Lourenço Gallo Júnior

Physical training as non-pharmacological treatment of neurocardiogenic syncope.

Background Characterized as a sudden and temporary loss of consciousness and postural tone, with quick and spontaneous recovery, syncope is caused by an acute reduction of systemic arterial pressure and, therefore, of cerebral blood flow. Unsatisfactory results with the use of drugs allowed the nonpharmacological treatment of neurocardiogenic syncope was contemplated as the first therapeutic option. Objectives To compare, in patients with neurocardiogenic syncope, the impact of a moderate intensity aerobic physical training (AFT) and a control intervention on the positivity of head-up tilting test (HUT) and orthostatic tolerance time. Methods Were studied 21 patients with a history of recurrent neurocardiogenic syncope and HUT. The patients were randomized into: trained group (TG), n = 11, and control group (CG), n = 10. The TG was submitted to 12 weeks of AFT supervised, in cycle ergometer, and the CG to a control procedure that consisted in 15 minutes of stretching and 15 minutes of light walk. Results The TG had a positive effect to physical training, with a significant increase in peak oxygen consumption. The CG did not show any statistically significant change before and after the intervention. After the intervention period, 72.7% of the TG sample had negative results to the HUT, not having syncope in the revaluation. Conclusion The program of supervised aerobic physical training for 12 weeks was able to reduce the number of positive HUT, as it was able to increase tolerance time in orthostatic position during the HUT after the intervention period.

Replacement of carvedilol for propranolol in patients with heart failure

BACKGROUND Large clinical trials using the betablockers carvedilol, metoprolol, bisoprolol and nebivolol have demonstrated improvement of survival and symptoms in patients with heart failure. Despite the lack of scientific evidence, it is plausible that their beneficial effects are extensible to other betablockers. OBJECTIVE To evaluate the impact of the replacement of carvedilol for propranolol on left ventricular function, functional capacity, quality of life, pressure levels, and cardiac autonomic control in patients with heart failure. METHODS Twenty nine patients receiving optimized drug therapy including maximum tolerated doses of carvedilol were divided into two groups: replacement of carvedilol for propranolol (n = 15) and continued carvedilol (n = 14). At baseline and 6 months later, clinical and laboratorial assessments were carried out with radionuclide ventriculography, echocardiography, Minnesota questionnaire, walk test, APBM and Holter monitoring. RESULTS The clinical and demographic characteristics were similar in the two groups at baseline. Individualized propranolol dose adjustment ensured a similar degree of beta-blockade, as assessed by resting heart rate and chronotropic reserve. The mean propranolol dose used was 109 +/- 43 mg/day. Only one patient presented with intolerance to propranolol, thus carvedilol was reintroduced. One death was recorded in group propranolol. Ejection fraction significantly increased in the propranolol group. No significant change was observed in the other cardiovascular variables after betablocker replacement. CONCLUSION Our results indicate that replacement of carvedilol for propranolol in patients with heart failure is not associated with deterioration of the ejection fraction, functional capacity, quality of life, and other cardiovascular variables related to autonomic and blood pressure control., PP.0-0).FUNDAMENTO: Grandes estudos clinicos empregando os betabloqueadores carvedilol, metoprolol, bisoprolol e nebivolol, demonstraram melhora da sobrevida e dos sintomas em pacientes com insuficiencia cardiaca. Apesar da falta de evidencias cientificas, e plausivel que o efeito benefico seja extensivel a outros betabloqueadores. OBJETIVO: Avaliar em pacientes com insuficiencia cardiaca o impacto da substituicao do carvedilol por propranolol sobre a funcao ventricular esquerda, capacidade funcional, qualidade de vida, niveis pressoricos e controle autonomico cardiaco. METODOS: Vinte e nove pacientes com terapeutica medicamentosa otimizada incluindo doses maximas toleradas de carvedilol foram divididos em dois grupos: substituicao de carvedilol por propranolol (n = 15) e manutencao de carvedilol (n = 14). Na condicao basal, e apos 6 meses, foram realizadas avaliacoes clinica e laboratorial com: ventriculografia nuclear, ecocardiografia, questionario de Minnesota, teste de caminhada, MAPA e Holter. RESULTADOS: As caracteristicas laboratoriais e demograficas foram similares nos dois grupos na avaliacao inicial. Ajuste individualizado da dose do propranolol garantiu grau semelhante de betabloqueio avaliado pela frequencia cardiaca em repouso e reserva cronotropica. A dose media de propranolol usada foi 109 ± 43 mg/dia. Apenas um paciente apresentou intolerância ao propranolol com retorno do carvedilol. Foi registrado um obito no grupo propranolol. A fracao de ejecao apresentou aumento significativo no grupo propranolol. As demais variaveis cardiovasculares nao sofreram modificacoes significativas apos troca do betabloqueador. CONCLUSAO: Nossos resultados indicam que a substituicao do carvedilol por propranolol em pacientes com insuficiencia cardiaca nao esta associada a deterioracao da fracao de ejecao, da capacidade funcional, da qualidade de vida e das variaveis cardiovasculares de controle pressorico e autonomico.

Addition of Protein in Carbohydrate Supplementation Does not Improve Performance of Amateur Runners in Exercise above the Anaerobic Threshold

There is no consensus in the literature that supports the inclusion of protein in the carbohydrate supplement in endurance exercise. The purpose of this study was to compare the physical performance of amateur runners under three different supplementation protocols: placebo (PLA), carbohydrate (CHO) and carbohydrate plus protein (CHO + PTN). Twelve amateur runners performed three exercise protocols on separate occasions consisting of 60 initial minutes with intensity referring to the Anaerobic Threshold (AT) and then 10% above the AT until exhaustion. Supplements (150 mL) were ingested 15 minutes before starting the activity and every 20 minutes until the first hour of exercise. Biochemical analyzes (blood glucose and lactate) and rating of perceived exertion (RPE) were measured before, during and after exercise protocols. Total caloric intake (Kcal) and macronutrients (g) were evaluated in the 24 hours preceding each exercise protocol. The time of exhaustion was higher for the CHO group when compared to the PLA group (24.6±13.6 vs. 15.2±8.9 minutes, p = 0.001) and the CHO + PTN group (24.6±13.6 vs. 18.6±8.4 minutes, p = 0.01). In general, glycemia was higher for the CHO and CHO + PTN groups when compared to the PLA group at all times whereas lactate, RPE and dietary assement did not show great differences. Our results suggest that, unlike supplementation with CHO alone, the addition of PTN in CHO supplements does not result in improved performance for the studied population and exercise intensity.

Influence of aerobic exercise training on left ventricular remodeling and neurohumoral response in patients with myocardial infarction

Purpose: The effects of aerobic training on ventricular remodeling (VR) and neurohumoral activation after myocardial infarction (MI) have not been completely elucidated. It was investigated the influence of aerobic training on physical fitness, on VR and neurohumoral response after MI. Methods: Sixteen patients with anterior wall myocardial infarction were randomized into two groups: training (TG=8) and control (CG=8). TG patients performed moderate-intensity aerobic training. Before and after a 12-week follow-up all patients underwent cardiac magnetic resonance, cardiopulmonary exercise testing and blood sampling for measurement of NT-proBNP. Results: In the follow-up, there was a significant increase in the ΔO2 pulse in the TG (6.4 ± 1.2 to 8.1 ± 1.7; p=0.01), with no significant change in the CG (7.0 ± 2.3 to 6.9 ± 3.0; p>0.99). It was observed an increase of LV mass/EDV ratio from 0.72 ± 0.19 to 0.96 ± 0.30 g.ml-1 (p=0.007) in the CG, but no change in the TG from 0.89 ± 0.33 to 0.96 ± 0.26 g.ml-1 (p=0.54). There was a significant decrease of NT-proBNP at rest and at effort peak in both groups. Conclusion: Aerobic training seems to have a protective effect over the spontaneous process of LV concentric remodeling after myocardial infarction, and it promotes an improvement of the LV systolic performance during dynamic physical effort, without triggering adverse neurohumoral activation. Correspondence to: Giovani Luiz De Santi, Division of Cardiology, Medical School of Ribeirao Preto, University of Sao Paulo, Av. Bandeirantes, n 3.900, Ribeirao Preto-SP, Brazil, Zip: 14048-900; Tel: +551636022599, +551636022782, +553498020315; Fax: +551636021504; E-mail: giovanidesanti@usp.br

Substituição do carvedilol pelo propranolol em pacientes com insuficiência cardíaca

BACKGROUND Large clinical trials using the betablockers carvedilol, metoprolol, bisoprolol and nebivolol have demonstrated improvement of survival and symptoms in patients with heart failure. Despite the lack of scientific evidence, it is plausible that their beneficial effects are extensible to other betablockers. OBJECTIVE To evaluate the impact of the replacement of carvedilol for propranolol on left ventricular function, functional capacity, quality of life, pressure levels, and cardiac autonomic control in patients with heart failure. METHODS Twenty nine patients receiving optimized drug therapy including maximum tolerated doses of carvedilol were divided into two groups: replacement of carvedilol for propranolol (n = 15) and continued carvedilol (n = 14). At baseline and 6 months later, clinical and laboratorial assessments were carried out with radionuclide ventriculography, echocardiography, Minnesota questionnaire, walk test, APBM and Holter monitoring. RESULTS The clinical and demographic characteristics were similar in the two groups at baseline. Individualized propranolol dose adjustment ensured a similar degree of beta-blockade, as assessed by resting heart rate and chronotropic reserve. The mean propranolol dose used was 109 +/- 43 mg/day. Only one patient presented with intolerance to propranolol, thus carvedilol was reintroduced. One death was recorded in group propranolol. Ejection fraction significantly increased in the propranolol group. No significant change was observed in the other cardiovascular variables after betablocker replacement. CONCLUSION Our results indicate that replacement of carvedilol for propranolol in patients with heart failure is not associated with deterioration of the ejection fraction, functional capacity, quality of life, and other cardiovascular variables related to autonomic and blood pressure control., PP.0-0).FUNDAMENTO: Grandes estudos clinicos empregando os betabloqueadores carvedilol, metoprolol, bisoprolol e nebivolol, demonstraram melhora da sobrevida e dos sintomas em pacientes com insuficiencia cardiaca. Apesar da falta de evidencias cientificas, e plausivel que o efeito benefico seja extensivel a outros betabloqueadores. OBJETIVO: Avaliar em pacientes com insuficiencia cardiaca o impacto da substituicao do carvedilol por propranolol sobre a funcao ventricular esquerda, capacidade funcional, qualidade de vida, niveis pressoricos e controle autonomico cardiaco. METODOS: Vinte e nove pacientes com terapeutica medicamentosa otimizada incluindo doses maximas toleradas de carvedilol foram divididos em dois grupos: substituicao de carvedilol por propranolol (n = 15) e manutencao de carvedilol (n = 14). Na condicao basal, e apos 6 meses, foram realizadas avaliacoes clinica e laboratorial com: ventriculografia nuclear, ecocardiografia, questionario de Minnesota, teste de caminhada, MAPA e Holter. RESULTADOS: As caracteristicas laboratoriais e demograficas foram similares nos dois grupos na avaliacao inicial. Ajuste individualizado da dose do propranolol garantiu grau semelhante de betabloqueio avaliado pela frequencia cardiaca em repouso e reserva cronotropica. A dose media de propranolol usada foi 109 ± 43 mg/dia. Apenas um paciente apresentou intolerância ao propranolol com retorno do carvedilol. Foi registrado um obito no grupo propranolol. A fracao de ejecao apresentou aumento significativo no grupo propranolol. As demais variaveis cardiovasculares nao sofreram modificacoes significativas apos troca do betabloqueador. CONCLUSAO: Nossos resultados indicam que a substituicao do carvedilol por propranolol em pacientes com insuficiencia cardiaca nao esta associada a deterioracao da fracao de ejecao, da capacidade funcional, da qualidade de vida e das variaveis cardiovasculares de controle pressorico e autonomico.

Sustitución del carvedilol por el propranolol en pacientes con insuficiencia cardíaca

BACKGROUND Large clinical trials using the betablockers carvedilol, metoprolol, bisoprolol and nebivolol have demonstrated improvement of survival and symptoms in patients with heart failure. Despite the lack of scientific evidence, it is plausible that their beneficial effects are extensible to other betablockers. OBJECTIVE To evaluate the impact of the replacement of carvedilol for propranolol on left ventricular function, functional capacity, quality of life, pressure levels, and cardiac autonomic control in patients with heart failure. METHODS Twenty nine patients receiving optimized drug therapy including maximum tolerated doses of carvedilol were divided into two groups: replacement of carvedilol for propranolol (n = 15) and continued carvedilol (n = 14). At baseline and 6 months later, clinical and laboratorial assessments were carried out with radionuclide ventriculography, echocardiography, Minnesota questionnaire, walk test, APBM and Holter monitoring. RESULTS The clinical and demographic characteristics were similar in the two groups at baseline. Individualized propranolol dose adjustment ensured a similar degree of beta-blockade, as assessed by resting heart rate and chronotropic reserve. The mean propranolol dose used was 109 +/- 43 mg/day. Only one patient presented with intolerance to propranolol, thus carvedilol was reintroduced. One death was recorded in group propranolol. Ejection fraction significantly increased in the propranolol group. No significant change was observed in the other cardiovascular variables after betablocker replacement. CONCLUSION Our results indicate that replacement of carvedilol for propranolol in patients with heart failure is not associated with deterioration of the ejection fraction, functional capacity, quality of life, and other cardiovascular variables related to autonomic and blood pressure control., PP.0-0).FUNDAMENTO: Grandes estudos clinicos empregando os betabloqueadores carvedilol, metoprolol, bisoprolol e nebivolol, demonstraram melhora da sobrevida e dos sintomas em pacientes com insuficiencia cardiaca. Apesar da falta de evidencias cientificas, e plausivel que o efeito benefico seja extensivel a outros betabloqueadores. OBJETIVO: Avaliar em pacientes com insuficiencia cardiaca o impacto da substituicao do carvedilol por propranolol sobre a funcao ventricular esquerda, capacidade funcional, qualidade de vida, niveis pressoricos e controle autonomico cardiaco. METODOS: Vinte e nove pacientes com terapeutica medicamentosa otimizada incluindo doses maximas toleradas de carvedilol foram divididos em dois grupos: substituicao de carvedilol por propranolol (n = 15) e manutencao de carvedilol (n = 14). Na condicao basal, e apos 6 meses, foram realizadas avaliacoes clinica e laboratorial com: ventriculografia nuclear, ecocardiografia, questionario de Minnesota, teste de caminhada, MAPA e Holter. RESULTADOS: As caracteristicas laboratoriais e demograficas foram similares nos dois grupos na avaliacao inicial. Ajuste individualizado da dose do propranolol garantiu grau semelhante de betabloqueio avaliado pela frequencia cardiaca em repouso e reserva cronotropica. A dose media de propranolol usada foi 109 ± 43 mg/dia. Apenas um paciente apresentou intolerância ao propranolol com retorno do carvedilol. Foi registrado um obito no grupo propranolol. A fracao de ejecao apresentou aumento significativo no grupo propranolol. As demais variaveis cardiovasculares nao sofreram modificacoes significativas apos troca do betabloqueador. CONCLUSAO: Nossos resultados indicam que a substituicao do carvedilol por propranolol em pacientes com insuficiencia cardiaca nao esta associada a deterioracao da fracao de ejecao, da capacidade funcional, da qualidade de vida e das variaveis cardiovasculares de controle pressorico e autonomico.

W2077 Rapid Gastrointestinal Transit in Patients with Alcohol-Related Chronic Pancreatitis Is Related to Impaired Distal Small Bowel Meal Accumulation and Autonomic Neuropathy

Background: Patients with alcohol-related chronic pancreatitis (ARCP) may have accelerated mouth-to-cecum transit, particularly in the presence of autonomic neuropathy. Nevertheless, the roles of gastric emptying (GE) and transit throughout proximal and distal small bowel in the origin of the abnormal gastrointestinal transit (GIT) in ARCP have not been much studied. Aim: To assess GIT and to determine the roles of GE and segmental transit throughout the proximal and the distal small bowel in ARCP patients. Method: Eighteen healthy controls and 40 male ARCP patients were studied, including 17 with diabetes mellitus and malabsorption, 10 with diabetes only, 3 with malabsorption only and 10 without diabetes or malabsorption. Autonomic neuropathy was detected in 20 patients by standardized cardiovascular tests. GIT was assessed by scintigraphy after ingestion of a liquid meal labeled with 99mTechnetium-phytate and defined as the time of meal arrival to the cecum. Abdominal scans were serially taken for 180 min with a gamma camera. Counts for regions of interest defined for the stomach, proximal and distal small bowel, and cecum yield data for calculation for GE half-time, and the times of meal arrival to the proximal and to the distal small bowel and the cecum. Accumulation of the meal in the distal small bowel was estimated as the proportion of ingested radioactivity found in this region by the time that cecum filling started. Results: GIT was significantly shorter (p 180min vs 102min; 50->180min) and 11 patients were considered as having definite abnormally accelerated GIT. There were no significant differences (p>0.20) between patients and controls concerning GE half-time (50min; 5-13min vs 55min; 16-83min). There were also no differences (p>0.50) between patients and controls regarding the times of meal arrival to the proximal (15min; 1-45min vs 13min; 3-70min) and distal small bowel (23min; 4-64min vs 30min; 12-83min). However, accumulation of the meal in the distal small bowel was lower (p 0.1). Univariate analysis showed that rapid GIT is associated with both impaired accumulation of the meal in the distal small bowel (7/11 vs 3/29; p=0.001) and autonomic neuropathy (10/11 vs 10/29; p= 0.003). Conclusion: Abnormally rapid GIT in ARCP patients does not seem to be due to accelerated GE but is related to impaired accumulation of the meal in the distal small bowel and to autonomic neuropathy.