Circulating natriuretic peptide concentrations in patients with end-stage renal disease: role of brain natriuretic peptide as a biomarker for ventricular remodeling.

OBJECTIVES: To determine levels of natriuretic peptides (NPs) in patients with end-stage renal disease (ESRD) and to examine the relationship of these cardiovascular peptides to left ventricular hypertrophy (LVH) and to cardiac mortality. PATIENTS AND METHODS: One hundred twelve dialysis patients without clinical evidence of congestive heart failure underwent plasma measurement of NP concentrations and echocardiographic investigation for left ventricular mass index (LVMI). RESULTS: Plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) concentrations correlated positively with LVMI and inversely with left ventricular ejection fraction, whereas C-type NP and Dendroaspis NP levels did not correlate with LVMI. In dialysis patients with LVH (LVMI >125 g/m2), plasma ANP and BNP concentrations were increased compared with those in dialysis patients without LVH (both P<001). In a subset of 15 dialysis patients without LVH or other concomitant diseases, plasma BNP concentrations were not significantly increased compared with those in 35 controls (mean +/- SD, 20.1+/-13.4 vs 13.5+/-9.6 pg/mL; P=.06), demonstrating that the BNP concentration was not increased by renal dysfunction alone. Furthermore, the BNP level was significantly higher in the 16 patients who died from cardiovascular causes compared with survivors (mean +/- SD, 129+/-13 vs 57+/-7 pg/mL; P<.003) and was significantly associated with greater risk of cardiovascular death in Cox regression analysis (P<.001), as was the ANP level (P=.002). CONCLUSIONS: Elevation of the plasma BNP concentration is more specifically related to LVH compared with the other NP levels in patients with ESRD independent of congestive heart failure. Thus, BNP serves as an important plasma biomarker for ventricular hypertrophy in dialysis patients with ESRD.

Long-term CAPD patients are volume expanded and display more severe left ventricular hypertrophy than haemodialysis patients.

BACKGROUND: Whether hypertension and left ventricular hypertrophy (LVH) are more prevalent in CAPD than in haemodialysis (HD) patients is still under discussion. METHODS: To examine this problem we compared a group of 51 CAPD patients, with a group of 201 HD patients. The evaluation included the measurement of atrial natriuretic peptide (atrial natriuretic factor (ANF)), taken as indicator of volume status, and echocardiographic measurements. RESULTS: CAPD patients were older, had been treated for a shorter time, and had lower serum albumin and phosphate than HD patients. Plasma ANF was higher (P<0.01) in CAPD (median 33.8 pmol/l (interquartile range 18.2-63.0)) than in HD patients (22.7 pmol/l (14.9-38.7)). Similarly, the left atrial volume was substantially higher (P<0.0001) in CAPD patients (49+/-22 ml) than in HD patients (37+/-17 ml), while the left ventricular end-diastolic diameter was similar in the two groups (CAPD 51+/-7 mm; HD 50+/-7 mm). Furthermore, left ventricular hypertrophy was more severe (P<0.0001) in CAPD (157+/-37 g/m(2)) than in HD patients (133+/-39 g/m(2)). The proportion of CAPD patients requiring antihypertensive drugs was markedly higher than that of HD patients (65 vs 38% P<0.001). Multivariate modelling showed that volume expansion and pressure load as well as serum albumin were independent predictors of left ventricular mass. CONCLUSIONS: Left ventricular hypertrophy is more severe in long-term CAPD patients than in HD patients. This finding is associated with evidence of more pronounced volume expansion, hypertension, and hypoalbuminaemia. Volume and pressure load along with factors associated with hypoalbuminaemia may aggravate LVH in uraemic patients on CAPD.

Diagnostic potential of cardiac natriuretic peptides in dialysis patients.

BACKGROUND: In the general population, the plasma concentrations of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) are useful to predict left ventricular hypertrophy (LVH) and LV systolic dysfunction. Whether these cardiac hormones have a similar diagnostic potential in dialysis patients is unknown. METHODS: We studied the diagnostic value of ANP and BNP for alterations in LV mass and function in a cohort of 246 dialysis patients without clinical evidence of heart failure. RESULTS: Both ANP and BNP were independently related to left ventricular mass (P < 0.0001) as well as to ejection fraction (P < 0.0001). In an analysis based on a prospectively defined threshold (95th percentile of the normal range), BNP had a significantly higher (P < 0.01) sensitivity (88%) than ANP (51%) for the diagnosis of LVH, but the positive predictive value of the two peptides was very similar (92 and 87%, respectively, P = NS). However, the negative predictive value of BNP for excluding LVH was 22% higher than that of ANP (53 vs. 31%, P = 0.05). Both natriuretic peptides had a high sensitivity for the detection of LV dysfunction (87 and 94%), but their positive predictive value was low (25 and 15%). Importantly, both ANP and BNP proved to be very useful for excluding this alteration (negative predictive value 97 and 96%, respectively). An analysis based on the "best cut-offs" of each peptide as identified on the basis of the ROC curves augmented the positive and negative prediction values of BNP for the diagnosis of LVH to 95 and 61%, respectively. This approach also raised the BNP-positive prediction value for the identification of LV dysfunction to 31% but did not modify the diagnostic potential of ANP (either for LVH or for LV dysfunction). CONCLUSIONS: Measuring the plasma concentration of cardiac natriuretic hormones, particularly BNP, may be useful for the identification of dialysis patients with LVH or for excluding systolic dysfunction.

Prediction of left ventricular geometry by clinic, pre-dialysis and 24-h ambulatory BP monitoring in hemodialysis patients: CREED investigators.

OBJECTIVE: Arterial hypertension is an established risk factor for left ventricular hypertrophy (LVH) in the uremic population. However, whether 24-h monitoring is a better predictor of LVH than clinic blood pressure and routine pre-dialysis measurements in these patients is still undefined. METHODS: This problem was studied in 64 nondiabetic hemodialysis patients without heart failure. The echocardiographic study as well as the clinic and 24-h ambulatory blood pressure (BP) measurements were performed during the day off-dialysis. Pre-dialysis arterial pressure was calculated as the average value of the 12 routine recordings taken during the month preceding the study. RESULTS: In multivariate models, including also sex, body mass index, hematocrit and serum cholesterol, pre-dialysis systolic, diastolic and pulse pressures were the only independent BP determinants of heart geometry. Twenty-four hour ambulatory BP monitoring (ABPM) did add significant (but weak) information to the prediction of left ventricular internal dimension, i.e. it increased by 9% (P = 0.01) the variance already explained by pre-dialysis diastolic BP and other significant covariates. However, 24-h ABPM did not add any significant and independent explanatory information to the corresponding pre-dialysis measurements for the posterior wall and interventricular septum measurements, and for left ventricular mass (-0.6 to +3.9%; average +1.1%). CONCLUSIONS: In dialysis patients, pre-dialysis BP is at least as strong a predictor of left ventricular mass as 24-h ambulatory monitoring. Thus, the average of 12 routine pre-dialysis measurements may be used to predict heart geometry in dialysis patients without any loss of information in comparison with 24-h ambulatory monitoring.

[Longitudinal echocardiographic study of HIV positive patients]. / Studio ecocardiografico longitudinale in pazienti HIV positivi.

BACKGROUND: From May 1992 to June 1996 the authors have studied a group of 39 subjects with positive anti-HIV, with echo 2D color Doppler examination, to evaluate with semi-annual controls, the wide variety of cardiac complications in the various phases of clinical evolution of the illness. METHODS: At the moment of recruiting, all the subjects with HIV infection were asymptomatic A1 (HIV + As). The patients whose average age was 29 +/- 5, were composed of 60% drug addicts, 17% homosexuals, 8% haemophiliacs and for the 15% heterosexual. RESULTS: The most frequent cardiac complications are represented by hypokinesia of the left ventricle (h-aLV) and by pericardial effusion (PE); more rarely of endocardial vegetations (EV), dilatation of the left ventricle (dLV) and tricuspid insufficiency (TI). The entity of damage and the number of cases observed, are correlated with the grade of clinical severity of the illness. CONCLUSIONS: In accordance with the literature data, cardiac pathologies, particularly in the first phases of the illness, are asymptomatic or paucisymptomatic, making the clinical-instrumental observation of the patient useful also in cardiology.

Helicobacter pylori-positive duodenal ulcer: a long-term double-blind randomized study in patients healed with H2-receptor antagonists.

BACKGROUND: The NIH Consensus Conference in 1994 (1) concluded that all patients with peptic ulcer disease should be tested and treated for Helicobacter pylori and that further evaluation was needed for patients in remission. MATERIALS AND METHODS: We evaluated in a double blind randomization 30 patients whose duodenal ulcers had been healed with H2-receptor antagonists and who remained in remission on maintenance therapy. After ulcer healing and the presence of H. pylori had been confirmed, these patients were randomized to receive eradication therapy or placebo and were followed for a mean period of 23 months. RESULTS: Almost all patients receiving placebo had ulcer recurrence, whereas the patients treated with antibiotics demonstrate a low recurrence rate. CONCLUSION: These data suggest, for the first time to our knowledge, the importance of treating with antibiotics duodenal ulcer patients whose disease is in remission.

Evaluation of left ventricular diastolic function by pulmonary venous and mitral flow velocity patterns in endurance veteran athletes.

More and more older people exercise endurance training. Physical activity regularly exercised has been proven to exert beneficial effects on the cardiovascular system. The aim of the present study was to investigate left ventricular diastolic function by analysis of the pulmonary venous flow velocity pattern (PVFVP) in conjunction with the mitral flow velocity pattern (MFVP) in endurance veteran athletes. The study was performed in 15 trained veteran athletes (mean age 60 +/- 10) and 15 sedentary older subjects (mean age 61 +/- 7). Between the two groups there were no differences of age, body surface area and blood pressure. All subjects were without evidence of cardiovascular diseases. They underwent transthoracal pulsed Doppler echocardiography and the following parameters were measured: early (E) and late (A) peak diastolic filling velocities from mitral flow and E/A ratio; peak forward flow velocities during systole (S) and diastole (D) and peak reverse flow velocity at atrial contraction (Ar) from right upper pulmonary vein. The peak early diastolic filling and E/A ratio resulted significantly increased in the veteran athletes compared with the older sedentary subjects (E 80.0 +/- 13.6 and 62.2 +/- 8.2, respectively, p < 0.01; E/A 1.20 +/- 0.1 and 0.90 +/- 0.1, respectively, p < 0.001), whereas there were no significant differences m the PVFVP between the two groups. Heart rate at rest was significantly lower in the veteran athletes compared with sedentary older subjects (58.3 +/- 8 and 72.8 +/- 7.6, respectively, p < 0.001). These data demonstrate an improvement of left ventricle diastolic function in endurance veteran athletes (E/A ratio > 1 ) in comparison with sedentary older subjects (E/A ratio > 1). Analysis of PVFVP suggests that the left atrial contribution to left ventricular filling increases with aging without any significant differences between the two groups. Therefore, left atrial function, i.e., the main determinant of PVFVP is not likely influenced by training. In conclusion, physical activity was found to attenuate alterations in the cardiovascular system that occur in advanced age by an improvement of left ventricular diastolic filling. These changes at rest may be due to a decreased sympathetic tone, as well as to an improvement of intrinsic properties of myocardium of the endurance veteran athletes.

Importance of training in prevention of the decline of physical performance in elderly sedentary persons and veteran athletes.

Thirty-five male veteran athletes were studied between 55 and 79 years of age, having exercised track-and-field sports in the amateur class for at least 15 years without interruption. These athletes were divided into power and endurance groups. The subjects examined were compared to a male control group of 30 elderly, healthy persons aged between 51 and 77 years, leading a sedentary lifestyle. All the subjects were submitted to a standard protocol using BOSCO ERGOJUMP. These trials permitted us to evaluate in the laboratory the explosive power of the inferior limbs, maximal alactic and lactic capacities. The results obtained suggest interesting correlations between the unwinding of physical activity and a deterioration of explosive and anaerobic power, above all in subjects over 65 years of age. Therefore, a regular training program could attenuate the modifications and the age-associated decline.

Body composition and bone mineral density in competitive athletes in different sports.

Bone mineral density (BMD) of the vertebral spine, appendicular skeleton, and whole body was studied in male athletes who chronically trained by different forms of skeletal loading. Eighteen subjects performed weight-bearing activity (canoeists, n = 18), and 14 performed non-weight-bearing activity (cyclists, n = 14). Twenty-eight age-matched male students served as non-athletic controls. The canoeists had significantly higher spine, pelvic and total body BMD than cyclists and controls. No intergroup difference was observed in the BMD of arms and legs despite the fact that physical activity of canoeists and cyclists were characterized by forceful muscular contractions. It is concluded that weight-bearing activity is essential to obtain beneficial skeletal effects on total and regional bone mass in young subjects.

[An evaluation of the pulmonary venous flow pattern by transesophageal and transthoracic Doppler echocardiography in a normal subject]. / Valutazione del pattern di flusso venoso polmonare mediante ecocardiografia Doppler transesofagea e transtoracica nel soggetto normale.

Transesophageal echocardiographic studies have permitted a pulmonary venous flow velocity pattern to be identified which is comparable to that recorder using invasive methods. The pattern consists of 4 stages: an anterograde systolic flow with an early (S1) and late (S2) peak velocity, a diastolic anterograde flow (D) and a retrograde flow liked to atrial contraction (Ar). The aim of this study was to evaluate the pattern of pulmonary venous flow velocity using transesophageal and transthoracic colour Doppler echocardiography in normal subjects in an attempt to: 1) determine normal values derived from the pulmonary venous flow pattern which may contribute to future studies; 2) find correlations between the pattern of pulmonary venous flow and a number of physiological, hemodynamic and echocardiographic parameters which take account of the morphological variations of this flow pattern within a normal range; 3) demonstrate the possibility of being able to carry out study using transthoracic colour Doppler echocardiography. The study was carried out in 38 normal subjects aged between 15 and 76 years old (mean 45 +/- 15) who underwent transthoracic and transesophageal colour-Doppler echocardiography. The following parameters were measured: left atrium diameter, diameters and telediastolic and telesystolic volumes of the left ventricle, ejection fraction and systolic percentage shortening of the left ventricle, peak velocity of the mitral flow pattern and the pulmonary venous flow pattern. The results obtained show that: 1) the pattern of pulmonary venous flow alters with ageing causing the prevalence of systolic over diastolic peak velocity; 2) the pulmonary venous flow parameters which appear to be most significant in hemodynamic terms are the peak velocities of the early systolic flow and anterograde diastolic flow and the ratios S1/S2 and S2/D; 3) the echocardiographic parameters most closely correlated with the peak velocity of pulmonary venous flow are the dimensions of the left atrium, telediastolic and telesystolic ventricular volumes, and the pattern of transmitral flow; 4) heart rate does not appear to influence the pulmonary venous flow pattern significantly (at least within the range of 50-100 b/min), except for retrograde flow. Similar results were obtained using transesophageal and transthoracic Doppler echocardiography and therefore if future studies succeed in obtaining useful information, of not only speculative but also practical interest, from the evaluation of pulmonary venous flow, these can be obtained using a simple, widespread and completely non-invasive method such as transthoracic Doppler echocardiography.

[Cholesterol bound to high density lipoproteins: critical review of the methods of analysis and personal data]. / Colesterolo legato alle lipoproteine ad alta densita': analisi critica delle metodiche di determinazione e casistica personale.

It is widely known that atherosclerosis through its complication, i.e. heart and brain infarction, is at the present the main cause of death. The atherosclerotic process has been shown in correlation with hyperlipemia especially as far as the plasma lipoprotein cholesterol level is concerned. A preminent role in removing cholesterol from tissues and arterial walls then in preventing atherosclerosis is played by a specific class of plasma lipoproteins, the high density lipoproteins (HDL). Since the HDL-colesterol level seems to have an inverse correlation with the atherosclerotic disease it is of primary importance to define a reliable and reproducible technique to measure it. One of the aims of this paper was to examine the different methods now available for such a determination. This analysis has underlined the discrepancy among the reference values reported in the literature. However, all the authors agree that only the simultaneous measurement of total and HDL-colesterol levels is of prognostic value. Personal studies are here reported on the relationship between total and HDL-colesterol levels and risk factor of cardiovascular diseases. The two mentioned laboratory analyses have been performed on blood samples from 250 between male and female human subjects of different age. The obtained results show that the highest HDL-colesterol concentrations determined by a lipoprotein precipitation procedure with dextran sulphate, are typical in the first ten years of life both in male and in female, while the lowest levels of plasma HDL-cholesterol have been evintiated during the fifth decade of life, when the total cholesterol and the risk of cardiovascular complications rich the highest values. In a following set of investigations, the already examined blood parameters together with the risk factor values have been examined in two groups of subjects, the first one represented by adult healthy persons the second one by patients of similar age from a cardiovascular division. The mean levels of total colesterol have been shown similar in both the experimental groups, while plasma HDL-cholesterol is significantly higher in the healthy group. This discrepancy is the cause of definitively higher risk factors in the hospitalized patients. In conclusion, the reported data furtherly stress that the total cholesterol values do not give "per se" any indication of atherogenic risk. They are useful only when examined together with the HDL-cholesterol levels. From that the opportunity to always include the determination of plasma HDL-cholesterol screening lipemic profiles.