Haemodynamic changes early in prodromal symptoms of vasovagal syncope.

AIMS: Vasovagal syncope (VVS) is often preceded by prodromal symptoms. The haemodynamic changes occurring during the prodrome have not been systematically investigated. The aim of the present study was to investigate the behaviour of blood pressure (BP), heart rate (HR) and sympathetic activity at the beginning of the prodrome in patients with tilt-induced VVS. METHODS AND RESULTS: Sixty-three patients with VVS underwent tilt testing. BP and HR were measured and blood samples for plasma catecholamine determination were obtained during the test. Twenty-seven patients developed syncope of whom all had a prodrome. From the last scheduled measurement before prodromal symptoms to the beginning of the prodrome, both systolic and diastolic BP decreased in all patients (from 105 +/- 16 to 74 +/- 20 mmHg, P<0.001, and from 68 +/- 13 to 51 +/- 12 mmHg, P<0 001, respectively) and HR decreased in 18 (67%) (from 89 +/- 22 to 80 +/- 25 beats/ min P<0 02). At the onset of loss of consciousness both BP and HR showed a further decrease (P<0.001). Plasma adrenaline significantly increased from the last sample before prodromal symptoms to the beginning of the prodrome (P<0.01) and showed a further increase during loss of consciousness (P<0.05), whereas plasma noradrenaline did not increase, as an expression of inhibition of sympathetic neural outflow. CONCLUSION: These results demonstrate that in patients with tilt-induced VVS, BP is consistently decreased at the beginning of prodromal symptoms because of the withdrawal of sympathetic activity, and HR is often reduced, probably because of increased vagal activity. We may infer that similar haemodynamic features also occur during spontaneous VVS.

Role of the serotonergic system in the genesis of vasovagal syncope.

AIMS: The hypotensive reflex responsible for vasovagal syncope appears related to a reduction in sympathetic neural outflow. Several animal studies suggest that serotonin may play a role in the genesis of this reflex, through inhibition of sympathetic activity. However, the role of the serotonergic system is unknown in humans. The purpose of the study was to investigate the role of the serotonergic system in the genesis of vasovagal syncope by means of the level of platelet and plasma serotonin, as well as plasma catecholamines, during tilt-induced syncope. METHODS AND RESULTS: Fifteen patients (age 34 +/- 16 years) with vasovagal syncope underwent a head-up tilt test (HUT, 60 degrees , 45 min). If syncope did not develop, 300 microg nitroglycerin was administered sublingually and patients continued to be tilted for a further 20 min. Blood samples were obtained in the supine position, and then after 3, 10, 15, 30, 45, 48 and 65 min of HUT. If syncope developed, blood samples were obtained at the beginning of the prodrome, during syncope and after the recovery of consciousness. Platelet and plasma serotonin and plasma catecholamines were measured using high-pressure liquid chromatography with electrochemical detection. Ten patients developed syncope during the unmedicated HUT and four after nitroglycerin. In these patients plasma adrenaline significantly increased from the last programmed sample before the prodrome to its beginning and showed a further increase during loss of consciousness, whereas plasma noradrenaline did not increase, as an expression of inhibition of sympathetic neural outflow. In the patients experiencing syncope, both platelet and plasma serotonin showed no significant change after tilt-up, at the beginning of prodrome, during syncope and after recovery of consciousness. CONCLUSION: These results do not suggest that the serotonergic system plays a role in the pathophysiology of vasovagal syncope.

Prominent anterior QRS forces: clinical, electrocardiographic and prospective study.

Recent data suggest that the prominent anterior QRS forces (R greater than or equal to S in V1 and/or V2 leads), in the absence of posterior myocardial infarction, right ventricular hypertrophy, or WPW syndrome, are related to an intraventricular conduction disturbance, at times rate-dependent. We followed 240 subjects with prominent anterior QRS forces and without the above mentioned diseases (study group), (mean age: 44.6 +/- 16 years, mean follow-up: 8 +/- 2 years) and 240 subjects without the anterior displacement (control group), (mean age: 44.4 +/- 14 years, mean follow-up: 7.9 +/- 1.9 years). The age distribution, sex, prevalence of organic heart disease, and follow-up period did not show significant differences between the two groups. QRS duration, prevalence of left ventricular hypertrophy pattern, S1 S2 S3 morphology, terminal r wave in AVR and s wave in V6 were similar in the two groups. During the follow-up period the incidence of right and left bundle branch block and fascicular block was very similar in the two groups of patients. These data suggest that prominent anterior QRS forces do not appear to be related to an initial involvement of the main bundle branches and fascicles and do not increase the likelihood of appearance of an intraventricular block of more advanced degree. The clinical, ECG and prospective data are not helpful in localizing either the ventricle or the area of the ventricle affected by conduction disturbance responsible for the anterior displacement. Our data suggest that the prominent anterior QRS forces express a normal variant of ventricular depolarization and that this finding does not have, per se, any unfavourable clinical implication.

Slight middle slurring in V1-V2 without bundle branch block. An electrocardiographic and follow-up study.

A slight middle slurring in V1 and/or V2 with rS morphology (R less than S) in these leads, without right or left bundle branch block is a nearly ignored electrocardiographic finding. The purpose of this work is to provide a prospective and electrocardiographic analysis of this finding. We followed 200 subjects with middle slurring in V1 and/or V2, in the absence of bundle branch block (study group), (age: 41.5 +/- 19 years, follow-up period: 5.7 +/- 2.5 years) and 200 subjects with rS morphology in V1-V2 without the middle slurring (control group), (age: 39.8 +/- 20 years, follow-up period: 5.2 +/- 2 years). The age, sex, prevalence of organic heart disease, QRS duration and follow-up period did not show significant differences between the two group. In the study group there was a higher prevalence of vertical axis (P less than 0.001), of S1S2S3 morphology (P less than 0.001) and of terminal r wave in a VR (P less than 0.05) compared to control group. During the follow-up period, a right bundle branch block appeared in 19 subjects of study group (incomplete in 15 and complete in 4) and in 2 (complete) of control group (P less than 0.001). A left bundle branch block appeared only in one patient of study group and in one of control group. We conclude that the isolated slight middle slurring in V1-V2 expresses an initial involvement of the right bundle branch system and increases the likelihood of appearance of right bundle branch block.

[Antiarrhythmic treatment with mexiletine in acute myocardial infarction (author's transl)]. / Trattamento antiaritmico con mexiletina nell'infarto acuto.

The effect of an introduced i.v. bolus of 250 mg of mexiletine was checked in cases of acute myocardial infarction with ventricular premature beats. On the 19 observed subjects 17 are male and 2 female: 18 cases with acute myocardial infarction and 1 with acute coronary failure. The introduction of the bolus was followed by an infusion of 0.75 mg/m for the successive four days. After 60 m' no significant changes in arterial pressure and in the heart rate were recorded. The Extrasistolies decrease from 11 +/- 3 to 3 +/- 2/m' (-71%, p less than 0.01); PQ and QT variations were not significant. After four days of infusion, systolic arterial pressure decrease from 135 +/- 4 to 121 +/- 3 (-10%; p less than 0.01), sinusal rate drops from 90 +/- 4 to 80 +/- 3 (-12%, p less than 0.05). The changes of diastolic arterial pressure, PQ and QT were not significant. Extrasistolies disappears entirely. A comparison between a mexiletine and a xilocaine i.v. bolus showed that mexiletine performs a higher antiarrhythmic activity.

[Therapeutical comparison between atenolol and nifedipine in effort angina (author's transl)]. / Comparazione terapeutica fra atenololo e nifedipina nell'angina da sforzo.

In order to assess the therapeutical efficacy of atenolol in stable angina pectoris of effort, we studied 40 patients with a positive exercise stress test. Our double-blind study included a first group of 20 patients treated with atenolol, 100 mg once daily, and a second group of 20 subjects, treated with nifedipine (10 mg 3 times daily). The exercise test was performed before the treatment, after one month of placebo and after one month of therapy with nifedipine or atenolol. The variables examinated were the frequency of anginal chest pain, the quantity of nitroglycerin taken by the patients, the arterial pressure, the heart rate and the double product at the peak of the exercise testing. Differences between the results obtained in the two groups weren't statistically significant.

[The antiarrhythmic effect of metoprolol (author's transl)]. / L'azione antiaritmica del metoprololo.

The antiarrhythmic effect of metoprolol after chronic treatment has been evaluated by 24 hour Holter monitoring in 16 patients with several premature ventricular beats and in 14 patients with chronic atrial fibrillation and compared with the effect of a placebo. Metoprolol induced a mean decrease of heart rate of 14.5% in the 16 patients and reduced the mean value/min of the ventricular premature beats of the 51.2%. In addition the use of metoprolol abolished the ventricular premature beats in 9 cases, while in two cases there was an increase of their frequency. In the 14 patients with chronic atrial fibrillation metoprolol was able to reverse to sinus rhythm three of the patients and in the remaining 11 decreased the ventricular heart rate of the 33%.

[Papillo-sphinctero-plasty in benign obstruction of the terminal choledochus]. / La papillo-sfintero-plastica nell'ostruzione benigna del coledoco terminale.

The indications for papillosphincteroplasty in benign obstruction of the terminal choledochus are explained. This technique is certainly preferable to drainage via a T tube--a method no longer applied in a personal series. Lastly, it is stated that the primary transduodenal approach is better than that via choledochotomy. Excellent results were obtained in 62% of cases, good results in 31%, and poor results due to recurrent cholangitis in 3%. Acute pancreatitis is the most dangerous complication, but was very rarely observed.

[Short-term and median-term effects of tienilic acid in hypertension]. / Effetti a breve e medio termine dell'acido tienilico nell'ipertensione.

Fifty nine patients suffering from slight or moderate essential arterial hypertension underwent hypotensive treatment. After one week of wash-out, therapeutic administration of tienilic acid in doses of 500 mg per day was begun; in the third week we combined a non diuretic hypotensive drug (prazosin, propranolol, alfametil-dopa). At the beginning of the study all patients underwent an ECG, a clinical cardiological examiniation, funduscopy examination, funduscopy examination, a heart X - ray in 3 standard positions and a routine blood test which was repeated during and at the end of the treatment. The patients' blood pressure taken in an upright and supine position, showed statistically significant reductions for both systolic and diastolic values in all 3 groups, whereas the routine blood tests gave evidence of a marked reduction in the uriacid, triglycerides and potassium levels. In order to correct the latter we had to administer high oral doses of potassium, and in one case admittance to hospital was necessary since the potassium level was lower then 2.5 mEq/l.

[Hemodynamic observations in a group of hypertensive patients treated with tienilic acid (author's transl)]. / Osservazioni emodinamiche in un gruppo di ipertesi trattati con acido tienilico.

In ten patients suffering from slight or moderate essential arterial hypertension, undergoing treatment with tienilic acid at 500 mg per day, various hemodynamic parameters were assessed by means of ecocardiographic and policardiographic studies carried out before, during and at the end of treatment. In all cases a return to normal blood pressure values was achieved. No statistically significant changes in these parameters were observed, whereas the blood tests showed a reduction in the uric acid level and a moderate reduction in the potassium level.