Silvia Bonatti

Influence of regression of left ventricular hypertrophy on left atrial size and function in patients with moderate hypertension

Objectives. The aim of the study was to evaluate the effect of regression of left ventricular (LV) hypertrophy on left atrial (LA) size and function in patients treated with telmisartan, an angiotensin II receptor blocker. Methods. Patients population included 80 patients with mild–moderate LV hypertrophy treated with telmisartan. Patients were followed over a period of 12 months from the start of telmisartan treatment. LA size was measured during systole from the parasternal long‐axis view from M‐mode. Atrial function was assessed by Doppler‐echocardiography and the following parameters were measured: transmitral peak A velocity, atrial filling fraction, atrial ejection force (AEF), peak E velocity, deceleration time and isovolumic relaxation time, LA maximal and minimal volume, and LV cardiac mass index (LVMI). Results. All patients had an increased LVMI and decrease during follow‐up. LA dimensions were greater at baseline and reduced after 1 year of treatment. LA volume indexes maximal volume, minimal volume and P volume were reduced compared with baseline value (maximal volume from 35±5 to 32±5, p<0.05; minimal volumes from 14±2 to 10±4, p<0.05). AEF, a parameter of atrial systolic function, increased from 12±3 to 15±2.4 (p<0.01). The reduction of LA volumes correlate with reduction of LVMI (LA maximal volume and LVMI r = 0.45; p<0.01; LA minimal volume and LVMI r = 0.34; p<0.05). A positive correlation was also found between LV mass index and P volume (r = 0.41; p<0.01), LV mass index and LA active emptying volume (r = 0.39; p<0.01), and LV mass index and LA total emptying volume (r = 0.38; p<0.05). Conclusions. The present study suggests that regression of LV hypertrophy due to telmisartan is associated with reduction of LA volumes that expresses variation of LV end‐diastolic pressure. The reduction of LV end‐diastolic pressure is associated with an increase in diastolic filling and with a significant reduction of active and passive emptying contribution of left atrium to LV stroke volume.

Effect of coffee consumption, lifestyle and acute life stress in the development of acute lone atrial fibrillation

Objective The study evaluated the relationships between acute stress, lifestyle and coffee consumption, and acute lone atrial fibrillation (AF). Methods The study group included 400 patients with mean age of 54 ± 11 years, 205 of whom were men. They all presented with a first episode of AF. Patients underwent a series of cognitive tests to evaluate acute psychological stress (mean life acute stress score). Lifestyle and nutritional parameters (diet, alcohol and espresso coffee consumption, smoking and obesity) were investigated. An age-matched and sex-matched control group was selected and compared. Results Recent stress, high intake of coffee, and obesity were associated with greater risk of AF. Acute stress induces an increase in coffee consumption and changes in lifestyle. The increase in coffee consumption was more marked in nonhabitual drinkers, leading to a higher risk of developing AF [odds ratio (OR) 4.1; 95% confidence interval (CI): 1.98–4.56; P < 0.001]. Spontaneous conversion of AF to sinus rhythm was observed in 191 patients (47%). Patients who experienced AF after an acute stress showed the highest probability of spontaneous conversion. High espresso coffee consumption (OR 0.86; 95% CI: 0.49–1.21; P < 0.01) and obesity (OR 0.88; 95% CI: 0.84–1.20; P < 0.01) were associated with a significantly greater risk of persistent AF. Conclusion Acute stress induced changes in lifestyle, including an increase in coffee consumption, leading to a higher risk of AF. Patients who developed AF after an acute stress showed the highest probability of spontaneous conversion. High espresso coffee consumption and obesity were associated with an increased risk of persistent AF.

Impact of prehospital diagnosis in the management of ST elevation myocardial infarction in the era of primary percutaneous coronary intervention: reduction of treatment delay and mortality.

Objectives The aim of the study is to assess, as primary endpoints, in-hospital mortality and percutaneous coronary intervention (PCI) mortality and to compare the outcome in ST elevation myocardial infarction (STEMI) patients with different pathways to a catheterization laboratory in the context of an area with 24 h availability of catheter facilities. Methods Three hundred and ninety-nine STEMI patients, referred to an interventional centre for primary PCI, were divided into two groups according to the different pathways to the catheterization laboratory. Group A had 263 patients diagnosed following admission to First Aid. Group B had 136 patients diagnosed in a prehospital setting with telemedicine equipment and transferred directly to the interventional centre by advanced life support (ALS) ambulance. Results Significantly shorter treatment delay was observed in group B patients than in group A (262 ± 112 vs. 148 ± 81 min in group A vs. B, P < 0.001). A significant reduction in total mortality was observed in group B compared with group A (8.7 vs. 3% in group A vs. B, P < 0.05). After multivariate analysis, predictors of in-hospital mortality are age and Killip class (P < 0.01), different pathways to catheterization laboratory, pre-PCI TIMI flow and onset-to-balloon time (P < 0.05). Conclusion The present study shows a reduction in treatment delay and in-hospital mortality by prehospital ECG and direct referral to catheterization laboratory.

Left atrial size and function after spontaneous cardioversion of atrial fibrillation and their relation to n-terminal atrial natriuretic peptide

L atrial (LA) stunning after cardioversion of atrial fibrillation (AF) has been reported during spontaneous conversion to sinus rhythm.1 This observation suggest that atrial stunning is a function of underlying arrhythmia and not of the mode of cardioversion. It is known that AF causes atrial dilation, and progressive LA enlargement occurs when AF becomes chronic.2 Recently, it has been shown that multiple factors contribute to LA enlargement, including the presence and persistence of arrhythmia.3 Many reports suggest that if sinus rhythm is restored then dilation may regress.4 The Framingham Study showed a relation between LA size and the risk of stroke in men and the risk of death in both genders.5–7 Previous studies have suggested that N-terminal atrial natriuretic peptide (NANP) levels are elevated in patients with AF.8,9 It is unclear whether AF rather than LA dilation,10 hemodynamic impairment,11 or another hormonal alteration, can result in the elevation of N-ANP levels.8 The present report evaluates the changes in LA size and function after spontaneous cardioversion of AF and their relation to N-ANP. • • • Hemodynamically stable patients referred for cardioversion for nonrheumatic AF between September 1997 and March 2000 were considered for inclusion in this investigation. The initial study group included 202 consecutive patients; 98 patients spontaneously recovered sinus rhythm within 48 hours from the onset of arrhythmia and were selected for the study (Group A). The study population included 57 men and 41 women of mean age 60 16 years; patients were compared with 98 ageand gender-matched control subjects (mean age 61 16 years) who underwent pharmacologic cardioversion within 48 hours from the onset of arrhythmia (Group B). Patients received intravenous propafenone 2 mg/kg of body weight; the drug was dissolved in 100 ml of 5% glucose and infused over 30 minutes. Exclusion criteria were: atrial flutter, valvular stenosis, valvular prosthesis, significant valvular insufficiency, atrial and/or left ventricular thrombosis, spontaneous echo contrast, patent foramen ovale or an atrial septal aneurysm, or decreased LV function (ejection fraction 45%). No patients received long-term therapy with antiarrhythmic drugs. Demographic and clinical characteristics of the patients are listed in Table 1. Clinical records included age, gender, time and circumstances of the onset of symptoms related to AF, and the duration of AF estimated from the initial onset of symptoms until the time of the in-hospital conversion. The protocol was approved by the Ethical Committee of our university and all patients signed an informed consent form. The initial Doppler echocardiographic study was performed during AF and after cardioversion (mean 3 1.5 hours). A complete monoand 2-dimensional color Doppler echocardiogram was performed in each patient using a commercial Hewlett-Packard echocardiograph (Andover, Massachusetts) with a 2.5-MHz probe. LA function was assessed using these parameters: (1) transmitral pulsed Doppler recorded from the apical 4-chamber view with the sample volume positioned between the tips of the mitral leaflets; peak early filling (E) and atrial filling (A) velocities; and From the Departments of Cardiology and Biomedics, University of Modena and Reggio Emilia, Modena, Italy. Dr. Mattioli’s address is: Department of Cardiology, University of Modena, Via del pozzo, 71, 41100 Modena, Italy. E-mail: mattioli.annavittoria@ unimo.it. Manuscript received December 17, 2002; revised manuscript received and accepted March 3, 2003. TABLE 1 Demographics and Clinical Characteristics

Left atrial anatomy and function after conversion from atrial fibrillation in hypertrophic hearts

The aim of the study was to evaluate the influence of left ventricular (LV) hypertrophy on left atrial (LA) electrical and mechanical function after cardioversion atrial fibrillation (A-Fib) of brief duration. Study group A included 100 patients with a first diagnosis of hypertension who had a moderate LV hypertrophy. The patient population included 64 men and 36 women with a mean age of 55 ±7 years who were hospitalized because of A-Fib and were cardioverted with external DC shock. Control group B included 100 patients without cardiac hypertrophy cardioverted because of lone A-Fib. Atrial function and size were assessed by Doppler echocardiography and the following parameters were measured: transmitral peak A velocity, atrial filling fraction, atrial ejection force, peak E velocity, deceleration time, and isovolumic relaxation time, LA maximal and minimal volume, and LV cardiac mass index. Baseline echocardiography showed that LA diameters and volumes were enlarged in all patients during A-Fib. After the restoration of sinus rhythm LA diameters and volumes decreased and the reduction was more evident in group B compared to group A. LA function as a continuous variable was negatively related to LV mass index (r = -0.77), LA diameter (r = -0.66 and r = -0.69 for the superoinferior diameter), LA maximal volume (r = -0.61) and LA minimal volume (r = -0.55) (all p<0.01). Atrial ejection force as a continuous variable was positively related to age (r =0.78), peak A wave velocity (r =0.71), systolic blood pressure (r =0.51), and IVRT (r =0.41) (all p<0.01). Hypertrophy influenced the recovery of atrial function after cardioversion of A-Fib. Atrial function was reduced in patients with LV hypertrophy even after A-Fib of brief duration.

Left atrial remodeling after short duration atrial fibrillation in hypertrophic hearts

trial fibrillation (AF) is the most common sustainedcardiac arrhythmia found in hypertensive patients. AFcauses atrial dilation, and progressive left atrial (LA)enlargement occurs once AF becomes chronic. In theFramingham heart study, LA enlargement was associatedboth with the duration of elevated blood pressure and withthe level of systolic pressure.