Daniela Imperiale

Aldosterone Antagonist Improves Diastolic Function in Essential Hypertension

Abstract—Experimental studies demonstrated that mineralocorticoid antagonists prevent or reverse myocardial fibrosis. Therefore, we tested the hypothesis that the aldosterone antagonist canrenone can improve left ventricular diastolic function in essential hypertension. Using digitized M-mode echocardiography and 24-hour blood pressure monitoring (ABPM), we realized a prospective, randomized, controlled study on 34 never-treated essential hypertensives with left ventricular diastolic dysfunction. Echocardiogram and ABPM were repeated after 6 months of effective antihypertensive treatment with ACE inhibitors and calcium antagonists (second evaluation) and then after a 6-month period with 17 patients randomly assigned to add canrenone 50 mg/d to the previous treatment (third evaluation). At the basal evaluation 32 patients had left ventricular concentric hypertrophy, and 2 patients had left ventricular concentric remodeling. All the patients had normal left ventricular systolic function. At the second evaluation blood pressure was reduced (P <0.0001), left ventricular mass index decreased (P <0.0001), and diastolic function improved (P <0.0001). After randomization, the canrenone and control groups had similar 24-hour blood pressure and left ventricular morpho-functional characteristics. At the third evaluation, despite unchanged blood pressure and similar decrease of left ventricular mass index, the canrenone group, compared with control group, showed a significantly greater increase in left ventricular diastolic indices. In essential hypertension, a low dose of aldosterone antagonist added to antihypertensive treatment significantly improved left ventricular diastolic function. This improvement, not accounted for by changes in blood pressure and left ventricular mass, can be therefore ascribed to a direct action of the drug on the myocardium.

Natriuretic peptides as markers of preclinical cardiac disease in obesity

Background  Aim of the study was to evaluate the role of atrial (ANP) and brain natriuretic peptides (BNP) as markers of preclinical cardiac disease in obesity.

Microalbuminuria in never-treated hypertensives: lack of relationship to hyperinsulinemia and genetic predisposition to hypertension

We evaluated the relationship of microalbuminuria to hyperinsulinemia and family history of hypertension in 92 never-treated essential hypertensives (mean 24-h blood pressure >140 or 90 mm Hg), with positive (F+) or negative (F-) family history of hypertension: 31 had microalbuminuria (MA+) (urinary albumin excretion [UAE], 30 to 300 mg/24 h) and 61 had normal (<30 mg/24 h) UAE (MA-). Glucose and insulin values before and 30, 60, 90, and 120 min after an oral glucose load were measured together with an index of peripheral insulin activity (10(4)/ insulin x glucose values at glucose peak). Subjects with and without microalbuminuria did not differ with regard to age, sex, body mass index, and 24-h heart rate, whereas 24-h, daytime, and nighttime systolic and diastolic blood pressure were significantly higher in MA+ than MA- patients. The prevalence of positive family history of hypertension was similar between MA+ and MA-, as were fasting and stimulated glucose and insulin values and the index of peripheral insulin activity. Subdividing the patients on the basis of family history of hypertension (59 F+, 33 F-) UAE was not significantly different between F+ and F-. UAE did not correlate with glucose and insulin parameters. From our results, in never-treated hypertensives, microalbuminuria is associated with higher blood pressure values, but is related neither to genetic predisposition to hypertension, nor to hyperinsulinemia; therefore, impaired insulin sensitivity and microalbuminuria are two components of the hypertensive syndrome, largely independent of each other.

Atrial Fibrillation and Antithrombotic Treatment in Italian Hospitalized Patients: A Prospective, Observational Study

AbstractBackground: We studied the prevalence of atrial fibrillation within a large Italian inpatient population, and evaluated the use of antithrombotic therapy among these individuals. Methods: A prospective cross sectional study (Phase 1) with a 1-year follow-up period (Phase 2) was conducted at a single Italian centre. During Phase 1, we conducted a chart review of all inpatients on 5 separate days, each 1 month apart, between January and May 1999. During Phase 2, at 1-year of follow-up, patients or their families were contacted to document the occurrence of new clinical events, as well as current antithrombotic therapy use. Results: A total of 3121 patient charts were reviewed. The prevalence of atrial fibrillation was 7.2%. Of these 224 patients, 21.3% were on oral anticoagulants, 29.7% on antiplatelets, while 49% received neither. Patients on oral anticoagulants were significantly younger (mean age 72.3 years) than those on antiplatelets (mean age 80.6 years; p<0.001) or neither therapy (mean age 80.7 years; p<0.001). At 1 year follow up, an acute ischaemic stroke occurred among 7.4% of the 121 contacted patients. Among patients with chronic atrial fibrillation [98], 25.5% were receiving an oral anticoagulant. Conclusions: Despite clear evidence from clinical trials, oral anticoagulants are significantly underused among patients with chronic atrial fibrillation. Methods should be developed to improve both physician and patient knowledge about the overall benefits of anti-thrombotic therapy among these individuals.

Microalbuminuria as a marker of preclinical diastolic dysfunction in never-treated essential hypertensives.

Using 24-h ambulatory blood pressure (BP) monitoring and digitized M-mode echocardiography, we evaluated whether microalbuminuria is related to preclinical left ventricular (LV) diastolic dysfunction in hypertensive patients. We selected 87 never-treated hypertensive patients (mean 24-h BP > 140 and/or > 90 mm Hg); albuminuria was evaluated as mean value of 24-h urinary albumin excretion (UAE) from two 24-h urine collections. Microalbuminuria was found in 28 patients, classified as MA+ (UAE 30 to 300 mg/24 h); 59 patients had normal UAE (< 30 mg/24 h) and were classified as MA-. The MA+ and MA- groups did not differ with regard to age, sex, body mass index, or 24-h heart rate, whereas 24-h, daytime, and nighttime systolic and diastolic BP were significantly higher in MA+ than in MA-. The LV mass index was greater in MA+, as was the prevalence of LV hypertrophy; peak shortening rate of LV diameter, index of systolic function, was normal in all, but was lower in MA+. Peak lengthening rate of LV diameter and peak thinning rate of posterior wall, indices of diastolic function, were lower in MA+ and the prevalence of diastolic dysfunction was higher in MA+. UAE was inversely correlated with both indices of LV diastolic function, also after correction for age, 24-h heart rate, 24-h BP, and LV mass. In conclusion, in never-treated hypertensive patients, microalbuminuria is not only associated with greater myocardial mass, but is also related with preclinical impairment of LV diastolic function. This relation, independent from increased BP or LV mass, strengthens the role of microalbuminuria as an early and reliable marker of preclinical cardiac involvement.

The embolic storm : dramatic peripheral complications of left ventricular thrombosis after myocardial infarction

Left ventricular thrombus is a common complication after acute myocardial infarction. Although anticoagulant treatment has an established role in reducing the rate of thrombus formation and embolic phenomena during acute myocardial infarction, prior studies showed that left ventricular thrombus and systemic embolization may develop irrespective of adequate anticoagulant therapy. We present a descriptive case of a patient with left ventricular thrombus who experienced dramatic peripheral embolic events soon after the onset of anterior myocardial infarction despite full anticoagulation, and we discuss possible pathogenesis.

[Major epidemiological changes and clinical variables in patients undergoing a program of heart rehabilitation after cardiac surgery - MEPHISTOPHELES].

BACKGROUND Recent observational studies show an increase of more complex and critically ill patients referred to Italian cardiac rehabilitation (CR) departments; the exact mechanisms underlying this phenomenon, however, have not been clearly identified. The aim of our study was to evaluate the epidemiological and clinical changes that occurred over the last decade in patients hospitalized in CR departments with high admittance rates. METHODS We have retrospectively evaluated all patients admitted between 2002 and 2009 to our division of CR (n = 3340, 1155 female, mean age 66.4 ± 11 years) after recent cardiac surgery. The study population was divided into two homogeneous groups: the four-year period 2002-2005, group A (n = 1614, 540 female, mean age 66.1 ± 10 years) and the four-year period 2006-2009, group B (n = 1726, 615 female, mean age 67.4 ± 11 years). Data were compared using specific indicators of clinical complexity. RESULTS Patients aged >75 years were more in group B compared to A (26.3 vs 19.8%, p<0.0001), as well as patients with recent complex surgical interventions, such as combined coronary artery bypass grafting and heart valve surgery (16.4 vs 10.2%, p<0.0001). An increased incidence of cardiovascular death (1.4 vs 0.6%, p=0.02), acute coronary syndrome (1.5 vs 0.7%, p=0.02) and persistent atrial fibrillation/flutter (13.5 vs 7.1%, p<0.0001) was observed in group B, as well as an increased prevalence of systolic heart failure (18.3 vs 9.0%, p<0.0001). Similarly, the incidence of acute respiratory failure episodes (1.0 vs 0.4%, p=0.05), the prevalence of patients admitted with a tracheostomy tube (2.6 vs 0.2%, p<0.0001) and the incidence of acute renal failure (1.1 vs 0.5%, p=0.05) were significantly increased in group B. Postoperative infections and surgical wound complications were 4-fold higher in group B (13.9 vs 3.1%, p<0.0001, and 12.8 vs 2.3%, p<0.0001, respectively). Compared to group A, patients of group B showed a significantly lower physical performance, as expressed by the Rivermead motility index (3.8 ± 1.1 vs 5.2 ± 0.8, p<0.001); moreover, the number of subjects able to perform an incremental training program was significantly lower in group B than group A (14.8 vs 60.6%, p<0.0001). Mean hospital stay was longer in group B than group A (25.4 ± 13 vs 22.1 ± 9 days, p<0.001). CONCLUSIONS Our study, by collecting data from a CR division in northern Italy with high admittance rates, demonstrates a dramatic increase in clinical complexity over the last few years. This points to the need for new expertise and major resources to be allocated to CR departments.

Ejection fraction/velocity ratio identifies prosthesis-patient mismatches in patients with aortic bioprosthetic valves and left ventricular dysfunction.

Objectives. Recently, a new echocardiographic nonflow corrected index (ejection fraction/velocity ratio [EFVR] = percent left ventricular ejection fraction [EF]/maximum aortic gradient) has been introduced and has shown excellent accuracy in quantifying the effective orifice area (EOA) in native aortic valves and bio‐prostheses. The objective of this study was to assess the utility of the EFVR to quantify the indexed EOA in patients with an aortic bioprosthesis and left ventricular dysfunction considering an indexed EOA value of 0.85 cm2/m2 or less to be indicative of a prosthesis‐patient mismatch (PPM), defined as an EOA of the inserted prosthetic valve of less than that of the normal human valve. Methods. We studied 100 patients (62 men and 38 women; mean age ± SD, 71 ± 8.6 years) with an aortic bioprosthesis and left ventricular dysfunction (EF ≤49%), and we evaluated the indexed EOA by both the continuity equation (CE) and EFVR. Results. We found a significant linear correlation between the CE and EFVR (r = 0.85; P < .0001) and good agreement between the two methods in identifying patients with an indexed EOA of 0.85 cm2/m2 or less; the correlation began to become nonlinear for patients with an indexed EOA of greater than 1.2 cm2/m2, which was not clinically relevant. Notably, all 11 patients with a discrepancy between the indexed EOA and EFVR (ie, EFVR ≤1.0 and indexed EOA >0.85 cm2/m2) also showed an indexed EOA of greater than 0.85 but less than or equal to 1.0 cm2/m2 (meaning the presence of a mild PPM). Conclusions. The EFVR can be considered a reliable echocardiographic alternative to the CE, especially in conditions in which that is technically difficult, allowing identification of a PPM (indexed EOA ≤0.85 cm2/m2) with excellent sensitivity and specificity.