Armando Calzolari

Exercise Testing and 24-Hour Ambulatory Blood Pressure Monitoring in Children with Williams Syndrome

The aim of the study was to assess workload capacity and blood pressure (BP) response to treadmill exercise and 24-hour BP monitoring in children with Williams syndrome. Seventeen children were examined (8 males and 9 females) whose mean age was 13.8 ± 3.6 years. Six patients were on antihypertensive therapy. Each patient underwent clinical examination and measurement of BP at rest, during exercise, and during 24-hour monitoring. Two-dimensional echocardiogram and echo-Doppler of renal arteries were performed. The test was stopped for muscular fatique or reduced cooperation. The patients, when compared to a population of healthy children, had reduced total time of exercise (7.3 ± 1.9 vs 14.3 ± 2.6 min, p < 0.001) and, at the same workload, increased heart rate (167 ± 19 vs 145 ± 16 beats/min, p < 0.001) and increased maximum systolic BP (146 ± 27 vs 128 ± 12 mmHg, p = 0.01). Ambulatory blood pressure measurement values showed higher systolic blood pressure both during daytime and nighttime. Our study confirms that children and adolescents with Williams syndrome are at high risk for hypertension, probably related to the alterations of large arteries. The data relating to the synthesis of elastin may have a direct relationship to the compliance of the arterial system, leading to hypertension.

Cardiovascular Hemodynamics: Relationships with Insulin Resistance in Obese Children

AbstractWe investigated blood pressure (BP), cardiac output (CO), and systemic vascular resistance (SVR) and their relationships with insulin and glucose blood levels in a group of 24 obese children (mean age, 11.9 ± 2.1 years; 19 males). The data were compared to those obtained from a group of 19 healthy controls of the same age (12.4 ± 2.1 years; p = NS; 13 males). BP at rest was measured and all subjects underwent an exercise testing on the treadmill (Bruce Prot.), time of exercise, maximal heart rate, maximum systolic blood pressure, CO, and SVR at rest and at peak exercise were considered. Only in the OC group were an oral glucose tolerance test were performed to calculate insulin sensitivity index (ISI) and echocardiography performed to determine the left ventricular mass (LVM). The relationships between cardiovascular and metabolic parameters were investigated. Student’s t-test and linear regression analysis were used when appropriate. OC had a significant reduction in TE and higher BP, and linear regression analysis showed significant correlations between BP, ISI, and LVM. We speculate that OC need a regular cardiovascular and metabolic screening to prevent the development of early cardiovascular damage.

Mid-term results, and therapeutic management, for patients suffering hypertension after surgical repair of aortic coarctation.

We designed our study to investigate the efficacy of a new therapeutic approach to late onset hypertension in patients after surgical repair of aortic coarctation. Several studies have shown a higher incidence of hypertension during daily activities, and during exercise, in patients after surgical correction of coarctation. To the best of our knowledge, however, no data exists concerning haemodynamics, the response of arterial pressures, and the effects of medications for lowering blood pressure during exercise or during daily activities.We studied 128 patients, aged 15.6 +/- 4.3 years, to determine the response of blood pressure as we administered treatment in the attempt to achieve a normotensive state. We excluded patient with associated cardiac abnormalities, apart from those with bicuspid aortic valves. We evaluated blood pressure at rest in both the right arm and leg to establish presence of any gradient, as well as the blood pressure in the arm during exercise testing, and by 24-hour ambulatory monitoring.Atenolol was prescribed for those with elevated values of blood pressure but with a normal increment of heart rate during exercise. We prescribed Candesartan for those with elevated levels of blood pressure but with reduced increments of heart rate, specifically maximal heart rates of less than 85% of their predicted value. Both drugs were used when one alone was not effective. We found that, in young patients, candesartan provided better control of blood pressure with no side-effects, especially as demonstrated using 24-hour ambulatory monitoring, while atenolol was less effective, with more side-effects. Our experience suggests that both drugs should be used in patients who are non-responsive to monotherapy.

Abnormal Hypertensive Response during Exercise Test in Normotensive Transplanted Children and Adolescents

We investigated the cardiovascular and respiratory conditions, at rest and in response to stress testing, in 10 children and adolescents with successful renal transplantation, to release certifications for participation in sports. Our patients were aged more than 6 years, transplanted 6 months or more before the study, with creatinine clearance > 40 ml/min/1.73 m2, without hypertension at rest. All but 1 were on cyclosporine A, prednisone and azathioprine. Two control study groups with the same chronological age and body surface area were paired with our patients. They underwent a graded exercise tread-mill test, during which maximal blood pressure and heart rate were recorded. Resting electrocardiogram, dynamic 24-hour electrocardiogram Holter monitoring and mono- and bidimensional echocardiograms were obtained before the test. Spirometry was performed to study lung flow and volume. A questionnaire collected information about physical activity patterns. Four categories, according to practice, frequency and duration of exercise, were identified: nonactive, starters, experienced and very experienced. Most children and adolescents were sedentary or mildly interested in sports and during treadmill test we observed reduced exercise capacity and systolic hypertensive response to increasing exercise testing.

Reciprocating supraventricular tachycardia in children: Low rate at rest as a major factor related to propensity to syncope during exercise

Reciprocating supraventricular tachycardia may have several clinical presentations, with symptoms often more severe during exercise or emotional stress. This study shows by using transesophageal atrial pacing, the factors related to syncope during exercise. Between May 1989 and June 1994, transesophageal atrial pacing was performed at rest and during exercise in 75 children aged > 6 years with suspected or documented episodes of paroxysmal supraventricular tachycardia. Reciprocating supraventricular tachycardia could be induced both at rest and during exercise in 22 patients (8 girls, 14 boys; mean age 10.6 +/- 2.7 years, range 7 to 15 years) with ventriculoatrial interval < 70 msec in 11 patients and > 70 msec in 11. At rest, all patients had palpitations caused by the induction of tachycardia. After conversion to sinus rhythm, when tachycardia was induced during exercise, symptoms did not change in 14 patients (group A), whereas symptoms worsened (presyncope) in eight (group B). The statistical analysis showed a significant difference of mean reciprocating supraventricular tachycardia rate at rest between the two groups (group A, 211 +/- 23 beats/min; group B, 173 +/- 33 beats/min; p = 0.0057) and reciprocating supraventricular tachycardia rate variation from rest to exercise (group A, 62 +/- 18 beats/min; group B, 105 +/- 24 beats/min; p = 0.0001). These data suggest that children with low tachycardia rate during normal activities may have syncope more frequently, independently of the tachycardia rate during exercise or emotional stress.

The influence of different surgical procedures on hypertension after repair of coarctation

We measured resting and exercise haemodynamics, as well as 24-hour ambulatory blood pressure, so as to study the influence on development of hypertension in children after repair of coarctation by either construction of a subclavian flap or end-to-end anastamosis. The patients in both groups were studied a mean time of 13 years after surgery. Thus, we divided 43 children who had undergone surgical repair of coarctation, and who were not on antihypertensive therapy, into a group of 22 patients who had undergone subclavian flap repair, with a mean age of 14 plus or minus 2.6 years, and another group of 21 patients undergoing end-to-end anastomosis, with a mean age of 13.5 plus or minus 3.9 years. We examined blood pressure at rest and during exercise, along with the measurement of cardiac output using impedance cardiography, and during 24-hour ambulatory monitoring. We recorded systolic and diastolic blood pressures, pulse pressure, cardiac output and total peripheral vascular resistance at rest and at peak exercise. During ambulatory monitoring, we measured mean pressures over 24 hours, in daytime and nighttime, 24-hour pulse pressure, and 24-hour mean arterial pressure. Students t test was used to judge significance, accepting this when p was less than 0.05. The group repaired using the subclavian flap showed significantly disadvantageous differences for diastolic blood pressure at rest, systolic blood pressure at peak exercise and for 24-hour systolic and diastolic blood pressure, 24-hour mean arterial pressure, and daytime and nighttime systolic blood pressure during ambulatory monitoring. Our findings suggest that, after repair using the subclavian flap in comparison to end-to-end anastomosis, patients show a higher incidence of late hypertension, both during exercise and ambulatory monitoring. The data indicate different residual aortic stiffnesses, these being lower after end-to-end anastomosis, which may be due to the greater resection of the abnormal aortic tissue when coarctation is repaired using the latter technique.

Energy expenditure and insulin sensitivity evaluation in obese children affected by hepatosteatosis.

The aim of our study was to evaluate the physical and sedentary activities and energy expenditure (EE) in a group of children affected by non‐alcoholic fatty liver disease (NAFLD), compared with normal and obese subjects, using a physical activity questionnaire (PAQ) and a SenseWear armband (SWA).

Impaired Energy Expenditure Despite Normal Cardiovascular Capacity in Children with Type 1 Diabetes

Background: Benefit of fitness on children with type 1 diabetes mellitus (T1DM) is still debated. Aim: To evaluate the influence of physical activity on metabolic balance and exercise tolerance in prepubertal children affected by T1DM. Methods: We analyzed 35 pre-/peripubertal T1DM children and 31 matched controls using an activity monitor (SenseWear Armbad) and physical activity questionnaire (PAQ) to assess energy expenditure (EE), total and active, sedentary and physical activities (h/day and Mets = metabolic equivalents). The maximal cardiopulmonary exercise test (CPET) was also performed. Results: Total physical activities and total and active EE (>3 Mets) resulted higher in controls than in T1DM patients and self-reported perception of physical and sedentary activities was altered in T1DM children as well in controls and were different from the measured data. No differences were found in CPET parameters with the exception of a higher maximal blood pressure in T1DM children. In multivariate analysis HbA1c negatively correlated with VO2. Conclusion: Prepubertal T1DM children seem to have a lower level of physical activity and EE and a probable altered feeling of physical and sedentary activities. On the other hand, T1DM children do not show any alteration of cardiovascular performance, although glycemic control (HbA1c) may play a role in cardiovascular performance.

Physical activity, fitness, and dyspnea perception in children with congenital diaphragmatic hernia†

We assessed whether physical activity could influence the performance and perception of dyspnea in children who were operated on for high risk congenital diaphragmatic hernia (CDH). We hypothesized that CDH children with normal activity would have better lung function and exercise performance level when compared to sedentary CDH subjects.

Sonographic biometry of liver and spleen size long after closure of abdominal wall defects

Little is known about the fate of the liver and spleen after closure of the abdominal cavity in patients with abdominal wall defects (AWD). Therefore, counselling families for long-term follow-up and in the case of surgery for acute disease, pregnancy or trauma may be difficult. A total of 18 patients ranging in age from 7 to 18 years, with AWD closed at birth, underwent ultrasound evaluation of liver and spleen size by determination of the index of liver size (ILS) and splenic volume (SV). These values were then correlated with some anthropometric parameters such as body mass index (BMI) and weight; correlation was also sought with some clinical features such as type of defect and direct or staged closure. Nearly all subjects exhibited weight above and BMI below the 50th percentile for age. ILS and SV were significantly above normal limits in all cases and no difference was found with regard to the type of defect. Conclusion:in patients having undergone surgery for abdominal wall defects, liver and spleen usually regain their normal shape and position even though size and volume appear to be larger than in normal controls.