Chiara Fossati

Addition of ivabradine to betablockers in patients with atrial fibrillation: Effects on heart rate and exercise tolerance.

Atrial fibrillation (AF) is one of the most common arrhythmias and is often responsible for impaired exercise tolerance and quality of life. Traditionally, in patients with persistent and/or permanent AF, heart rate (HR) control is obtained by using drugs that prolong atrioventricular (AV) node refractoriness such as β-adrenergic receptor blockers (βBs), nondihydropyridine calcium channel blockers, and digitalis glycosides. However a significant proportion of subjects with AF has poor HR control. According to current evidences βBs, the most effective drugs in achieving HR control, fail to obtain their goal in about 30% of cases [1]. Ivabradine, according to the traditional view, is a HR reducing agent that selectively inhibits the If current in the sinus node, without affecting heart contractility, relaxation and peripheral vascular resistance [2]. Recent studies conducted mainly in animal models support the hypothesis that ivabradine could have clinically valuable effects on AF by slowing the AV node conduction [3–5]. The goal of the present study was to test whether the addition of ivabradine to patients with persistent/permanent AF already taking βBs could be capable of improving HR control and clinical conditions of these patients. We evaluated 6 patients, mean age 66.4, (SD = 7), males/females: 4/2, with persistent or permanent AF already treated with βBs. Patients were considered suitable for this study if they fulfilled the following inclusion criteria: 1) they were taking the highest tolerated dose of a βB and no further increase were possible; 2) patients had HR N 110 bpy ata restingECG[6]; and3)they had dyspnea arisingfor mild efforts. Exclusion criteria were unstable clinical conditions (hospital admission in the last three months) or a previous diagnosis of pre-excitation. The study protocol was conform to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by San Raffaele Ethics Committee. After the enrollment and before starting ivabradine administration, all subjects underwent a 24/h ambulatory ECG monitoring (AEM) and asixminutewalkingtest(6MWT)withevaluationofthesubjectiveperceptionofdyspneathroughtheBorgsscalescore.AEMand6MWTwere repeated after one, two and three months. The starting dose of

Ranolazine improves insulin resistance in non-diabetic patients with coronary heart disease. A pilot study ☆

BACKGROUND The aim of this pilot study was to evaluate if ranolazine (R) could improve insulin resistance (IR) in obese/overweight non-diabetic patients with coronary heart disease (CHD). METHODS The study enrolled 40 patients with already diagnosed CHD, previous revascularization, residual ischemia at ergometric test and IR. Mean age was 62.4±9years, M/F=31/9. Patients were randomly assigned to one of the two following groups: group 1 (20 patients) started R at dose of 500mg/bid; group 2 (20 patients) increased the dose of beta/blockers or calcium-channel blockers without introducing R. IR was defined as having HOMA-IR>2.5. At baseline and after 12weeks, all subjects performed an ergometric test and 12h fasting blood sample collection for determining glucose and insulin levels. RESULTS At 12weeks follow-up visit HOMA-IR significantly decreased in group 1 (from 3.1±1.7 to 2.3±0.9; p=0.02) while it remained unchanged in group 2 (from 3.0±1.4 to 2.8±1.2; p=0.14) (between groups p=0.009). At 12weeks follow-up visit patients of both groups obtained a significant increase of ischemic threshold at ergometric test, compared to baseline, (group 1 from 308.4±45s to 423.9±57s, p=0.0004); (group 1 from 315.7±63s to 441.2±51s, p=0.0001); without between groups difference (p=0.25). CONCLUSIONS Our data suggest that starting R, instead of increasing the dose of beta-blockers/calcium-channel blockers, could be a preferable choice in obese/overweight CHD subjects with residual ischemia after revascularization.

The use of platelet-rich plasma (PRP) in the treatment of gastrocnemius strains: a retrospective observational study

Abstract The aim of the present retrospective observational study was to evaluate the time of functional recovery following a specific combined therapeutic approach characterized by an active exercise therapy carried out immediately after Platelet-rich plasma (PRP) injections for the treatment of the muscular lesion of the distal musculotendinous junction of the gastrocnemius medial head.Medical records of 31 subjects treated with three PRP intra-lesional ultrasound guided injections and 30 patients treated with the standard therapeutic approach (control group) were analyzed. Both groups followed the same rehabilitation therapy. Patients in the control group were able to start active exercise with a significant delay when compared to the PRP treated subjects: 17 ± 7.2 days and 9 ± 3.8 days (p = 0.0001), respectively. This delay was mainly due to the persistence of pain in the subjects in the control group. The time necessary to return to walk without pain was significantly shorter in the PRP treated group: 24.27 ± 12.36 days versus 52.4 ± 20.03 days in the control group (p < 0.001) as well as the time needed to fully return to practice the previous sport activity: 53.33 ± 27.74 days versus 119.3 ± 43.87 days in the control group (p < 0.001).The present study showed that ultrasound guided delivery of PRP into the site of muscle injury has to be considered a valid therapeutic approach with the potentiality of significantly reduce time and costs for reaching a complete functional recovery.

Reference values of left heart echocardiographic dimensions and mass in male peri-pubertal athletes

Background Several articles have proposed reference values in healthy paediatric subjects, but none of them has evaluated a large population of healthy trained adolescents. Design The study purpose was to establish normal echocardiographic measurements of left heart (aortic root, left atrium and left ventricular dimensions and mass) in relation to age, weight, height, body mass index, body surface area and training hours in this specific population. Methods We retrospectively evaluated 2151 consecutive, healthy, peri-pubertal athletes (100% male, mean age 12.4 ± 1.4 years, range 8–18) referred to a single centre for pre-participation screening. All participants were young soccer athletes who trained for a mean of 7.2 ± 1.1 h per week. Results Left ventricular internal diameters, wall thickness, left ventricular mass, aortic root and left atrium diameters were significantly correlated to age, body surface area, height and weight (p < 0.01). Age, height, weight and body surface area were found associated with chamber size, while body mass index and training hours were not. Inclusion of both age and body size parameters in the statistical models resulted in improved overall explained variance for diameters and left ventricular mass. Conclusion Equations, mean values and percentile charts for the different age groups may be useful as reference data in efficiently assessing left ventricular parameters in young athletes.

Right Ventricular Dysfunction is related with Poor Exercise Tolerance in Elderly Patients with Heart Failure with Preserved Ejection Fraction

Background: Exercise intolerance (EI) is a cardinal feature in subjects with heart failure with preserved ejection fraction (HFpEF). Factors related to EI in such patients are not completely understood.

Irritable oesophagus: A new cause of Sandifer's syndrome

Sir, Sandifer’s syndrome is a rare paediatric manifestation of gastro-oesophageal reflux (GOR) disease characterized by distonic movements. GOR disease is characterized by pathological GOR and associated symptoms. In children, patients with normal oesophageal exposure to acid and a significant association between reflux episodes and symptoms have been identified and described as having ‘‘irritable oesophagus’’ [1,2]. A 1-y-old female was referred to our Paediatric Gastroenterology Unit because, from the tenth month of life, she experienced 8 12 daily episodes of abnormal movements (rotation of head and neck, and arching of the upper part of the trunk). A gastrointestinal barium study excluded the presence of hiatus hernia (HH). An oesophagogastroscopy with biopsies was normal. To detect pathological GOR as well as to investigate the relationship between GOR episodes and abnormal movements, the patient underwent 24-h gastro-oesophageal pH monitoring (Figure 1). Since all parameters were normal, GOR disease was excluded. In order to verify the relation between GOR episodes and abnormal movements, we calculated specificity and sensitivity indices as well as the binomial formula (references in [1]). On the basis of such investigations, irritable oesophagus was diagnosed and the patient was treated with omeprazole (1 mg/kg/d) for 4 wk. During the first week of therapy, the number of abnormal movements decreased, and thereafter no abnormal movements occurred. The patient was followed for 6 mo, and no abnormal movements have been reported. In 1964, Kinsbourne described Sandifer’s syndrome, characterized by abnormal movements and HH [3]. In 1977, Murphy and Gellis [4] reported that the abnormal movements were related to GOR disease and that the presence of HH was not necessary in this syndrome. This case report demonstrates that irritable oesophagus is a new cause of Sandifer’s syndrome.