Domenico Del Forno

Long-term effects of cardiac rehabilitation on end-exercise heart rate recovery after myocardial infarction.

Background Heart rate recovery (HRR) is a marker of vagal tone that is a powerful predictor of mortality in patients with coronary artery disease. Design This study aims at evaluating the effects of long-term exercise training on HRR after acute myocardial infarction (AMI), in order to clarify whether prolonged exercise training could maintain a long-term improvement of HRR. Methods Forty-four patients after AMI were enrolled in a 3-month hospital-based exercise training programme. At the end, patients were subdivided into two groups: group A (n = 22), patients discharged with a specific home-based exercise training programme and instructions for improving leisure-time physical activity; group B (n = 22), patients discharged with generic instructions to maintain physical activity. All patients underwent a cardiopulmonary exercise test before, at the end of 3 months exercise training and at 6 months follow-up. Results At the end of the hospital-based exercise training programme we observed an increase in peak oxygen consumption [VO2peak; from 13.9 ± 3.6 to 18 ± 2.7 ml/kg per min (A) and from 14.1 ± 3.9 to 17.9 ± 2.1 ml/kg per min (B), P<0.001] and in HRR [from 17.1 ± 1.8 to 23.4 ± 1.4 beats/min (A), and from 18.8 ± 2.1 to 24.3 ± 1.9 beats/min (B), P<0.001]. At 6 months’ follow-up we observed a further improvement in VO2peak (from 18.0 ± 2.7 to 20.3 ± 2.7 ml/kg per min, P<0.001) and in HRR (from 23.4 ± 1.4 to 27.8 ± 2.1 beats/min, P<0.001) in group A, but a significant decrease in VO2peak and in HRR in group B (P<0.001). Conclusion Long-term exercise training is useful for maintaining or improving the beneficial results of the standard 3-month exercise training programme on cardiovascular capacity and HRR. This observation may bear beneficial prognostic effects on patients after AMI.

Left ventricular remodelling in patients with moderate systolic dysfunction after myocardial infarction: favourable effects of exercise training and predictive role of N-terminal pro-brain natriuretic peptide.

Aims To investigate the effects of exercise training (ET) on left ventricular (LV) volumes, cardiopulmonary functional capacity and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in postinfarction patients with moderate LV dysfunction. Methods Sixty-one postinfarction patients were randomized into two groups: group T [n = 30, LV ejection fraction (EF) 41.6 ± 11.3%, mean ± SD] entered a 6-month ET programme, whereas group C (n = 31, EF 42.0 ± 7.6%, P=NS) did not. NT-proBNP assay, Doppler-echocardiography and cardiopulmonary exercise test were performed upon enrolment and at sixth months. Results At sixth months, trained patients showed an improvement in workload (+26%, P<0.001), Vo2peak (+31%, P<0.001), LV end-diastolic volume index (LVEDVI; −9%, P<0.001), a reduction in NT-proBNP (−71%, P<0.001) and a significant correlation between changes in NT-proBNP and in LVEDVI (r=0.858, P<0.001). Baseline NT-proBNP correlated with changes in LVEDVI in both trained (r=0.673, P<0.001) and untrained (r=0.623, P<0.001) patients. Group C showed unfavourable LVEDVI dilation (+8%, P<0.001; T vs. C group, P<0.001) and a smaller reduction in NT-proBNP (−40%, P<0.001; T vs. C group, P<0.001). Conclusions Six month ET induced a favourable LV remodelling and a marked fall in NT-proBNP that could predict LV remodelling in postinfarction patients with moderate LV dysfunction.

Growth Hormone Deficiency in Patients with Chronic Heart Failure and Beneficial Effects of Its Correction

CONTEXT A reduced activity of the GH/IGF-I axis in chronic heart failure (CHF) has been described by several independent groups and is associated with poor clinical status and outcome. OBJECTIVE The aim of the current study was to investigate the prevalence of GH deficiency in a patient population with CHF and evaluate the cardiovascular effects of GH replacement therapy. DESIGN AND SETTING The randomized, single-blind, controlled trial was conducted at the Federico II University. PARTICIPANTS One hundred fifty-eight patients with CHF, New York Heart Association class II-IV, underwent a GH stimulation test. Sixty-three patients satisfied the criteria for GH deficiency, and 56 of them were enrolled in the trial. INTERVENTION The treated group (n = 28) received GH at a replacement dose of 0.012 mg/kg every second day (approximately 2.5 IU). MAIN OUTCOMES MEASURES Changes in physical performance and various cardiovascular indexes were measured. RESULTS GH replacement therapy improved quality of life score (from 46 +/- 5 to 38 +/- 4; P < 0.01), increased peak oxygen uptake and exercise duration (from 12.9 +/- .9 to 14.5 +/- 1 ml/kg x min and from 520 +/- 36 to 586 +/- 43 sec, respectively; P < 0.01), and flow-mediated vasodilation (from 8.8 +/- 1.3 to 12.7 +/- 1.2%; P < 0.01). GH increased left ventricular ejection fraction (from 34 +/- 2 to 36 +/- 2%; P < 0.01) and reduced circulating N-terminal pro-brain natriuretic peptide levels (from 3201 +/- 900 to 2177 +/- 720 pg/ml; P = 0.006). No significant changes from baseline were observed in controls. CONCLUSIONS As many as 40% of patients with CHF are GH deficient. GH replacement therapy in these patients improves exercise capacity, vascular reactivity, left ventricular function, and indices of quality of life.

Reduction of N terminal-pro-brain (B-type) natriuretic peptide levels with exercise-based cardiac rehabilitation in patients with left ventricular dysfunction after myocardial infarction.

Introduction N-terminal-pro-brain (B-type) natriuretic peptide (NT-pro-BNP) is a peptide hormone released from ventricles in response to myocyte stretch. The aim of the study was to investigate the influence of exercise training on plasma NT-pro-BNP to verify if this parameter could be used as a biological marker of left ventricular remodelling in myocardial infarction patients undergoing an exercise training programme. Methods Forty-four patients after myocardial infarction were enrolled into a cardiac rehabilitation programme, and were randomized in two groups of 22 patients each. Group A patients followed a 3-month exercise training programme, while group B patients received only routine recommendations. All patients underwent NT-pro-BNP assay, and cardiopulmonary exercise test before hospital discharge and after 3 months. Results In Group A, exercise training reduced NT-pro-BNP levels (from 1498 ± 438 to 470 ± 375 pg/ml, P = 0.0026), increased maximal (V O2peak + 4.3 ± 2.9 ml/kg per min, P<0.001; Powermax + 38 ± 7, P<0.001) exercise parameters and work efficiency (Powermax/V O2peak + 1.3 ± 0.4 Power/ml per kg per min, P<0.001); there was also an inverse correlation between changes in NT-pro-BNP levels and in V O2peak (r = −0.72, P<0.001), E-wave (r = −0.51, P<0.001) and E/A ratio (r = 0.59, P<0.001). In group B, at 3 months, no changes were observed in NT-pro-BNP levels, exercise and echocardiographic parameters. Conclusion Three months exercise training in patients with moderate left ventricular systolic dysfunction after myocardial infarction induced a reduction in NT-pro-BNP levels, an improvement of exercise capacity and early left ventricular diastolic filling, without negative left ventricular remodelling. Whether the reduction of NT-pro-BNP levels could be useful as a surrogate marker of favourable left ventricular remodelling at a later follow-up remains to be further explored.

Two-year multicomprehensive secondary prevention program: favorable effects on cardiovascular functional capacity and coronary risk profile after acute myocardial infarction.

Background Cardiac rehabilitation includes interventions aimed at facilitating physical, psychological and emotional recovery following the acute phase of myocardial infarction (AMI). To date, optimal cardiac rehabilitation program duration and frequency of patient contact has yet to be identified. Objective The present study was performed to evaluate the effects of two different strategies of secondary prevention (2 years, multifactorial continued educational and behavioral intervention versus usual care) implemented into a cardiac rehabilitation setting on several cardiovascular endpoints indicating cardiovascular functional exercise capacity and coronary risk profile in patients with recent AMI. Methods This was a prospective randomized study including 52 postinfarction patients. Initially, all patients were enrolled in a 3-month outpatient cardiac rehabilitation program. Thereafter, they were randomly subdivided into two groups (I = intervention group; C = control group), each composed of 26 patients, and followed for 24 months. Results At the end of the 3-month outpatient cardiac rehabilitation program, both groups showed a significant (P < 0.05) improvement in cardiopulmonary parameters (maximal oxygen consumption, maximal workload) and in cardiovascular risk profile (BMI, lipid profile). During the 24-month study period, group I showed stabilization or even improvement (P < 0.05) of both cardiopulmonary parameters and cardiovascular risk profile, whereas group C patients showed a deterioration or significant impairment (P < 0.05) of the same parameters. Clinical events occurred in 27% of patients in the control group (n = 7) and in 11% in the training group (n = 3) (P < 0.05). Conclusion Long-term, multifactorial educational and behavioral intervention maintained for 2 years in a multicomprehensive cardiac rehabilitation setting represents a valid strategy for improving long-term cardiovascular functional capacity and cardiovascular risk profile in postinfarction patients.

Emotional Eating e Binge Eating: Stress e disturbi del comportamento alimentare

Puo capitare di mangiare non per fame, ma in risposta a sentimenti ed emozioni, in particolare rabbia o stress. In questi casi si e di fronte a episodi di Emotional Eating, consistenti in una perdita di controllo per cui non e piu il corpo a dettare cosa e quanto mangiare, bensi le emozioni vissute in quel momento. Alcune persone tendono ad abbuffarsi quando sono tristi o particolarmente annoiate, per altri invece e un modo per evitare di pensare a questioni delicate della propria vita. L’Emotional Eating spesso porta a mangiare in eccesso e soprattutto cibi con un alto contenuto di calorie e di grassi, come i dolci.

Tecniche psicologiche basate sulle evidenze per il trattamento delle patologie legate allo stress

L’interdipendenza tra mente e corpo trova nella storia delle scienze umane e naturali una convalida costante da cui originano molti approcci teorici in tema di eziopatogenesi delle patologie.

I processi cognitivo-emotivi coinvolti nei disturbi da somatizzazione

In ambito medico e ormai largamente condivisa l’idea che il benessere fisico abbia una sua influenza su sentimenti ed emozioni e che questi, a loro volta, abbiano ripercussioni sul corpo. Oggi prevale una visione multifattoriale secondo cui ogni evento (e quindi anche una affezione organica) e conseguente all’intrecciarsi di molti fattori, tra i quali quello psicologico riveste notevole importanza. Quest’ultimo, infatti, a seconda della sua natura, puo agire favorendo l’insorgere di una malattia o, al contrario, agevolando la guarigione. Come vedremo piu avanti, la medicina tradizionale per molto tempo si e avvicinata al paziente utilizzando il principio di causalita e cercando di spiegare le malattie fondandosi su dati obiettivi e correlabili fra loro in modo diretto; mentre invece oggi si tende a perseguire una visione unitaria del soggetto e della malattia.

La diagnosi delle patologie legate allo stress in ambito medico-legale

Il ricorso alle discipline della mente in ambito giudiziario presuppone particolare cautela e competenza da parte dell’operatore professionale chiamato a esprimere il proprio parere tecnico. Infatti, oltre alle problematiche di natura squisitamente medico-legale relative a un corretto inquadramento nosografico della patologia di mente, anche in relazione allo stato anteriore del malato, nonche alla valutazione del nesso di causalita tra la presunta causa e il lamentato effetto e allo smascheramento di atteggiamenti simulatori (e, piu raramente, di pretestazione), non sfugge che, seppure le discipline psicologiche e il diritto si occupano spesso dello stesso oggetto di studio — il comportamento umano — le loro prospettive di indagine hanno ottiche non coincidenti. Mentre in diritto il comportamento umano e esaminato con una concezione che privilegia il rapporto normativo-collettivo, nelle discipline psicologiche l’attenzione e focalizzata sugli aspetti funzionali-soggettivi, con non poche difficolta di relazionalita laddove l’incontro professionale avviene per finalita di natura forense. Alla richiesta di certezze da parte di chi e chiamato ad amministrare la giustizia per la formulazione di sentenze eque si contrappone una disciplina, la psicologia, che storicamente si confronta con conoscenze e interpretazioni costantemente in evoluzione, in cui il dato scientifico e sottoposto a rivisitazioni e approfondimenti ravvicinati temporalmente anche per effetto di variabili sociali e ambientali che hanno dinamiche di cambiamento molto accelerate.