Silvia Amato

Parathyroidectomy erase increased myocardial electrical vulnerability in patients with primary hyperparathyroidism

BACKGROUND Patients with primary hyperparathyroidism (pHPT) show an increased bioelectrical risk not related to cardiovascular complications, this risk seems to persist after surgery and this last finding is still controversial and probably related to follow-up length. METHODS The aim of the study is to evaluate QT parameters in 11 patients with primary hyperparathyroidism (pHPT) 18 months after parathyroid surgery using computed standard 12-leads ECG compared to those of 29 healthy subjects (HS). RESULTS In pHPT patients, 4 months after parathyroidectomy QT and QTc dispersion persist significantly higher than HS. 18 months after surgery, QT and QTc dispersion resulted comparable with HS. QT dispersion was found significantly higher in pHPT at 4 months respect 18 months after parathyroidectomy. CONCLUSIONS ECG alteration after parathyroidectomy gradually return within normal limits and we can affirm that surgery erase bioelectrical risk in pHPT.

Heart rate, conduction and ultrasound abnormalities in adults with joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type.

Joint hypermobility syndrome (JHS) and Ehlers-Danlos syndrome, hypermobility type (EDS-HT) are two clinically overlapping heritable connective tissue disorders strongly associating with pain, fatigue and other secondary aspects. Though not considered a diagnostic criterion for most EDS subtypes, cardiovascular involvement is a well-known complication in EDS. A case-control study was carried out on 28 adults with JHS/EDS-HT diagnosed according to current criteria, compared to 29 healthy subjects evaluating resting electrocardiographic (ECG), 24-h ECG and resting heart ultrasound data. Results obtained in the ECG studies showed a moderate excess in duration of the PR interval and P wave, an excess of heart conduction and rate abnormalities and an increased rate of mitral and tricuspid valve insufficiency often complicating with “true” mitral valve prolapse in the ecocardiographic study. These variable ECG subclinical anomalies reported in our sample may represent the resting surrogate of such a subnormal cardiovascular response to postural changes that are known to be present in patients with JHS/EDS-HT. Our findings indicate the usefulness of a full cardiologic evaluation of adults with JHS/EDS-HT for the correct management.

Lack of the QTc physiologic decrease during cardiac stress test in patients with type 2 diabetes treated with secretagogues

Patients with type 2 diabetes are at increased susceptibility to a prolonged QT interval. Furthermore, insulin secretagogues, drugs used to treat diabetes, may prolong QT interval and provoke arrhythmias. We evaluated whether secretagogues can affect QTc interval during cardiac stress test in 20 patients with type 2 diabetes treated with secretagogues. ECG stress test was performed in all patients. QTc interval was calculated both before cardiac stress test (BCST) and at acme of cardiac stress test (ACST). Diabetic patients treated with secretagogues showed longer QTc-ACST values than those treated with metformin only. QTc-ACST values resulted shorter than QTc-BCST values in control group. Diabetic patients treated with secretagogues showed QTc-ACST values significantly longer than QTc-BCST values. In our study, diabetic patients treated with secretagogues did not show the QTc physiologic decrease that is a protective against arrhythmias. These results suggest to evaluate, in these patients, QT length, even during routine cardiac stress test.

Atrioventricular block associated with Crohn's relapsing colitis in a 12‐year‐old child

To the Editor: Inflammatory bowel diseases (IBDs) are associated with extraintestinal manifestations. Many systems or organs, i.e., eye, skin, liver, bone, and joints are frequently involved in IBD, but cardiac involvement is considered rare. Myopericarditis, worsening of congestive heart failure, sinusal symptomatic bradycardia, and heart block have been described in IBD patients as side effects of infliximab (chimeric monoclonal antibody to tumor necrosis factor-a). Cardiac conduction disturbances associated with IBD, in the absence of infliximab treatment, have been described in only a few case reports regarding adult patients with ulcerative colitis. Cardiac conduction system disturbance in children with Crohn’s disease (CD), not treated with infliximab, have not been reported yet. We describe the case of a 12-year-old child with CD involving the terminal ileum. There was no past history of cardiac disease and no evidence of myocardial ischemia or recent viral infection. The patient was treated with nutritional therapy (Modulen) and with azathioprine, but he was not treated with any anti-TNFa drugs. CD had been in remission for 6 months when the child developed bloody diarrhea without any systemic symptoms. He was hospitalized for relapse of CD. Colonoscopy showed active pancolitis. Laboratory data showed hemoglobin 11.8 mg/dL, white cells 9340 (neutrophils 79.4%), erythrocyte sedimentation rate (ESR) (31 mm/h), and D-dimer (782 mg/dL). Serology for cytomegalovirus, Epstein–Barr virus, and Mantoux test were negative. Fecal exam was positive for Clostridium difficile and antiSaccharomyces cerevisiae antibodies (ASCA) were high (160; normal value < 14). ECG showed first-degree atrioventricular block which was absent in previous electrocardiogram (ECG) (Fig. 1) and it was confirmed by 24-hour ECG monitoring. To assess autonomic system balance, heart rate variability (HRV), by short computed ECG monitoring (10 minutes), was recorded. Low LF/HF ratio (0.36), which is a sign of increased parasympathetic tone, was shown. Treatment with intravenous methylprednisone for 2 days was started. After 48 hours the bloody diarrhea cleared. Subsequently, oral therapy was carried out for several weeks. The azathioprine therapy was later replaced with methotrexate 20 mg/week intramuscularly, salazopyrin 2 cp 3 times a day, and folic acid. Metronidazole for C. difficile infection was also administered. On 3-month follow-up both outpatient review of bowel habits and colonoscopy were normal. Hematochemical parameters returned to normal range (hemoglobin 12.4 mg/dL, white cell 5000, ESR 8 mm/h). The LF/HF ratio returned to normal values (1.48). Monitoring ECG for 5 hours confirmed the persistence of atrioventricular block (PR mean 0.21 sec; normal value for age: 0.09–0.18 sec). To today, atrioventricular block is still present. We describe the case of a child with first-degree atrioventricular block associated with CD. This heart block, absent in previous ECG, appeared during the relapse of colitis and did not disappear at termination of relapse and is still present after 12 months. The excess of vagal activity, observed during relapse of disease, seems not have been implicated in the origin of atrioventricular block because of its persistence after vagal reequilibrium. Atrioventricular block in CD has been associated with infliximab therapy, but our patient had not been treated with this drug. Azathioprine and aminosalycilates seem to play a role in the etiology of pericarditis, but not in cardiac conduction disturbances. In conclusion, in our case both autonomic imbalance and drug therapy do not seem to be implicated in atrioventricular block, so it might be that the inflammatory state of relapsing colitis has caused damage to the cardiac conduction system cells. Microvascular endothelial dysfunction has been found in IBD patients. We speculate that some ischemic microdamage in the cardiac conduction system of our FIGURE 1. ECG recorded in Lead II before (A) and during (B) relapse of CD. ECG in B shows atrioventricular block.

A Lower Level of Entropy in Circadian Rhythm of the Sinus R‐R Intervals Suggests a Prevalence of the Cardiac Sympathetic Regulation in Early Physiological Pregnancy

The study estimates the unpredictable disorder (chaos) within the 24 h pattern of sinus R‐R intervals (SRRI) in clinically healthy pregnant women (CHPW) and clinically healthy non‐pregnant women (CHNPW), in order to evaluate the early gestational changes in neurovegetative cardiac pacing. SRRI were provided by the 24‐h Holter ECG of 10 CHPW and 10 CHNPW. SRRI were investigated by descriptive conventional statistics by means of the Time and Frequency Domain Analysis, and subsequently, in their chaotic component by means of entropy analysis. Both the SRRI and entropy were tested via the Cosinor method to better decipher whether or not the periodic disorder in heart rate variability is modified in pregnancy as a result of a gestational tonic resetting of the cardiac sympatho‐vagal regulation. Cosinor analysis documented that the circadian rhythm of both the SRRI and entropy were preserved in CHNPW and CHPW. However, the circadian rhythm of SRRI and entropy in CHPW exhibited a significantly decreased 24 h mean. Via the analysis of the rhythmicity of entropy, this study has documented that the chaos in the 24 h pattern of SRRI is less prominent in CHPW than in CHNPW. Such a reduction of level in the deterministic periodic chaos of heart rate variability provides evidence that, in early pregnancy, a tonic elevation of the sympathetic activity regulates cardiac pacing.

The loss of entropy circadian rhythm in sinusal R-R intervals of type 1 diabetic pregnant women suggests an indeterministic chaos in cardiac pacing (minimum delirium cordis syndrome). A newly identifiable type of silent cardiac dysautonomia?

Objective — The scope of this study is to detect whether or not the entropy (E) circadian rhythm (CR) is maintained preserved in sinusal R-R intervals (SRRI), its loss being the expression of a transition to an indeterministic chaos in heart rate variability (HRV). Methods — The E of SRRI was estimated in 14 type 1 diabetic pregnant women (DPW) in the first trimester of an apparently uncomplicated gestation (7 patients - mean age = 30.3 ± 4.1 y - without clinical and laboratory evidence of cardiac autonomic neuropathy, and 7 patients - mean age = 30.7 ± 3.6 y - with positive tests for a cardiac dysautonomia).The E CR was studied via the single cosi-nor method, and summarized via the population-mean cosinor method. Results — The E CR was found not to be preserved in both the investigated type 1 DPW, despite the occurrence of the SRRI CR. Conclusions — The loss of the E CR confirms that in type 1 DPW there is a transition to an indeterministic disorder in HRV due to the lack of an autocorrelated periodic chaos in cardiac pacing. Such an unphysiological neurovegetative regulation suggests a new silent cardiac dysautonomic syndrome, that we intend to call “minimum delirium cordis syndrome” (MDCS). Can the MDCS be regarded as a condition of cardiovascular risk? To answer this question, it seems justified to suggest that the study of the E CR should be added to the routine tests that are presently applied to clinical analysis of the Holter ECG, being the classic tests of linear analysis not methodologically suitable for detecting the indeterministic chaos of the MDCS.