Clinical and Prognostic Significance of Idiopathic Left Bundle-Branch Block in Young Adults.

AIMS: LBBB is rare in healthy young adults, and its long-term prognosis is uncertain. METHODS: 56 subjects (aged <50 years), in whom an LBBB was discovered by chance in the absence of clinical and echocardiographic evidence of heart disease, were collected in a multicenter registry. RESULTS: 69% were males. Mean age at the time of discovery of LBBB was 37 ± 11 years. Mean QRS duration was 149 ± 17 m sec and 35% had left axis deviation. All patients had a normal echocardiogram, except for left ventricular dyssynchrony; 37 patients underwent coronary angiography (30) or myocardial scintigraphy during effort Eriksson and Wilhelmsen (2005), and in all cases obstructive coronary artery disease was excluded. In 2/30 patients who underwent coronary angiography, an anomalous origin of the CX artery from the right coronary sinus was found. Thirty patients underwent cardiac magnetic resonance; in 60% it was normal, while in 40% it revealed late enhancement, which in 33% was localized in the basal septum, suggesting fibrosis of the left bundle branch. During follow-up (12+/10 years, median 10 years) no sudden death occurred. At the end of follow-up, all patients were alive, except for one who suffered accidental death. Two patients (3.5%) underwent PM implantation owing to syncope. The echocardiogram at the end of follow-up revealed LV dysfunction in only one patient. CONCLUSIONS: In young adults without apparent heart disease, LBBB is a heterogeneous condition. In the vast majority of cases, the prognosis is good and no ventricular dysfunction occurs over time. However, as only 18% of our patients were aged >60 years at the end of follow-up, we cannot establish the prognosis in older age-groups.

Heart failure in women and men during acute coronary syndrome and long-term cardiovascular mortality (the ABC-3* Study on Heart Disease) (*Adria, Bassano, Conegliano, and Padova Hospitals).

AIMS: We investigated the gender-based differences in the association between heart failure (HF) during acute coronary syndrome (ACS) and post-discharge, long-term cardiovascular (CV) mortality. METHODS AND RESULTS: The present study included 557 patients enrolled in three intensive coronary care units and discharged alive. HF during ACS was evaluated by Killip class and left ventricular ejection fraction (LVEF). Interaction between gender and HF after 15years of follow up was studied using Cox models including a formal interaction term. Median age was 67 (interquartile range [IQR], 59-75) years, 29% were females, 37% had non-ST elevation myocardial infarction and 32% Killip class>1, and median LVEF was 53% (IQR 46-61). All but five patients were followed up to 15years, representing 5332 person-years. Of these, 40.2% died of CV-related causes. Crude CV mortality rate was higher among women (52.2%) than men (35.3%; P<0.0001). At a univariable level, a negative interaction between female gender and Killip class for CV mortality was found [hazard ratio (HR)=0.51 (0.34-0.77), P=0.002]. In five multivariable models after controlling for age, main CV risk factors, clinical features, post-discharge medical treatment, and mechanical coronary reperfusion, the interaction was significant across all models [HR=0.63 (0.42-0.95), P=0.02 in the fully adjusted model]. LVEF showed no significant hazard associated with female gender on univariable analysis [HR=1.4 (0.9-0.2.0), P=0.11] but did so in all adjusted models [HR=1.7 (1.2-2.5), P=0.005 in the fully adjusted model]. CONCLUSION: Gender is a consistent, independent effect modifier in the association between HF and long-term CV mortality after ACS.

Long-term effect of continuing sports activity in competitive athletes with frequent ventricular premature complexes and apparently normal heart.

The long-term outcome of athletes with frequent ventricular premature complexes (VPCs) and apparently normal heart has not been fully clarified. To evaluate the clinical and prognostic significance of VPCs and the influence of continuing sports activity during follow-up, we studied 120 healthy athletes (96 men; median age 16 years) in whom frequent VPCs (>100 VPCs/24 hours) were discovered by chance during preparticipation screening. All athletes were followed up for a median of 84 months. During follow-up, 96 underwent serial 24-hour Holter recording and 62 underwent serial echocardiography. The median number of VPCs/24 hours on basal Holter was 3,760. During follow-up, 81 athletes continued sports activity, whereas 39 did not. No athlete died or developed overt heart disease. The median number of VPCs/24 hours decreased in both athletes who continued sports activity and those who did not (from 3,805 to 1,124, p <0.0001 and from 5,787 to 1,298, p <0.0001, respectively). During follow-up, left ventricular ejection fraction slightly decreased to <55% in 9 of 62 athletes who, in respect to the remaining 53, had more VPCs/24 hours both in the basal state (12,000 vs 3,880) and during follow-up (10,702 vs 1,368), and a longer follow-up (95 vs 36 months). In conclusion, (1) frequent VPCs in athletes without heart disease have a long-term benign prognostic significance, (2) sporting activity does not modify this benign outcome, (3) during follow-up, the burden of VPCs decreases whether or not subjects continue sports activity, and (4) in 14.5% of athletes, ejection fraction slightly decreases over time.

[Pathophysiology of atrioventricular conduction disturbances in sports practitioners]. / I disturbi di conduzione normali e patologici dello sportivo giovane-adulto.

In athletes practicing endurance sports, atrioventricular conduction disturbances may be physiological. This holds true for first-degree atrioventricular blocks, type 1 second-degree atrioventricular blocks, and slight ventricular activation delays (slurred S wave in V1). On the contrary, right (RBBB) and left bundle branch blocks (LBBB) and fascicular blocks (left anterior [LAH] and left posterior hemiblocks [LPH]), either isolated or associated with RBBB, are rare in asymptomatic athletes. The latter can be the consequence of structural heart disease or primary degeneration of the intraventricular conduction system (Lev-Lenègre disease). In our experience, LPH and LPH+RBBB have always a pattern of familial recurrence. LAH+RBBB may be familial (40-60%). Isolated RBBB is rarely familial. LBBB is never familial. Families with hereditary conduction disorders may also have a history of juvenile sudden death. Patients with LBBB may show coronary artery anomalies. The long-term prognosis of intraventricular conduction disorders in asymptomatic subjects, without apparent heart disease, is unknown.

Anemia does not preclude increments in cardiac performance during a short period of intensive, exercise-based cardiac rehabilitation.

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.

[Anemia and myocardial ischemia: relationships and interferences]. / Anemia ed ischemia miocardica: relazioni ed interferenze.

Of all the pathologies that cause a critical reduction in oxygen supply to the tissues, atherosclerosis is undoubtedly the most frequent. At the coronary level, ischemia causes a critical imbalance in oxygen supply and demand to the myocardium. Protracting this condition induces necrosis since, when the heart surpasses certain limits, it is incapable of modulating its metabolism in relation to the availability of energy substrates. Recently, internists and cardiologists have been examining the role of anemia as a cause or cofactor in the development of myocardial ischemia. The drop in circulating erythrocyte mass and consequent drops in hemoglobin and hematocrit represent obstacles to oxygen transport and delivery to tissues. Tachycardia secondary to anemia leads to a shorter diastolic phase and reduction in arterial pressure, phenomena which are particularly prominent in acute anemia. Such changes can result in serious repercussions for people suffering from coronary disease, leading often to documentable myocardial damages. On the other hand, in chronic anemia the compensation phenomenom--represented by an increase in heart rate, cardiac output, ventricular volume and contractility--requires integrity of the cardiac apparatus, thus explaining the very serious repercussions of the anemic state for cardiac patients. Recently, the possibility of preventing and treating anemia-induced or anemia-exacerbated ischemia has been confirmed in the literature, albeit not unequivocably, demonstrating that this topic deserves particular attention.