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BACKGROUND: The benefits of exercise training in patients with chronic heart failure (CHF) are due to a combination of cardiac and peripheral adaptations. Separating these 2 components is normally impossible, except for patients implanted with total artificial heart (TAH), where cardiac adaptation cannot occur. METHODS AND RESULTS: We report the case of a patient implanted with a CardioWest-TAH who underwent a comprehensive strength and endurance training program and was evaluated by repeated peak cardiopulmonary exercise tests. The patient experienced a 24% increase of peak oxygen consumption and an improvement in recovery kinetics during the training period of 29 months. CONCLUSION: This unique situation of a patient with a TAH, and therefore a fixed peak cardiac output, allows us to isolate training-induced changes in the periphery, that suggest greater oxygen extraction and more efficient metabolic gas kinetics during the exercise and recovery phases. [ABSTRACT FROM AUTHOR]

Purpose: During treatment of bone and joint infections (BJIs) with multiple antibiotic therapy, hypokalemia has been reported as a rare side effect. The aim of this study was to evaluate incidence and risk factors for hypokalemia in a cohort of patients treated with multidrug therapy for BJIs, in a single center., Methods: We retrospectively reviewed 331 clinical files of 150 consecutive patients (65% males; median age 59 years, 95% CI 55-62) admitted repeatedly to our Osteomyelitis Department for treatment of chronic BJIs. Besides surgical debridement, patients received a combination of oral and intravenous antibiotics. Routine laboratory tests were performed at admittance and repeated at least weekly. Possible hypokalemia risk factors were recorded and analyzed., Results: Progressive kalemia reduction occurred in > 39% of patients during hospitalization; prevalence of marked hypokalemia (K +  < 3.5 mEq/l) increased from 5% at admission to 11% (up to 22%) at day 14. Correlated factors were: age ≥ 68 years (p = 0.033), low serum albumin (p = 0.034), treatment with vancomycin (p < 0.001), rifampicin (p = 0.017) and ciprofloxacin (p < 0.001) and use of thiazide (p = 0.007) or loop diuretics (p = 0.029 for K +  < 3.5 mEq/l). At multivariate regression analysis, the main determinants of hypokalemia were simultaneous use of diuretics (p = 0.007) and older age (p < 0.049)., Conclusions: Appearance of severe hypokalemia is a frequent event among patients treated for BJIs with multiple antibiotic therapy, when this is prescribed in older age patients and associated with simultaneous use of diuretics. Due to possible increase in mortality risk in the short term, particular caution should be paid during intensive antibiotic treatment in these groups of patients.

This clinical skills review describes the most common cardiac auscultatory findings in adults after heart surgery and correlates them with prognostic indicators. It was written for noncardiologist health care providers who work in outpatient cardiac rehabilitation programs.Mechanical prosthetic valves produce typical closing and opening clicks. Listening to their timing and features, as well as to presence and quality of murmurs, contributes to the awareness of potential prosthesis malfunction before other dramatic clinical signs or symptoms become evident. In patients with biological prostheses, murmurs should be carefully evaluated to rule out both valve malfunction and degeneration. Rubs of post-pericardiotomy pericarditis should prompt further investigation for early signs of cardiac tamponade. Third and fourth heart sounds and systolic murmurs in anemic patients should be differentiated from pathological conditions. Relatively new groups of heart surgery patients are those with chronic heart failure treated with continuous-flow left ventricle assist devices. These devices produce characteristic continuous noise that may suddenly disappear or vary in quality and intensity with device malfunction. After heart transplantation, a carefully performed and regularly repeated cardiac auscultation may contribute to suspicion of impending acute rejection. During cardiac rehabilitation, periodic cardiac auscultation may provide useful information regarding clinical-hemodynamic status and allow detection of heralding signs of possible complications in an efficient and low-cost manner.

During outpatient cardiac rehabilitation after an acute coronary syndrome or after an episode of congestive heart failure, a careful, periodic evaluation of patients' clinical and hemodynamic status is essential. Simple and traditional cardiac auscultation could play a role in providing useful prognostic information.Reduced intensity of the first heart sound (S1), especially when associated with prolonged apical impulse and the appearance of added sounds, may help identify left ventricular (LV) dysfunction or conduction disturbances, sometimes associated with transient myocardial ischemia. If both S1 and second heart sound (S2) are reduced in intensity, a pericardial effusion may be suspected, whereas an increased intensity of S2 may indicate increased pulmonary artery pressure. The persistence of a protodiastolic sound (S3) after an acute coronary syndrome is an indicator of severe LV dysfunction and a poor prognosis. In patients with congestive heart failure, the association of an S3 and elevated heart rate may indicate impending decompensation. A presystolic sound (S4) is often associated with S3 in patients with LV failure, although it could also be present in hypertensive patients and in patients with an LV aneurysm. Careful evaluation of apical systolic murmurs could help identifying possible LV dysfunction or mitral valve pathology, and differentiate them from a ruptured papillary muscle or ventricular septal rupture. Friction rubs after an acute myocardial infarction, due to reactive pericarditis or Dressler syndrome, are often associated with a complicated clinical course.During cardiac rehabilitation, periodic cardiac auscultation may provide useful information about the clinical-hemodynamic status of patients and allow timely detection of signs, heralding possible complications in an efficient and low-cost manner.

Background Erectile dysfunction may predict future cardiovascular events and indicate the severity of coronary artery disease in middle-aged men. The aim of this study was to evaluate whether erectile dysfunction (expression of generalized macro- and micro-vascular pathology) could predict reduced effort tolerance in patients after an acute myocardial infarction. Patients and methods One hundred and thirty-nine male patients (60 ± 12 years old), admitted to intensive cardiac rehabilitation 13 days after a complicated acute myocardial infarction, were evaluated for history of erectile dysfunction using the International Index of Erectile Function questionnaire. Their physical performance was assessed by means of two six-minute walk tests (performed two weeks apart) and by a symptom limited cardiopulmonary exercise test (CPET). Results Patients with erectile dysfunction (57% of cases) demonstrated poorer physical performance, significantly correlated to the degree of erectile dysfunction. After cardiac rehabilitation, they walked shorter distances at the final six-minute walk test (490 ± 119 vs. 564 ± 94 m; p < 0.001); at CPET they sustained lower workload (79 ± 28 vs. 109 ± 34 W; p < 0.001) and reached lower oxygen uptake at peak effort (18 ± 5 vs. 21 ± 5 ml/kg per min; p = 0.003) and at anaerobic threshold (13 ± 3 vs.16 ± 4 ml/kg per min; p = 0.001). The positive predictive value of presence of erectile dysfunction was 0.71 for low peak oxygen uptake (<20 ml/kg per min) and 0.69 for reduced effort capacity (W-max <100 W). Conclusions As indicators of generalized underlying vascular pathology, presence and degree of erectile dysfunction may predict the severity of deterioration of effort tolerance in post-acute myocardial infarction patients. In the attempt to reduce the possibly associated long-term risk, an optimization of type, intensity and duration of cardiac rehabilitation should be considered.

The presence of major depressive symptoms is usually considered a negative long-term prognostic factor after an acute myocardial infarction (AMI); however, most of the supporting research was conducted before the era of immediate reperfusion by percutaneous coronary intervention. The aims of this study are to evaluate if depression still retains long-term prognostic significance in our era of immediate coronary reperfusion, and to study possible correlations with clinical parameters of physical performance. In 184 patients with recent ST-elevated AMI (STEMI), treated by immediate reperfusion, moderate or severe depressive symptoms (evaluated by Beck Depression Inventory version I) were present in 10 % of cases. Physical performance was evaluated by two 6-min walk tests and by a symptom-limited cardiopulmonary exercise test: somatic/affective (but not cognitive/affective) symptoms of depression and perceived quality of life (evaluated by the EuroQoL questionnaire) are worse in patients with lower levels of physical performance. Follow-up was performed after a median of 29 months by means of telephone interviews; 32 major adverse cardiovascular events (MACE) occurred. The presence of three vessels disease and low left ventricle ejection fraction are correlated with a greater incidence of MACE; only somatic/affective (but not cognitive/affective) symptoms of depression correlate with long-term outcomes. In patients with recent STEMI treated by immediate reperfusion, somatic/affective but not cognitive/affective symptoms of depression show prognostic value on long-term MACE. Depression symptoms are not predictors "per se" of adverse prognosis, but seem to express an underlying worse cardiac efficiency, clinically reflected by poorer physical performance.

Aim: To assess the prevalence of depressed heart rate variability (HRV) after an acute myocardial infarction (MI), and to evaluate its prognostic significance in the present era of immediate reperfusion., Methods: Time-domain HRV (obtained from 24-h Holter recordings) was assessed in 326 patients (63.5 ± 12.1 years old; 80% males), two weeks after a complicated MI treated by early reperfusion: 208 ST-elevation myocardial infarction (STEMI) patients (in which reperfusion was successfully obtained within 6 h of symptoms in 94% of cases) and 118 non-ST-elevation myocardial infarction (NSTEMI) patients (percutaneous coronary intervention was performed within 24 h and successful in 73% of cases). Follow-up of the patients was performed via telephone interviews a median of 25 mo after the index event (95%CI of the mean 23.3-28.0). Primary end-point was occurrence of all-cause or cardiac death; secondary end-point was occurrence of major clinical events (MCE, defined as mortality or readmission for new MI, new revascularization, episodes of heart failure or stroke). Possible correlations between HRV parameters (mainly the standard deviation of all normal RR intervals, SDNN), clinical features (age, sex, type of MI, history of diabetes, left ventricle ejection fraction), angiographic characteristics (number of coronary arteries with critical stenoses, success and completeness of revascularization) and long-term outcomes were analysed., Results: Markedly depressed HRV parameters were present in a relatively small percentage of patients: SDNN < 70 ms was found in 16% and SDNN < 50 ms in 4% of cases. No significant differences were present between STEMI and NSTEMI cases as regards to their distribution among quartiles of SDNN ( χ 2 =1.536, P = 0.674). Female sex and history of diabetes maintained a significant correlation with lower values of SDNN at multivariate Cox regression analysis (respectively: P = 0.008 and P = 0.008), while no correlation was found between depressed SDNN and history of previous MI ( P = 0.999) or number of diseased coronary arteries ( P = 0.428) or unsuccessful percutaneous coronary intervention (PCI) ( P = 0.691). Patients with left ventricle ejection fraction (LVEF) < 40% presented more often SDNN values in the lowest quartile ( P < 0.001). After > 2 years from infarction, a total of 10 patients (3.1%) were lost to follow-up. Overall incidence of MCE at follow-up was similar between STEMI and NSTEMI ( P = 0.141), although all-cause and cardiac mortality were higher among NSTEMI cases (respectively: 14% vs 2%, P = 0.001; and 10% vs 1.5%, P = 0.001). The Kaplan-Meier survival curves for all-cause mortality and for cardiac deaths did not reveal significant differences between patients with SDNN in the lowest quartile and other quartiles of SDNN (respectively: P = 0.137 and P = 0.527). Also the MCE-free survival curves were similar between the group of patients with SDNN in the lowest quartile vs the patients of the other SDNN quartiles ( P = 0.540), with no difference for STEMI ( P = 0.180) or NSTEMI patients ( P = 0.541). By the contrary, events-free survival was worse if patients presented with LVEF < 40% ( P = 0.001)., Conclusion: In our group of patients with a recent complicated MI, abnormal autonomic parameters have been found with a prevalence that was similar for STEMI and NSTEMI cases, and substantially unchanged in comparison to what reported in the pre-primary-PCI era. Long-term outcomes did not correlate with level of depression of HRV parameters recorded in the subacute phase of the disease, both in STEMI and in NSTEMI patients. These results support lack of prognostic significance of traditional HRV parameters when immediate coronary reperfusion is utilised., Competing Interests: Conflict-of-interest statement: No author has any conflict of interest to declare.

Background: Depressed heart rate variability (HRV) is usually considered a negative long-term prognostic factor after acute myocardial infarction. Anyway, most of the supporting research was conducted before the era of immediate reperfusion by percutaneous coronary intervention (PCI). Main aim of this study was to evaluate if HRV still retains prognostic significance in our era of immediate PCI., Methods and Results: Two weeks after STEMI treated by primary PCI, time-domain HRV was assessed from 24-h Holter recordings in 186 patients: markedly depressed HRV (SDNN <70ms or <50ms) was present in 16% and in 5% of cases, respectively; patients with left ventricle ejection fraction (LVEF) <40% presented more often SDNN values in the lowest quartile. Physical performance was also assessed, by 6-minute walk tests (6MWT) and by cardiopulmonary exercise test (CPET). After >2years from infarction, occurrence of major clinical events (MCE) was investigated. Cases with or without MCE did not differ by initial HRV parameters; Kaplan-Meier events-free survival curves were similar between patients with lowest quartile SDNN and the remaining ones (χ 2 0.981, p=0.322). By the contrary, events-free survival was worse if patients walked shorter distances at 6MWT (χ 2 6.435, p=0.011), developed poorer ventilatory efficiency at CPET (χ 2 10.060, p=0.002), or presented LVEF <40% (χ 2 7.085, p=0.008)., Conclusions: In primary-PCI STEMI patients, markedly abnormal HRV was found in a small percentage of cases. HRV seems to have lost its prognostic significance, while parameters indicating LV function (LVEF and physical performance) could allow better prognostication in primary-PCI STEMI patients., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: It is known that coronary heart surgery leads to varying degrees of cardiac autonomic derangement, clinically detectable as depression of heart rate variability (HRV) parameters. Few studies report that also surgical replacement of the aortic valve (SAVR) may lead to HRV abnormalities, while very little is known about the autonomic effects obtained after less invasive aortic valve replacement techniques. The study aimed to evaluate HRV after SAVR and to compare it with two less invasive techniques, transapical (TaAVI) and tranfemoral (TfAVI) aortic valve implant., Methods: Time-domain heart rate variability (HRV) parameters have been studied by 24-h Holter ECG in 129 patients after SAVR, in 63 patients after TfAVI and in 19 patients after TaAVI., Results: All HRV parameters were significantly depressed in SAVR, while they were almost completely preserved in TfAVI patients; TaAVI cases showed a somehow intermediate behaviour [(SDNN respectively: 71.0±34.9 vs 95.9±29.5 (p<0.001) vs 84.4±32.6ms (p=ns)]. Mean heart rate during the 24-h Holter was 8% higher in SAVR patients than in both TfAVI and TaAVI patients. The reported results were not correlated with echocardiographic ejection fraction, or presence of abnormal glucose metabolism, or degree of anaemia or treatment with beta-blockers., Conclusions: SAVR leads to profound depression of some cardiac autonomic parameters, while less invasive procedures allow better preservation of HRV. In particular TfAVI does not induce any significant deterioration of HRV parameters and seems to be the strategy of valve implant with less impact on the cardiovascular autonomic system., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

An increasing number of patients with end-stage heart failure are being treated with continuous-flow left ventricular assist devices (cf-LVADs). These patients provide new challenges to the staff in exercise-based cardiac rehabilitation (CR) programs. Even though experience remains limited, it seems that patients supported by cf-LVADs may safely engage in typical rehabilitative activities, provided that some attention is paid to specific aspects, such as the presence of a short external drive line. In spite of initial physical deconditioning, CR allows progressive improvement of symptoms such as fatigue and dyspnea. Intensity of rehabilitative activities should ideally be based on measured aerobic capacity and increased appropriately over time. Regular, long-term exercise training results in improved physical fitness and survival rates. Appropriate adjustment of cf-LVAD settings, together with maintenance of adequate blood volume, provides maximal output, while avoiding suction effects. Ventricular arrhythmias, although not necessarily constituting an immediate life-threatening situation, deserve treatment as they could lead to an increased rate of hospitalization and poorer quality of life. Atrial fibrillation may worsen symptoms of right ventricular failure and reduce exercise tolerance. Blood pressure measurements are possible in cf-LVAD patients only using a Doppler technique, and a mean blood pressure ≤80 mmHg is considered "ideal." Some patients may present with orthostatic intolerance, related to autonomic dysfunction. While exercise training constitutes the basic rehabilitative tool, a comprehensive intervention that includes psychological and social support could better meet the complex needs of patients in which cf-LVAD may offer prolonged survival.

Introduction: Complete denervation of transplanted heart exerts protective effect against postoperative atrial fibrillation; various degrees of autonomic denervation appear also after transection of ascending aorta during surgery for aortic aneurysm., Objective: This study aimed to evaluate if the level of cardiac denervation obtained by resection of ascending aorta could exert any effect on postoperative atrial fibrillation incidence., Methods: We retrospectively analysed the clinical records of 67 patients submitted to graft replacement of ascending aorta (group A) and 132 with aortic valve replacement (group B); all episodes of postoperative atrial fibrillation occurred during the 1-month follow-up have been reported. Heart Rate Variability parameters were obtained from a 24-h Holter recording; clinical, echocardiographic and treatment data were also evaluated., Results: Overall, 45% of patients (group A 43%, group B 46%) presented at least one episode of postoperative atrial fibrillation. Older age (but not gender, abnormal glucose tolerance, ejection fraction, left atrial diameter) was correlated with incidence of postoperative atrial fibrillation. Only among a subgroup of patients with aortic transection and signs of greater autonomic derangement (heart rate variability parameters below the median and mean heart rate over the 75th percentile), possibly indicating more profound autonomic denervation, a lower incidence of postoperative atrial fibrillation was observed (22% vs. 54%)., Conclusion: Transection of ascending aorta for repair of an aortic aneurysm did not confer any significant protective effect from postoperative atrial fibrillation in comparison to patients with intact ascending aorta. It could be speculated that a limited and heterogeneous cardiac denervation was produced by the intervention, creating an eletrophysiological substrate for the high incidence of postoperative atrial fibrillation observed., Competing Interests: No conflict of interest

Background: Cardiac autonomic dysfunction, clinically expressed by reduced heart rate variability (HRV), is present in patients with congestive heart failure (CHF) and is related to the degree of left ventricular dysfunction. In athletes, HRV is an indicator of ability to improve performance. No similar data are available for CHF., Objectives: The aim of this study was to assess whether HRV could predict the capability of CHF patients to improve physical fitness after a short period of exercise-based cardiac rehabilitation (CR)., Patients and Methods: This was an observational, non-randomized study, conducted on 57 patients with advanced CHF, admitted to a residential cardiac rehabilitation unit 32 ± 22 days after an episode of acute heart failure. Inclusion criteria were sinus rhythm, stable clinical conditions, no diabetes and ejection fraction ≤ 35%. HRV (time-domain) and mean and minimum heart rate (HR) were evaluated using 24-h Holter at admission. Patients' physical fitness was evaluated at admission by 6-minute walking test (6MWT) and reassessed after two weeks of intensive exercise-based CR. Exercise capacity was evaluated by a symptom-limited cardiopulmonary exercise test (CPET)., Results: Patients with very depressed HRV (SDNN 55.8 ± 10.0 ms) had no improvement in their walking capacity after short CR, walked shorter absolute distances at final 6MWT (348 ± 118 vs. 470 ± 109 m; P = 0.027) and developed a peak-VO2 at CPET significantly lower than patients with greater HRV parameters (11.4 ± 3.7 vs. an average > 16 ± 4 mL/kg/min). Minimum HR, but not mean HR, showed a negative correlation (ρ = -0.319) with CPET performance., Conclusions: In patients with advanced CHF, depressed HRV and higher minimum HR were predictors of poor working capacity after a short period of exercise-based CR. An individualized and intensive rehabilitative intervention should be considered for these patients.

Background: Transcatheter aortic valve implantation plays a leading role in the management of aortic stenosis in patients with comorbidities but no data are available about cardiac rehabilitation in these subjects. This study aimed to compare safety and efficacy of an early, exercise-based, cardiac rehabilitation programme in octogenarians after a traditional surgical aortic valve replacement versus transcatheter aortic valve implantation., Methods: Seventy-eight consecutive transcatheter aortic valve implantation patients were studied in order to evaluate the effect of an exercise-based cardiac rehabilitation programme in comparison to 80 of a similar age having surgical aortic valve replacement. Functional capacity was assessed by a 6 min walking test on admission and at the end of the programme. When possible, a cardiopulmonary exercise test was also performed before discharge., Results: The two groups were similar in terms of gender and length of stay in cardiac rehabilitation; as expected, the transcatheter aortic valve implantation group had more comorbidities but no major complications occurred in either group during rehabilitation. All patients enhanced autonomy and mobility and were able to walk at least with the assistance of a stick. In those patients who were able to perform the 6 min walking test, the distance walked at discharge did not significantly differ between the groups (272.7 ± 108 vs. 294.2 ± 101 m, p = 0.42), neither did the exercise capacity assessed by cardiopulmonary exercise test (peak-VO2 12.5 ± 3.6 vs. 13.9 ± 2.7 ml/kg/min, p = 0.16)., Conclusions: Cardiac rehabilitation is feasible, safe and effective in octogenarian patients after transcatheter aortic valve implantation as well as after traditional surgery. An early cardiac rehabilitation programme enhances independence, mobility and functional capacity and should be highly encouraged., (© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Axial-flow left ventricular assist devices (LVADs) are increasingly used as destination therapy in end-stage chronic heart failure (CHF), as they improve survival and quality of life. Their effect on exercise tolerance in the early phase after implantation is still unclear. The aim of this study was to evaluate the effect of LVADs on the exercise capacity of a group of CHF patients within 2 months after initiation of circulatory support. Cardiopulmonary exercise test data were collected for 26 consecutive LVAD-implanted CHF patients within 2 months of initiation of assistance; the reference group consisted of 30 CHF patients not supported by LVAD who were evaluated after an episode of acute heart failure. Both LVAD and reference groups showed poor physical performance; LVAD patients achieved lower workload (LVAD: 36.3 ± 9.0 W, reference: 56.6 ± 18.2 W, P < 0.001) but reached a similar peak oxygen uptake (peak VO2 ; LVAD: 12.5 ± 3.0 mL/kg/min, reference: 13.6 ± 2.9 mL/kg/min, P = ns) and similar percentages of predicted peak VO2 (LVAD: 48.8 ± 13.9%, reference: 54.2 ± 15.3%, P = ns). While the values of the O2 uptake efficiency slope were 12% poorer in LVAD patients than in reference patients (1124.2 ± 226.3 vs. 1280.2 ± 391.1; P = ns), the kinetics of VO2 recovery after exercise were slightly better in LVAD patients (LVAD: 212.5 ± 62.5, reference: 261.1 ± 80.2 sec, P < 0.05). In the first 2 months after initiation of circulatory support, axial-flow LVAD patients are able to sustain a low-intensity workload; though some cardiopulmonary exercise test parameters suggest persistence of a marked physical deconditioning, their cardiorespiratory performance is similar to that of less compromised CHF patients, possibly due to positive hemodynamic effects beginning to be produced by the assist device., (Copyright © 2013 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Purpose: In congestive heart failure (CHF) patients, a profound cardiac autonomic derangement, clinically expressed by reduced heart rate variability (HRV), is present and is related to the degree of ventricular dysfunction. Implantation of a left ventricular assist device (LVAD) can progressively improve HRV, associated with an increased circulatory output. Data from patients studied at different times after LVAD implantation are controversial. The aims of this study were to assess cardiac autonomic function in the early phases after axial-flow LVAD implantation, and to estimate the potential relevance of recent major surgical stress on the autonomic balance.
, Methods: HRV (time-domain; 24-h Holter) was evaluated in 14 patients, 44.8 ± 25.8 days after beginning of Jarvik-2000 LVAD support; 47 advanced stage CHF, 24 cardiac surgery (CS) patients and 
30 healthy subjects served as control groups., Inclusion Criteria: sinus rhythm, stable clinical conditions, no diabetes or other known causes of HRV alteration.
, Results: HRV was considerably reduced in LVAD patients in the early phases after device implantation in comparison to all control groups. A downgrading of HRV parameters was also present in CS controls. Circadian oscillations were highly depressed in LVAD and CHF patients, and slightly reduced in CS patients.
, Conclusions: In CHF patients supported by a continuous-flow LVAD, a profound cardiac dysautonomia is still evident in the first two months from the beginning of circulatory support; the degree of cardiac autonomic imbalance is even greater in comparison to advanced CHF patients. The recent surgical stress could be partly linked to these abnormalities.

Background: An abnormal glucose tolerance (AGT) in coronary artery disease (CAD) patients could negatively influence recovery after an acute event but the question, relevant in the field of cardiac rehabilitation (CR), is still controversial., Design: Prospective study, aiming to establish the prevalence of AGT and its possible influence on functional recovery in CAD patients without a previous diagnosis of diabetes mellitus (DM)., Methods: An oral glucose tolerance test was performed on 230 CAD patients without known DM, submitted to a 2-week period of intensive exercise-based CR after a recent acute myocardial infarction or coronary artery bypass graft. Functional capacity was assessed by a cardiopulmonary exercise test (CPET) and by 6-minute walking tests (6MWT) performed both on admission and at discharge., Results: The prevalence of AGT in our population was 53%. Exercise capacity was lower in AGT patients (maximum workload achieved at CPET 79.3 ± 29.9 vs. 91.8 ± 36.9 W, p = 0.01; peak-VO(2) 17.8 ± 4.7 vs. 19.8 ± 5.6 ml/kg/min, p = 0.01). In the subgroup of AGT patients characterized by an inferior walking capacity at baseline, the increment in the distance walked was less than in the controls (Δ6MWT: 81.9 ± 60.1 vs. 109.1 ± 72.1, p = 0.04). An independent, negative, association was observed between AGT and Δ6MWT in patients with lower baseline test, and between maximum workload and peak-VO(2) in the whole population., Conclusions: A high prevalence of AGT was observed in a population of CAD patients without known DM after an acute coronary event. AGT is associated to a lower functional recovery, and to a reduced exercise capacity at the end of CR.

Background and Aims: Anemia seems to be rather common in cardiac rehabilitation patients but it is not known whether it could influence cardiovascular performance indexes and prognosis immediately after an acute cardiac event. The purposes of this study were to define its prevalence and to investigate the safety and efficacy of an intensive exercise-based cardiac rehabilitation in patients with and without anemia., Methods: 436 participants (77% males; mean age 64 ± 13 years) were submitted to a two-week cardiac rehabilitation program consisting of low to medium intensity, individualized training with respiratory, aerobic and calisthenic exercises (three sessions daily, six times per week). A six-minute walking test was performed at enrolment and repeated at discharge together with a cardiopulmonary test., Results: Anemia, as defined according to World Health Organization criteria, was detected in 328 patients (75.2% of the entire population). The distance walked increased from 381 ± 117 m at baseline to 457 ± 110 m (p < 0.001) after a mean period of 12.4 ± 4 days. A direct correlation was found between hemoglobin concentrations and both the absolute distance walked (r = 0.48; p < 0.001) and peak VO(2) (r = 0.39; p < 0.001). Anemic patients walked a significantly shorter distance at baseline and at discharge (p < 0.001); however, both groups showed the same increment in the distance walked: 76.0 ± 61 m vs 76.0 ± 60 m (p = 0.99)., Conclusions: Our data indicate: 1) a high prevalence of anemia in the study population and 2) that, in spite of a clear reduction in exercise capacity, a moderate anemia does not preclude increments in cardiac performance during a short period of intensive, exercise-based cardiac rehabilitation.

Aim: HIV infection causes cardiac autonomic neuropathy (CAN); little is known about the relevance of CAN in sub-Sahara African patients, in spite of the highest prevalence of AIDS in that population. The authors assessed prevalence rates of CAN in HIV-positive treatment-naïve African patients and investigated the correlation between degree of immunodeficiency and CAN., Methods: Thirty HIV-positive patients and 11 HIV-negative controls underwent a battery of cardiovascular autonomic function tests; the Ewing-Clarke score was calculated along with the stage of severity of CAN. The patients' immunological status was evaluated by CD4 T-lymphocytes counts., Results: During paced respiration of normal depth, the patients showed shorter baseline RR intervals (739.2+/-136.0 vs 846.2+/-88.7 ms; P<0.05), with an inverse correlation with CD4 counts, and lower heart rate variability (85.3+/-73.0 vs 123.0+/-46.2 ms; P<0.02). Although patients with lower CD4 counts tended to present blunted response to hand-grip and cold-face tests, no linear correlation was found between results of cardiovascular reflex tests and CD4 counts. Eight patients (27%) obtained borderline Ewing-Clarke scores; 9 patients resulted affected by early (6 pts, 20%) or intermediate (3 pts, 10%) stage of CAN., Conclusion: Signs of HIV-related CAN are present in 30% of the African HIV+ patients observed, with no direct correlation to their immunological status. Based on the relevance of the problem and the presence of signs of CAN even in newly diagnosed and treatment-naïve patients, the authors suggest that all HIV-patients should be screened for the presence of the complication, in view of the possible serious events associated with it.

Background: Human immunodeficiency virus (HIV) infection is associated with autonomic neuropathy. The resultant autonomic dysfunction impairs quality of life and can have fatal consequences. Our aim was to clearly define the symptoms of autonomic dysfunction in African HIV-positive patients and determine whether these symptoms were related with (a) autonomic reflex responses (b) the degree of immunosupression., Methods: Thirty-one HIV-positive treatment-naïve African patients (mean CD4 cell count 269.5 +/- 253.4/mm3) and 12 healthy controls completed a detailed questionnaire (Autonomic System Profile, Mayo Clinic, Rochester, MN) relating to specific symptoms of autonomic dysfunction. After completion of the questionnaire, subjects underwent a standard battery of autonomic reflex tests., Results: The autonomic symptom score was higher in the male HIV-positive patients (26.7 +/- 14.7 points) and female patients with CD4 <200/mm3 (24.7 +/- 18.0) than sex-matched controls (male controls, 9.9 +/- 6.8, P < 0.05; female controls, 8.8 +/- 10.1; P < 0.05). Six patients had scores indicative of severe autonomic dysfunction (>43.8 points). The most common autonomic symptoms were: orthostatic intolerance, secretomotor and gastrointestinal dysfunction. There was no relationship between CD4 cell counts and autonomic symptom scores. The blood pressure response to sustained handgrip was blunted, but all other cardiovascular reflex tests were within the normal range or borderline., Conclusion: African HIV-positive patients report symptoms of autonomic dysfunction, despite normal or borderline autonomic reflex responses.

Pharmacokinetic and pharmacodynamic properties were studied after intravenous administration of ajmaline 1 mg/kg in an anuric patient, who underwent the electrophysiological ajmaline test. The magnitude and rate of onset of the typical electrophysiological effects of ajmaline (prolongation in atrio-Hisian and His-ventriculum conduction times) were within the range of normal values. The plasma concentration curve showed a triexponential decay with half-lives as follows: initial phase (t1/2 alpha) 1.34 min, fast elimination phase (t1/2 beta) 10.13 min and terminal (slow) phase (t1/2 gamma) 258.6 min. Other relevant pharmacokinetic parameters calculated were: total plasma clearance 45.91 L/h; volume of distribution 285.6L; protein binding 47%. Five hours after administration the patient underwent a 3.5h haemodialysis without any substantial increase in the slope of the final elimination phase of the curve. A major problem in interpreting the pharmacokinetic results is the lack of reliable reference data in healthy subjects. It is likely that the ajmaline t1/2 reported in the literature (13.4 min) does not reflect the true terminal t1/2 of the drug, because it was determined during an unduly short sampling period (30 min). Nevertheless, if we compare just the first 30 min of the concentration-time curves, our results are nearly superimposable on those found in healthy subjects.

The acute effects of ibopamine (active ingredient of Inopamil), an orally active dopaminergic agent, were invasively evaluated in 16 consecutive patients with idiopathic dilated cardiomyopathy (New York Heart Association Functional Class II and III) Single doses of 100 and 200 mg were administered to 7 and 9 patients, respectively, and two repeated doses of 100 mg were studied in 6 patients. In order to assess the onset of cardiovascular effect, control hemodynamic measurements were repeated 5, 10, 15, 20, 30, 60, 120, and 180 min after ibopamine 200 mg. Both the tested doses of ibopamine increased the mean pulmonary arterial pressure and the mean pulmonary wedge pressure, with a maximal effect 15 min after drug ingestion (+ 47.0 and + 65.4% in the 200 mg group, p less than 0.002). Pulmonary pressures returned to baseline or lower values beyond 60 min. Systemic arterial pressure showed a small transient increase (+ 7.9% in the 200 mg group at 15 min), but fell significantly below baseline after 120 min, a larger decrease occurring in the 100 mg group (p less than 0.05). Ibopamine had a slower but more prolonged effect on cardiac output (increase of up to 32.1% at 60 min) and systemic vascular resistances. Repeated doses (100 mg after an 8-h interval) elicited comparable cardiovascular effects. Oral ibopamine caused a significant increase in mean pulmonary arterial and capillary pressures as early as 5 min after drug ingestion, before cardiac output and peripheral vascular resistances were affected. A biphasic hemodynamic response was also observed after single and repeated low (100 mg) doses of ibopamine.

After D.C. countershock to terminate cardiac arrhythmias, in 3 out of 8 patients studied, an increase in both plasma myoglobin (Mb) and CK-MB (assessed by radioimmunoassay) was found. In 2 patients there was an increase of only plasma Mb and in 1 an increase of only CK-MB. In 2 cases no increase of either parameters was found. It is suggested that the radioimmunoassay technique for measuring Mb and CK-MB might have a greater reliability than other techniques for the detection of myocardial damage.

Phonocardiographic examination was carried out in 40 patients who had undergone to aortic valve replacement with the Björk-Shiley prothesis. The regular function of the prothesis was evaluated on the basis of the physical, radiological and electrocardiographic data. In the majority of the cases the first sound was slight. The prosthetic closing sound was made of two components (a2, A2) and the opening sound by one or more components (C1, C2, C3). A sistolic aortic murmur was always present, and a diastolic murmur has been found in 20% of the cases.

symptomatic dilated cardiomyopathy were studied in order to evaluate the effect of long term sympathetic beta-blockade with metoprolol. Clinical evaluation, stress test, two-dimensional echocardiography, 24 hour ambulatory electrocardiography and hemodynamic assessment with Swan-Ganz catheter were performed before enrollment in the study. Patients were randomly assigned to the relative placebo (8 pts) or metoprolol group (12 pts) in a single-blind fashion. The placebo group received standard therapy (digitalis, diuretics, vasodilators and anticoagulants as needed), while the metoprolol group, along with standard therapy received low-dose beta-blockade, starting with 6.25 mg twice daily and then doubling every 4 days on the two daily administrations. The therapeutic end-point was 100 mg. Patients received less than 100 mg if their systolic blood pressure was less than 100 mmHg or if their resting heart rate was less than 55 beats/min. Patients were clinically assessed every month and a 24-hour electrocardiography, echocardiography and hemodynamic control was repeated after six months. In the metoprolol group there was one sudden death and two drop-outs.(ABSTRACT TRUNCATED AT 250 WORDS)

Fifty-five patients were hospitalized in a Coronary Care Unit within the first 24 hours after onset of symptoms of an acute myocardial infarction. The sum of positive and negative ST-segment deflections of their twelve leads electrocardiograms (epsilon ST12) showed a maximum within the 3rd hour from the onset of symptoms. Thereafter, in the first 24 hours, there was a marked reduction in epsilon ST12, with a steep and significant fall within the 7th hour from symptoms. In the following nine days of this study, the patients showed 4 different epsilon ST trends, but there was no significant correlation with CPK curves, or with the kind of therapy the patients underwent. An irregular trend of epsilon ST12 or a secondary late rise (after 36 hours from symptoms) suggest an unfavorable prognosis (1 death in the epsilon ST-3 group, and 2 deaths + 1 ventricular fibrillation in the epsilon ST-4 group). No significant difference results between the patients treated with high doses Heparin plus Acetyl-Salicylic-Acid (A.S.A.), and the patients treated with A.S.A alone, though the first treatment seems to reduce the values of epsilon ST12 more rapidly; perhaps this behaviour is due to the use of antiplatelet drug A.S.A in both groups, and to the relatively small number of patients.