[Exercise electrocardiography in the sanitary surveillance of workers with physical strain]. / Elettrocardiografia da sforzo nella sorveglianza sanitaria di lavoratori con impegnativo dispendio energetico.

To evaluate the opportunity of exercise electrocardiography (ECG) in the sanitary surveillance of workers with physical strain, we estimated the energy consumption of the duties of 22 electrical workers (males; age: 35-56 years). They subsequently underwent Treadmill exercise ECG, determining for each worker the maximal METs (multiples of basal metabolism) and the critical potency (P(CRIT)). In one subject, myocardial ischemia arose 9 minutes after the beginning of the test. The others interrupted the test after 7-13 minutes for tiring; 5 of them showed ventricular extra systoles, paired or isolated. Twelve subjects presented arterial hypertension, at rest and/or during exercise. Ergonomic analysis revealed that the occupational duties were between 1.5 and 8.0 METs. The energy consumption of the job on the whole was 4-6 METs (medium intensity). The maximal METs reached by the examined subjects were between 8.8 and 15.6; however, only 11 workers went reassuringly over the 4 METs required by duty analysis at P(CRIT). One subject was declared unfit for the job, and a judgement of partial idoneity was expressed for 3 workers. Preventive and therapeutic indications were given to 12 subjects. Aerobic training was suggested to 10 workers. The study indicates that an ergonomic evaluation is advisable for the most energy consuming occupational duties. In such cases, the sanitary surveillance should include a cardiologic assessment with exercise ECG, reproducing the physical strain of the specific job.

[Management of occupational stress among patients with cardiac diseases]. / Gestione dello stress occupazionale in pazienti cardiopatici.

The object of our study was the evaluation of psycophysic condition, stress perception and coping in a sample of subject in cardiac rehabilitation. Our study recruited 48 worker patients (44 male, M = 50.5 +/- 8.8; 4 female, M = 50.8 +/- 8.7). They were submitted to: 1) cardiac evaluation and rehabilitation in DH regimen; 2) psychological assessment; 3) work's characteristic evaluation. The evaluation were made at the moment of recruitment and six month later 42 subjects went back to work after 81.8 +/- 49 days; 2 subjects had a worsening of their clinic conditions not consistent with an occupational resumption; 4 subjects didn't go back to work. In the 42 worker subjects we have find a significant decrease of anxiety (p < 0.019) and depression levels (p < 0.004); a significant improvement of Quality of Life perception in its physical (p < 0.000) and psychic aspects (p < 0.021) and an improvement about the ability to reorganize the work to better ménage stress (p < 0.012).

[Work outcome evaluation of cardiac surgery patients after rehabilitation training]. / Valutazione dell'outcome ripresa occupazionale di pazienti riabilitati cardioperati.

The aim of this study was to investigate the incidence of job resumption and the influence of clinical, psychological and functional factors in patients who underwent cardiac surgery. 859 patients were evaluated (mean age 66 +/- 9, 72% M, 28% F, 75% retired, 7% housewives and 18% still working) following admission in a Cardiac Rehabilitation Center; within 5 days of cardiac surgery. Six months after surgery, 80% of the patients resumed their previous occupation. The variables which positively influenced the latter were: a) left ventricular ejection fraction > 35% (p = 0.002), average-high education (p = 0.002), younger patients (p = 0.032), absence of complications during the 6 months post-surgery (p = 0.001), having attended frequent educational programs during the rehabilitation period (p = 0.022), a precise knowledge of the illness (p = 0.001), lack of depression (p =0.0001) and anxiety (p = 0.0001). Our data confirm, in accordance with the recent guidelines, the importance of a rehabilitative intervention which comprises physical, educational and psychological support.

Comparison of dobutamine stress echocardiography and exercise stress Thallium-201 SPECT for detection of myocardial ischemia after acute myocardial infarction treated with thrombolysis.

In order to compare the ability of dobutamine stress echocardiography (DSE) and exercise Thallium-201 SPECT to detect myocardial ischemia in patients with myocardial infarction (MI) treated with thrombolysis, 43 prospectively selected patients with MI treated with thrombolysis underwent within 1 month from MI DSE, stress-redistribution-reinjection Thallium-201 SPECT and coronary angiography. The echocardiographic and scintigraphic images were analyzed for the presence of myocardial ischemia using a 11-segment left ventricular model. DSE and exercise Thallium-201 SPECT detected myocardial ischemia in the infarct zone in 72% and 72% (31/43) of patients and ischemia at a distance in 12% (5/43) and 19% (8/43) of patients with a concordance of 67% and 88%, respectively. A significant agreement between DSE and exercise Thallium SPECT was found in the evaluation of the extent of both myocardial necrosis and stress-induced myocardial ischemia. DSE and exercise Thallium SPECT showed similar sensitivity (79 vs 76%), specificity (60 vs 60%) and accuracy (77 vs 74%) for detection of a critical stenosis of the infarct-related artery; there was also no significant difference between the tests in sensitivity, specificity and accuracy for detection of the multivessel disease. In conclusion, initially after thrombolyzed MI, DSE and exercise Thallium-201 SPECT detect myocardial ischemia in the infarct zone in a high proportion of patients and show a similar accuracy for the diagnosis of a critical stenosis of the infarct-related coronary artery and of the multivessel disease.

Assessment of right ventricular function in patients with congestive heart failure by echocardiographic automated boundary detection.

In patients with chronic heart failure, echocardiographic automated boundary detection (ABD) can reliably assess right ventricular function. The measurements obtained by ABD were highly reproducible, strongly correlated with radionuclide right ventricular ejection fraction, and superior to those obtained by conventional manual echocardiographic methods.

[Cardiomyoplasty. Critical review of experimental and clinical results]. / Cardiomioplastica. Revisione critica dei risultati sperimentali e clinici.

Cardiomyoplasty (CMP) is a surgical therapy for dilated cardiomyopathy. In this procedure the "latissimus dorsi" is wrapped around the heart and chronically paced synchronously with ventricular systole. CMP has been performed in more than 500 cases worldwide, 42 cases in Italy, with variable degrees of success. Despite symptomatic improvement in the majority of patients surviving the procedure, objective hemodynamic effects have not been consistently demonstrated. The hemodynamic effect of CMP has been the subject of a great deal of experimental and clinical research over the past decade. This article discusses in detail the published results of experimental and clinical cardiomyoplasty, with particular emphasis on hemodynamic effects and limitations of the procedure.

Left ventricular filling pattern and pulmonary wedge pressure are closely related in patients with recent anterior myocardial infarction and left ventricular dysfunction.

To determine whether mitral flow velocity can be used to estimate mean pulmonary wedge pressure (PWP) in patients with left ventricular dysfunction, 50 patients with recent Q-wave anterior infarction and a reduced ejection fraction (less than 40%) underwent simultaneous pulsed-wave Doppler measurements of mitral flow and right heart catheterization. Doppler tracings and PWP were recorded at rest, after passive leg lifting (45 degrees) and (in 15 patients with increased PWP) after 5 mg sublingual ISDN. Significant correlations were found between the ratio of peak early to peak late diastolic velocity (E/A) and PWP (r = 0.83). Early diastolic deceleration and the ratio of the time velocity integral of atrial contribution to the total time velocity integral were also correlated to PWP (r = 0.80 and r = 0.79 (respectively). The E/A ratio was less than 1 in 25 patients and more than 1 in the remaining 25. An E/A ratio of at least 1 predicted a PWP of more than 20 mmHg with a sensitivity of 100% and a specificity of 86%. In all five patients, in whom the PWP was less than 20 mmHg at baseline and became greater with leg lifting, the E/A ratio changed from less than 1 to more than 1. After ISDN, changes in E/A ratio from more than 1 to less than 1 identified all 12 patients with a PWP falling below 20 mmHg. In conclusion, patients with recent Q-wave anterior infarction and a reduced ejection fraction mitral flow velocity-derived variables correlate with PWP representing a reliable index for the diagnosis of markedly increased PWP.(ABSTRACT TRUNCATED AT 250 WORDS)

Left atrial appendage dysfunction: a cause of thrombosis? Evidence by transesophageal echocardiography-Doppler studies.

The blood flow velocity patterns within the left atrial appendage were studied by transesophageal color flow imaging and pulsed Doppler in 84 patients. At the time of the study, 57 of the patients were in sinus rhythm, 25 were in atrial fibrillation, and two were in atrial flutter. The relationships between atrial rhythm, blood flow pattern and the presence/absence of spontaneous echocardiographic contrast or thrombus within the appendage were investigated. Transesophageal echocardiography allowed recording of blood flow velocities in 81 of the 84 patients studied. In 51 of the 55 patients in sinus rhythm the pulsed Doppler study showed a biphasic blood flow pattern, whereas a multiphasic pattern was found in the two patients with atrial flutter and in 14 patients with atrial fibrillation. In four patients with sinus rhythm and 10 patients with atrial fibrillation, no significant blood flow velocity could be detected. Thrombus or spontaneous echocardiographic contrast were found within the left atrial appendage in 20 patients, and in all these patients blood flow was either absent or significantly reduced. Our findings indicate that an absent or low blood flow velocity within the left atrial appendage represents a predisposing factor for thrombosis. Isolated left atrial appendage dysfunction has been documented in four patients during sinus rhythm, which may lead to thrombosis. This observation may offer an explanation for cardioembolic events that occur occasionally in patients without apparent heart disease and sinus rhythm.

The effects of physical training in post-myocardial infarction patients with exercise-induced silent ischaemia.

To assess the clinical significance of monitoring during physical training in post-myocardial infarction (MI) patients with asymptomatic exercise-induced ischaemia, we studied 232 patients who were survivors of first recent acute MI and consecutively admitted to the same CCU, who underwent an exercise test (ET) and coronary angiography within two months of the acute event. We selected the 97 patients with multivessel disease. Among them, 60 showed a negative ET and no angina; 37 showed a positive ET with significant ST segment depression, 32 of them had no angina. The 37 patients with positive ET repeated the stress test within a week. In eight of them, the two ETs differed because ischaemia was induced once with and once without precipitation of angina, while the workload (WL) and double product (DP) at the ischaemic threshold of 0.1 mV ST segment depression were not different. During a four-week training period, seven of the asymptomatic patients complained of effort angina and three of angina at rest. To assess training effects, we selected 60 non-consecutive patients with asymptomatic (38) and symptomatic (22) exercise-induced ischaemia. All the symptomatic and 25 asymptomatic patients followed a four-week physical training programme based on the ischaemic threshold. The remaining 13 asymptomatic patients did not undergo physical training. The pre-training period ergometric patterns were comparable between painful and pain-free patients. Training resulted in a similar increase in the WL at the ischaemic threshold (+45% in asymptomatic and +47% in symptomatic patients, both P less than 0.05), without any difference in the DP threshold.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reproducibility of ergometric parameters at the ischemic threshold: study of 160 patients with effort coronary insufficiency]. / Riproducibilità dei parametri ergometrici rilevati alla soglia ischemica: studio su 160 pazienti con insufficienza coronarica da sforzo.

To assess the reproducibility of ergometric parameters at the ischemic threshold, 160 patients, with coronary artery disease and exercise-induced S-T segment depression (102 with previous AMI), were evaluated by means of two control exercise tests performed, in pharmacological wash-out, on different days within 48 hours. The mean values of work load (WL), heart rate (HR) and double product (DP) did not show any statistical difference between the two exercise tests at 0.1 mV S-T depression (ischemic threshold), recorded by a computer assisted electrocardiograph system (Marquette CASE); on the contrary blood pressure (BP) slightly, but significantly (p less than 0.05) decreased at the second test (173.9 +/- 27.2 vs 179.8 +/- 25.8). The variability of the DP values in each subject at 0.1 mV S-T depression, expressed as numerical (delta) and percentage (delta %) differences, exhibited normal distributions. The delta DP showed a mean +/- 1 SD of -157.5 +/- 3271.5 beats x mmHg/min and the delta % DP a mean of +/- 1 SD of 1.46 +/- 16.4%. The values within a standard deviation from the mean (from +3114 to -3429 when numerical differences and from +17.8 to -14.9 when percentage differences) were used for defining the reproducibility of the ischemic threshold. No correlation was found between the delta % DP and the percentage differences in work load at the ischemic threshold. So, DP being more strictly related to MVO2, appears more apt in defining the ischemic threshold reproducibility. A good correlation (r = 0.821) was found between delta DP and delta % DP.(ABSTRACT TRUNCATED AT 250 WORDS)

Does the study of anaerobic metabolism give quantitative information on left ventricular dysfunction during exercise?

The anaerobic threshold (AT) has been proposed as an index to assess the functional status of patients with chronic heart failure. The focus of this report was to evaluate in post-myocardial infarction patients the utility of the AT for (a) assessing the severity of exercise-induced left ventricular impairment, (b) determining the responses obtained from different treatments and (c) prescribing exercise training. We found that the AT level was lower in patients with abnormal haemodynamic patterns during exercise. The AT was correlated to different degrees of exercise-induced left ventricular impairment. The nitrate and calcium-antagonist effects have been evaluated in patients with abnormal exercise haemodynamics. The resting and exertional results were in agreement with the vasodilator effects. Moreover, the time from onset of exercise to the appearance of the AT was significantly increased by the treatments. Thus, AT during pharmacological treatments may be a non-invasive useful parameter for assessing their haemodynamic effects. Finally, a 4-week intermittent training programme based on AT level was evaluated in patients with abnormal resting and exertional haemodynamics. The results showed an improvement of the exercise cardiovascular tolerance without negative effects on left ventricular function. Therefore, the AT seems to be useful when prescribing a rational and individualized training programme.

[Left ventricular aneurysm in recent myocardial infarction. Echocardiographic study]. / L'aneurisma ventricolare sinistro nell'infarto miocardico recente. Studio ecocardiografico.

UNLABELLED: Detection of post-infarction left ventricular aneurysm may have important clinical and therapeutic consequences. Differences in selection and in diagnostic criteria account for the wide range of incidence of left ventricular aneurysm in angiographic and autopsy series. To assess the incidence and related pathological features of ventricular aneurysm, 410 consecutive patients were studied by two-dimensional echocardiography 3 to 8 weeks after the onset of an acute myocardial infarction. In 395 patients (96.3%) technically adequate echograms were obtained: 42 patients (10.6%) had evidence of left ventricular aneurysm defined as a well demarcated bulge in diastole and in systole with a thinned, a-diskinetic walls. The incidence rate of left ventricular aneurysm was 17% in 188 anterior myocardial infarctions, 1.9% in 157 inferior ones, 25.9% in 27 anterior plus inferior infarctions; ventricular aneurysms were not found in any of 15 lateral and 8 posterior myocardial infarctions. Aneurysms were apical or apical-anterior in 25 patients (59.5%), apical-septal in 8 (19%), apical-diaphragmatic in 3 (7.1%), apical-septal-diaphragmatic in 3 (7.1%) and postero-basal in 3 (7.1%). Intraaneurysmal thrombi were detected in 24 patients (57.1%). In 12 cases echograms showed pericardial effusion; this was more frequent (28.6%) than in patients without an aneurysm (7.9%; p less than 0.001). Among patients with an aneurysm, heart failure was present in 19 (45.2%), mitral regurgitation in 3 (7.1%), of systemic emboly in 4 (9.5%), severe ventricular arrhythmias in 4 (9.5%) and angina in 5 (11.9%). IN CONCLUSION: left ventricular aneurysm is a frequent early complication of myocardial infarction. Two-dimensional echocardiography provides non-invasive direct information on localization, extent and related pathological features of ventricular aneurysm and thus appears to be a useful screening technique.

Is old age a contraindication to cardiac rehabilitation after acute myocardial infarction?

Fifty male patients older than 65 years of age (mean 66.3) underwent a symptom-limited exercise test on an average of 34 days after acute myocardial infarction. After 4 weeks of supervised rehabilitation training and after one-year follow-up, the patients underwent controlled exercise tests. The ergometric parameters were compared with respective values in 10 healthy males (mean age 66.4, range 65-75). The rehabilitation training induced a substantial improvement in physical capacity (total work from 3149 +/- 1326 to 4791 +/- 1403 kg; P less than 0.001) with a better cardiovascular response: increased maximum oxygen pulse (from 8.97 +/- 2 to 10.7 +/- 2; P less than 0.001), decreased heart rate (from 120.5 +/- 16.1 to 111.3 +/- 14.7 beats min-1; P less than 0.05) and a decreased double product at a 75 W work load (from 22 866 +/- 4005 to 20 472 +/- 3982 beats min-1 mmHg; P less than 0.05). The recovery of physical capacity and cardiovascular tolerance in the physical exercise was nearly complete as compared with healthy subjects of the same age. During the training period one patient died from heart failure. In all the other patients the same improvement was still maintained one-year later. In conclusion, old age does not seem to be per se a contraindication to cardiac rehabilitation. Physiological beneficial effects from cardiac rehabilitation can also be received by patients older than 65 years of age.

Exertional hypotension after myocardial infarction.

A retrospective study was conducted on 488 patients admitted in our rehabilitation center after a recent acute myocardial infarction. Purpose of the study was to assess the incidence and prognostic value of exertional hypotension in these patients. Of 488 patients admitted to the study 33 (6%) were found to have exertional hypotension; 14 patients had an inferior myocardial infarction, 18 patients had an anterior myocardial infarction, 3 patients had a history of previous myocardial infarction. In the follow-up period (28.3 +/- 13.2 months) the worse prognosis (death or pulmonary oedema) was associated with the presence during exercise of hypotension, ST segment elevation in leads were Q waves were present and no ST depression in other leads. In conclusion, recent anterior myocardial infarctions associated with hypotension and ST segment elevation during exercise appear to be at risk for future cardiac events.

[The cost of energy and cardiovascular expenditure in basketball players during a game]. / Stima dell'impegno energetico e cardiovascolare del giocatore di basket nel corso di una gara.

Energy expenditure was evaluated for 6 Basket players while exercising on a cyclergometer. Oxygen consumption (VO2), pulmonary ventilation (VE), heart rate (HR), respiratory quotient (QR) and other parameters were estimated at various levels of load (25 Watt each step of 3 minutes duration), till to submaximal load of 175 Watt. The same subjects participate to a regular Basket game and their heart rate was continuously stored on a tape recorder (Holter). Arterial blood pressure was also taken whenever possible (timeout, etc). From the laboratory and field data, estimates were made for the oxygen consumption together with energy cost of the game. This can be assume a net value of 0.1339 Kcal X Kg-1 X min-1.

[The peripheral component during dynamic muscular exertion: study of a group of basketball players]. / La componente periferica nel corso dell'esercizio muscolare dinamico: studio su un gruppo di cestisti.

The peripheral factor (PF), i.e. the ratio: artero-venous oxygen extraction to total peripheral resistences, has been studied in a total of 8 professional basket players under controlled work-load conditions. The results obtained by continuous monitoring heart rate, oxygen consumption, pulmonary ventilation, arterial blood pressure etc, have shown that from 0 to 150 watt work-load, the PF increases linearly showing a slope of 83 degrees, whereas from 150 to 200 watt the pendence reduces up to 45 degrees. The absolute value of PF from a resting value of 3.83 mlo2 X min-1 X mmHg-1 increases up to 21,64 (at 150 watt) and to a maximum of 23.45 mlo2 X min-1 X mmHg-1 at 200 watt. The slope of the first range of load (83 degrees) is quite similar to what previously observed in endurance athletes (cyclists) whereas the 45 degrees angular coefficient indicates that the increased energy demand in basket-players can be obtained only with a large cardiac load.