the West, is occasionally encountered in Japanese persons, but there have been only a few reports of its coexistence with atrial septal defect. Our present report is the first case of apical hypertrophic cardiomyopathy with atrial septal defect associated with renal failure, hypothyroidism and primary amenorrhea that could represent a multi-organ syndrome. This hypothesis was supported by the finding of the same characteristics in a sister of the patient.

Left and right ventricular adaptation assessed by Doppler tissue echocardiography in athletes

BACKGROUND

Changes induced by intensive training in the morphology and kinetics of both ventricles in athletes (soccer players) were assessed by 2-dimensional echocardiography and Doppler tissue echocardiography (DTE). DTE has yet to find widespread application in sports medicine, and the right ventricle (RV) is often neglected in the examination of athletes. DTE-determined velocities were measured along the short and long axis in the left ventricle (LV) and over the long axis in the RV. Wall displacements (systolic shortenings and diastolic elongations) were computed at each site as time-velocity integrals. Normalized velocities and excursions were calculated with reference to the long and short diastolic dimensions.

METHODS

A total of 20 athletes and 15 age- and sex-matched control subjects were enrolled in the study. All participants underwent history screening, physical examination, electrocardiogram, and blood analysis.

RESULTS

The athletes had significantly greater RV long-axis dimension and LV short-axis dimension than control subjects. LV ejection fraction was similar in the 2 groups. In athletes, peak systolic velocities were significantly increased along the LV short axis and the RV long axis. Early diastolic velocities were significantly increased for the LV short axis and nonsignificantly increased at all other sites. The ratio of these peak velocities to the proper diastolic dimension (fractional or normalized velocities) did not significantly differ between the groups. Time-velocity integrals (ie, wall tissue displacements) were increased in all directions examined in both ventricles, both in systole and early diastole. However, normalized or percent shortenings and elongations were similar in athletes and control subjects.

CONCLUSION

These data suggest that an increase in RV and LV cavity size is associated with higher DTE-reported velocities in athletes. These higher velocities correspond to greater excursions of the muscle segments involved. Normalized velocities and excursions, however, indicate an unchanged fractional shortening, so that contractility has to be considered unaffected in these athletes. We suggest that DTE is instructive in unveiling functional adaptations of the heart in athletes, but questions of data interpretation have to be settled. For example, one should be cautious in comparing absolute velocities between chambers of different size. Nonnormalized velocities may be an objectionable index in the presence of cardiac enlargement.

Effects of the reduction of preload on left and right ventricular myocardial velocities analyzed by Doppler tissue echocardiography in healthy subjects

AIMS

Previous studies using Doppler Tissue Echocardiography (DTE) have suggested that the early-diastolic myocardial velocity behaves as a relatively load-independent index of left ventricular relaxation in patients with cardiac diseases; it is not ascertained if this holds true also in normal human hearts.

METHODS AND RESULTS

We assessed the influence of a progressive reduction of preload, obtained by Lower Body Negative Pressure (LBNP), on the diastolic and systolic myocardial waves compared to the inflow patterns estimated in left and right ventricles in nine healthy subjects. LBNP caused a significant decrease in end-diastolic volume, stroke volume and systolic arterial pressure, whilst heart rate increased only at maximum preload reduction; meridional end-systolic stress did not change significantly. The early (E') and late (A') myocardial velocities, at mitral and tricuspid annulus, decreased similarly during lower body suction, so that E'/A' ratio did not change. However, due to reduced early (E) but unchanged late (A) diastolic velocities, the E/A ratio of inflow patterns decreased. Systolic (S') myocardial velocities also decreased during LBNP. LBNP induced greater changes of myocardial diastolic and systolic velocities in the right than in the left ventricle.

CONCLUSION

In this study, myocardial E', A' and S' velocities, in both the left and the right ventricle, were significantly affected by preload in healthy subjects. Our results support the usefulness of the E'/A' ratio as a relatively load-independent index of diastolic function.

Doppler tissue echocardiography: myocardial wall motion velocities in essential hypertension

AIMS

Doppler tissue echocardiography (DTE) was applied to extract the myocardial wall velocities along different planes and evaluate the left ventricular function in essential hypertension.

METHODS AND RESULTS

Fifty-four hypertensives (HT) were compared to a control group of 31 normotensive (NT) subjects. The short-axis shortening and lengthening was assessed through the parasternal projections, sampling from interventricular septum and posterior wall. Through the apical projections the mitral annulus excursion was observed at four sites (anterior, posteroseptal, lateral, inferior walls) to assess the longitudinal dynamic of the heart. In each myocardial segment, peak velocity and time-velocity integral for systolic (S) and diastolic waves (E and A) were measured and their means for the long- and short-axis directions were calculated. Significant changes in hypertensives involved mainly the longitudinal motion. In diastole, the E-wave relaxation velocity was significantly decreased and the late A-wave velocity was unchanged. The E/A velocity ratio was significantly reduced. Relaxation velocity was negatively correlated to age, left ventricular mass and diastolic blood pressure. In systole, the peak S-wave shortening velocity was reduced and no association with age, left ventricular mass and blood pressure could be demonstrated. The range of segmental data produced by DTE proved useful to manufacture sensitive indices for recognition of hypertensive damage. Single DTE variables also proved slightly more sensitive than those extracted from the mitral flow pattern for the discrimination of HT patients.

CONCLUSION

The presence of impaired relaxation was confirmed by DTE in a large portion of patients with hypertension and left ventricular hypertrophy. A peculiar systolic disturbance is evidenced by this technique. DTE-derived information can be used to detect early and quantify target-organ damage and its progression or regression during antihypertensive treatment.

Estrogen derivative relaxes rabbit aorta via the endothelial receptor system

BACKGROUND

It is well known that sexual hormones, in particular estrogens, may influence the cardiovascular system. Experimental and clinical studies have shown that estrogen directly or indirectly modulates the reactivity of vascular smooth muscle but at present the mechanism of action of this hormone has yet to be clarified. The aim of this study was to evaluate the vascular effects of a synthetic non-steroid estrogen, diethylstilbestrol, and the possible involvement of endothelial function.

METHODS

We investigated, on aortic strips of a female rabbit, the inhibitory effects of diethylstilbestrol on the contractions induced by different spasmogenic agents, noradrenaline (10(-6) M), angiotensin II (10(-6) M), serotonin (10(-6) M), and KCl (10(-1) M). Some experiments were performed in high K+, Ca++-free solution. In some experiments endothelial function was abolished by mechanical ablation. Another series of experiments was incubated (30 min) with N(G)-monomethyl-L-arginine, which inhibits nitric oxide synthase or with tamoxifen, a specific antagonist of estrogen receptors.

RESULTS

At doses from 10(-6) M to 10(-4) M, diethylstilbestrol showed an evident spasmolytic action on contractions induced by noradrenaline, angiotensin II and serotonin but no significant effect was observed on KCl spasm. The inhibitory response of diethylstilbestrol to increased vascular tone induced by noradrenaline disappeared when the endothelial function, validated by the acetylcholine test, was abolished by mechanical ablation. When tested in high K+, Ca++-free solution, diethylstilbestrol did not significantly shift the cumulative dose-response curve of calcium. In the experiments performed with N(G)-monomethyl-L-arginine, diethylstilbestrol failed to induce vasodilation suggesting that its action may be related to synthesis of nitric oxide. Moreover, in the presence of tamoxifen, diethylstilbestrol was unable to induce vasodilation.

CONCLUSIONS

The early occurrence of vasodilation is in favor of a direct effect and seems to exclude a regulation of gene expression. These results suggest that estrogens may directly regulate vascular tone interacting with its specific endothelial cell receptors through the release of nitric oxide.