Silvia Perna

The cardiopulmonary exercise test is safe and reliable in elderly patients with chronic heart failure.

Aim To assess safety and feasibility of cardiopulmonary exercise test (CPX) in elderly patients with chronic heart failure (CHF) and left ventricular dysfunction. Methods and results We analysed 395 cardiopulmonary exercise tests (CPXs) performed in 227 clinically stable patients with CHF [mean age 76 years, males 70%, mean New York Heart Association (NYHA) class 2.2 ± 0.5] and impaired left ventricular function (mean ejection fraction 43 ± 12%). Ninety-eight out of 395 CPXs (25%) were performed in patients older than 80 years. A standard bicycle exercise ramp protocol was used, with increments of 10 W/min. An expiratory exchange ratio (RER) ≥ 1.05 at the peak of CPX was considered as the index of maximal exercise. Average workload was 65 ± 23 W. No adverse reactions were observed, although one test was stopped for non-sustained ventricular tachycardia. The main reasons for stopping were exhaustion (50%), dyspnoea (30%), maximal predicted heart rate (17%), orthopaedic problems (2.5%) and significant ST segment depression (0.5%). In the overall cohort, 80% of patients achieved an RER ≥ 1.05 and, in 56% of them, the RER was ≥ 1.15. The anaerobic threshold (AT) was detectable in 80% of CPXs, and mean oxygen consumption (VO2) at AT was 9 ± 6 ml/kg per min, whereas mean peak VO2 was 11 ± 3 ml/kg per min. In the cohort of patients aged > 80 years, 71% reached an RER ≥ 1.05 and 47% reached an RER ≥ 1.15. In these older patients, AT was detectable in 68% of CPXs performed, and the mean peak VO2 was 10 ± 3 ml/kg per min. Conclusions In elderly patients with CHF, the CPX is safe, feasible and able to provide basic information for individual risk assessment. These findings potentially extend the indications of CPX, which is currently applied to selected middle-aged patients with CHF, to the elderly population.

Additive prognostic value of cardiopulmonary exercise testing in elderly patients with heart failure.

To date, the role of CPET (cardiopulmonary exercise testing) for risk stratification in elderly patients with HF (heart failure) with depressed or preserved ventricular function has not been evaluated. In the present study, we analysed whether CPET is useful in predicting outcome in this population. A total of 220 NYHA (New York Heart Association) class I-III patients with HF > or =70 years of age [median age, 75 years; 23% had NYHA class III; and 59% had preserved ventricular systolic function (left ventricular ejection fraction > or =40%)] performed maximal CPET (peak expiratory exchange ratio >1.00). Median peak oxygen uptake was 11.9 ml.kg(-1) of body weight.min(-1), median VE/VCO(2) slope (slope of the minute ventilation/carbon dioxide production ratio) was 33.2 and 45% had an EVR (enhanced ventilatory response) to exercise (VE/VCO(2) slope > or =34). During 19 months of follow-up, 94 patients (43%) met the combined end point of death and hospital admission for worsening HF, arrhythmias or acute coronary syndromes. By Cox multivariable analysis, a creatinine clearance of <50 ml/min {HR (hazard ratio), 1.657 [95% CI (confidence interval), 1.055-2.602]} and EVR [HR, 1.965 (95% CI, 1.195-3.231)] were the best predictors of outcome, while ventricular function had no influence on prognosis. In conclusion, in elderly patients with HF, a steeper VE/VCO(2) slope provides additional information for risk stratification across the spectrum of ventricular function and identifies a high-risk population, commonly not considered in exercise testing guidelines.

Role of electroanatomic mapping in assessing the extent of atrial standstill: diagnostic and therapeutic implications.

Atrial standstill is characterized by failure of atrial excitation, either spontaneous or induced by atrial electric stimulation. We report the case of a 38-year-old man with severe bradycardia and junctional escape rhythm associated with dilative cardiomyopathy. Electroanatomic mapping showed the absence of atrial viability in almost the entire right atrial endocardial surface and excluded the feasibility of atrial pacing.

Ultrasound Monitoring of Carotid Lesions in Hypertension

Hypertension is one of the most common medical problems in industrialised societies and represents a major risk factor for cardiovascular morbidity and mortality. Most of the complications from hypertension occur in patients with mild hypertension in whom atherosclerotic disease, especially in coronary arteries, is more frequent.As recently suggested in European Society of Cardiology—European Society of Hypertension (ESC/ESH) Guidelines for Management of Hypertension, diagnostic procedures in patients with hypertension are aimed at the following: (i) establishing blood pressure levels (and consequently grade of hypertension); (ii) identifying possible secondary causes of hypertension according to rational algorithms; and (iii) evaluating the overall cardiovascular risk by identifying other risk factors, target organ damage and concomitant diseases or accompanying clinical conditions.Epidemiological data have shown a close relationship between atherosclerotic changes in the carotid artery (such as intima media thickness and plaques) and an increased risk of infarction and/or cerebrovascular disease. These observations have recently prompted increasing interest in investigating alterations in the carotid artery wall in patients with hypertension or in patients with other cardiovascular conditions.Measurements of the intima-media complex can also be used as relevant intermediate endpoints of antihypertensive treatment trials. In fact, it is important to establish the effectiveness of therapy administered by quantifying progression/regression of target organ damage using intermediate phenotypes of cardiovascular disease, and thus not only through the evaluation of blood pressure reduction.In this article, we briefly review the impact of the presence of vascular lesions on natural history and risk stratification in patients with hypertension, as well as the effects of therapeutic control of the vascular lesions and regression, in order to sustain systematic evaluation of the arterial tree in hypertension.