Influence of tilt training on activation of the autonomic nervous system in patients with vasovagal syncope.

OBJECTIVE: Tilt training is a new treatment for vasovagal syncope. Its therapeutic efficacy is thought to be the result of the desensitization of cardiopulmonary receptors, but it could be the influence of the tilt training on the activation of the autonomic nervous system as well. METHODS AND RESULTS: The study group consisted of 24 vasovagal patients (17 women and 7 men) aged 32.5 +/- 11.8 years. The diagnostic head-up tilt test was performed according to the Italian protocol with nitroglycerin if necessary. The monitoring head-up tilt test was performed according to the Westminster protocol without provocation, after 1 to 3 months of tilt training. Holter ECG recordings for HRV parameters (time and frequency domain) were obtained from selected 2-min intervals before, during and after the diagnostic and monitoring tilt test. The diagnostic test was positive in the passive phase in 6 and after provocation in 18 patients. During the training period no syncope occurred. Analysing the HRV parameters we demonstrated the following findings: I. mRR decreases immediately after assumption of a vertical position in both tests (diagnostic and monitoring) but in the diagnostic test its further decrease occurs earlier than in the monitoring test; 2. the absolute power of the HF component is greater in the early phase of tilt after tilt training than in the corresponding period in the diagnostic test. CONCLUSIONS: After a longer period of tilt training the activation of the sympathetic nervous system in response to the erect position is diminished.

Aspirin resistance in ischaemic heart disease.

BACKGROUND: In spite of the usage of acetylsalicylic acid (aspirin) in the secondary prevention of ischaemic heart disease (IHD), new thrombo-embolic events occur in more than half of patients. Aspirin resistance may be partially responsible for this phenomenon. AIM: To assess the prevalence of aspirin resistance in patients with IHD and to correlate this phenomenon with the progression of atherosclerosis, concomitant diseases and other medication. METHODS: The study group consisted of 205 patients (mean age 65.8 years, 95 females) with stable angina, recent coronary angiography and positive result of non-invasive stress tests, treated with 75 mg of aspirin for at least one week. Platelet aggregation was measured using the optical aggregation method. Aspirin resistance was defined as a mean collagen and ATP-induced platelet aggregation >70%. RESULTS: Aspirin resistance was found in 41 (20%) patients and was significantly associated with previous coronary artery bypass grafting (CABG) (p<0.01) and three-vessel disease (p<0.05). Previous CABG was the only independent risk factor for the presence of aspirin resistance (OR 5.6; 95% CI 2.0-15.4; p<0.01). CONCLUSIONS: Aspirin resistance is present in 20% of patients with stable angina. Previous CABG is an independent risk factor of this phenomenon.

[Pharmacotherapy of chronic heart failure in clinical practice]. / Farmakologiczne leczenie przewleklej niewydolnosci serca w praktyce klinicznej.

Chronic heart failure affects between 1-5% of the population and rise steeply with age. Most patients with chronic heart failure should be routinely managed with a combination of 4 types of drugs: a diuretic, an angiotensin converting enzyme inhibitors (ACE-I), beta-blocker and usually digitalis. Diuretics are essential for symptomatic treatment when fluid overload is present, and should always be administrated in combination with ACE-I if possible. ACE-I improves survival and symptoms and reduces hospitalization in patients with moderate to severe ventricular systolic dysfunction, and in the absence of fluid retention should be given first. Angiotensin II receptor antagonist could be considered in patients who not tolerate ACE-I. beta-blocking agents are recommended for treatment of patients with stable, mild, moderate and severe heart failure unless there is a contraindication. Bisoprolol, metoprolol and carvedilol have been associated with reduction in total mortality, cardiovascular mortality and sudden death. Cardiac glycosides are indicated in atrial fibrillation and any degree of symptomatic heart failure in order slow ventricular rate. Indications for antiarrhythmic drug therapy include atrial fibrillation, non-sustained or sustained ventricular tachycardia. Oral anticoagulation reduces the risk of stroke in patients with atrial fibrillation, and there is a lack of evidence to support the use of antithrombotic therapy in patients in sinus rhythm.

QT dispersion and myocardial viability in patients after acute myocardial infarction.

BACKGROUND: In recent years QT dispersion (QTd) in post-infarct patients was estimated in many studies, but still little is known about its association with the presence of dysfunctional but viable myocardium. AIM: We investigated the relation between dispersion of QT interval and myocardial viability in patients after acute myocardial infarction (AMI). MATERIAL AND METHODS: In 52 patients (mean age 67.2+/-11.7) treated thrombolytically because of AMI 12-lead ECG and low dose-high dose dobutamine echocardiography was performed on 14th day after treatment. QTd and regional myocardial contractility were estimated three times: at baseline, low dose dobutamine (LDD) (10-15 microg/kg per min) and high dose dobutamine (HDD) infusion (up to 40 microg/kg per min). RESULTS: Patients with viable myocardium had lower baseline QTd than patients with only necrosis in infarct zone. Significant increase in QTd was shown during LDD and HDD both in patients with and without myocardial viability. During infusion of HDD QTd was significantly higher in patients with myocardial ischemia. The greatest percentage increase of QTd at HDD was shown in patients with biphasic response to dobutamine infusion i.e. with myocardial viability evidenced at LDD and myocardial ischemia at HDD. CONCLUSION: Patients with preserved myocardial viability had lower QTd values compared to those with similar left ventricular dysfunction but caused only by post-infarction necrosis. Ischemia evoked on 14th day after AMI was accompanied by greater increase in QTd in patients with myocardial viability in infarct region than in patients without. It may be one of the reasons of greater risk of serious ventricular arrhythmias in such patients during myocardial ischemia.

[Cardiovascular diseases as a cause of sudden death in athletes]. / Schorzenia sercowo-naczyniowe jako przyczyna naglych zgonów sportowców.

Cardiac arrhythmias are the reason of the most sudden deaths in athletes. The annual risk of sudden death at athletes is between 5 to 10 per one million. Benign arrhythmia including bradyarrhythmias, atrial and ventricular premature contractions are common in the athletes. Supraventricular arrhythmias such as atrial fibrillation, nodal reciprocal entrant tachycardia and Wolff-Parkinson-White syndrome are less common. Perhaps the rarest and the most dangerous arrhythmias are ventricular arrhythmias, among them arrhythmias secondary to hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, long QT syndrome, and anomalous origin of coronary arteries. Asymptomatic bradyarrhythmias (if the heart rate in bradyarrhythmia appropriate increases with exercise), supraventricularis tachycardias, and atrial premature contractions without structural heart disease are not the contraindication to sports Athletes with premature ventricular contraction, nonsustained ventricular tachycardia and non structural heart disease are without athletic restrictions as long as the arrhythmias do not worsen and they not cause dyspnea or presyncope during exertion. Frequent or multiform premature ventricular contraction or sustained ventricular tachycardia indicate a higher risk, and all participation in athletic should be restricted.

[Therapeutic approach to patients with neurocardiogenic syncope]. / Postepowanie lecznicze u chorych na omdlenia neurokardiogenne.

Vasovagal syncopes are the most common cause of loss of consciousness and if they occur frequently they contribute to the marked decrease of the quality of life and need treatment. One of important problems is the possibility of injury during the syncope. In older patients it can lead to the fractures of extremities, complications of which could be life-threatening. Another problem is the reaction of the surrounding people trying to help the unconscious by keeping him in the vertical position. It promotes hypotonia and could cause damage of organs such as brain or heart. The authors review the current literature on the management of patients with vasovagal syncope. It seems that the conservative approaches preferring patient reassurance and training methods are successful in syncope prevention and help avoid the side effects and complications of pharmacological therapy or pacemaker implantation. These last two methods should be reserved for patients with the most severe symptoms of the disease.

[Adrenomedullin--the link between the sympathetic nervous system activation and peripheral vasodilatation in some patients with vasovagal syncope]. / Adrenomedullina-ogniwo laczace aktywacje ukladu wspólczulnego z obwodowa wazodylatacja u wybranych chorych z omdleniami wazowagalnymi.

UNLABELLED: Adrenomedullin (ADM) is a potent vasodilator playing role in regulation of central hemodynamic. The concentration of plasma ADM in healthy people increases under the influence of orthostatic stress. In patients with vasovagal syncope (VS) the changes in ADM concentration could be responsible either for syncope provocation or prevention. The aim of the study was to assess the influence of phase of the head-up tilt test (HUTT) in which the syncope occurred on the plasma concentration of ADM. MATERIAL AND METHODS: The study was performed in 25 patients (pts) (18 women and 7 men), mean age 45.0+/-16.1 years with cardiodepressive reactions during HUTT according to the Italian protocol with nitroglycerine (NTG) provocation if necessary: Syncope was caused in 23 pts due to vasovagal reaction: in 17 pts syncope occurred after NTG provocation (group 1), and in 6 pts occurred in the passive phase of tilt (group 2a), in 2 pts due to dysautonomic reactions (group 2b). The head-up tilt test was performed according to ESC guidelines. The blood for ADM concentration was drawn after 30 min supine rest (ADM 1) and immediately after syncope (ADM 2). ADM level was measured using radioimmunological method. The results. In group 1 plasma level of ADM significantly decreased after the HUTT (3.2+/-3.4 vs 1.7+/-1,4 pg/0.1 ml; p<0.05) and in group 2a increased significantly (1.3+/-0.8 vs 2.7+/-1.3 pg/0.1 ml; p<0.05) comparing to baseline values. The ADM concentration did not differ between the groups in baseline conditions and was significantly higher after the syncope in group 2a (p<0.05). Conclusions. The excessive increase of ADM concentration during the passive phase of HUTT could play the causative role in pathogenesis of VS occurring early during the HUTT. In patients with VS after NTG provocation the decrease of ADM concentration can be the result of hemodynamic changes in the presence of vasodilating drug and may be the mechanism that could prevent the syncope.

[The influence of Chlamydia pneumoniae infection on acute coronary syndromes]. / Ostre zespoly wiencowe a zakazenia Chlamydia pneumoniae.

UNLABELLED: Chlamydia pneumoniae is one of the infectious factors the role of which is considered in the process of atherosclerosis and its complications. THE AIM: Of the study was to assess the incidence of Ch. pneumoniae infection in the patients with acute coronary events. The study was carried out in 36 patients, mean age 61.2 +/- 13.4 years, 27 men and 9 women hospitalised in our Department with the diagnosis of previous or recent acute myocardial infarction. The control group consisted of 19 subjects, aged 61.1 +/- 14.3 years, 10 men and 9 women hospitalised due to other reasons. In all studied patients during the first 24 hours venous blood was taken for the assessment of fibrinogen and C-reactive protein (CRP) concentrations and titres of IgA and IgG anti-Ch. pneumoniae antibodies, and pharyngeal swabs were done for Ch. pneumoniae assessment. RESULTS: Positive swab tests were found in 19% of the patients, positive IgG titres in 80% and IgA in 64% of the patients. In the control group the corresponding values were 11, 79, 42%, respectively. In the patients with positive IgG titres, negative IgA titre result was observed in 21% and in the control group in 53% (p < 0.05). The CRP level was significantly higher in the studied patients than in the control group (24.2 vs 4.2 mg/l; p < 0.05). CONCLUSIONS: 1. The high percentage of positive serologic tests and rare positive results of pharyngeal swabs indicate a frequent contact with Ch. pneumoniae in human population. 2. Ch. pneumoniae infection exerts no significant influence on the unspecific markers of inflammation. 3. The higher frequency of seroconversion-positive IgG and negative IgA titres--in the control group indicates the role of prolonged or acute Ch. pneumoniae infection in the development or progression of coronary atherosclerosis and its complications.

[The influence of physical exercise on heart rate variability]. / Wplyw wysilku fizycznego na parametry zmiennosci rytmu serca.

Heart rate variability is controlled by the influence of autonomic nervous system, whereas one part of the system modulates the activity of the other. There is evidence of increased sympathetic activity in patients (pts) with essential hypertension. The aim of the study was to assess the persisting influence of increased sympathetic activity 30 min after moderate physical exercise on heart rate variability in patients with arterial hypertension. The study was performed in 19 patients (10 women, mean age 52.7 +/- 9.5 years and 9 men, mean age 37.7 +/- 8.8 years) with stage I (6 pts) and stage II (13 pts) arterial hypertension. All studied pts had sinus rhythm, were free of diabetes, coronary heart disease and congestive heart failure. 24-hour Holter monitoring was performed and for 30 min before the exercise test the pts stayed in supine rest. The exercise tests were performed between 10 and 11 a.m. Immediately after the exercise all pts stayed in supine position for 30 min. The heart rate variability parameters were studied using Holter monitoring system Medilog Optima Jet and were then analysed statistically. The mean energy expenditure during the exercise was 5.8 +/- 1.1 METs and the maximal heart rate was 148.1 +/- 20.3 bpm. All studied HRV parameters were significantly different in the assessed time period compared to the baseline values (p < 0.001). Significant correlation was found between the age of the studied patients and the mean RR interval, what can be considered as a hyperkinetic (hyperadrenergic) circulatory status and shorter RR interval in younger pts. Significant negative correlation between the age and SDNN parameter (r = -0.65, p < 0.001), 30 min after the exercise mirrors the prolonged adrenergic influence in older pts. The present study shows that the influence of moderate physical exercise on heart rate variability in pts with essential hypertension is extended over 30 min period after exercise and is more pronounced in older pts. The studies on HRV should be performed at longer time intervals after exercise.

[Controversies in the conduction and evaluation of clinical trials results for the treatment in vasovagal syncope]. / Kontrowersje wokól sposobu prowadzenia i oceny wyników badan dotyczacych leczenia omdlen wazowagalnych.

The vasovagal syncope is a reflex reaction to various stimuli leading to the marked hypotension with or without bradycardia with loss of consciousness and fall of postural muscle tone. The vast majority of the patients recover spontaneously but if the syncope occurs frequently and causes injury of the patients body it worsens the quality of life and needs appropriate treatment. The injuries requiring hospitalization occur approximately in 10% of the patients with vasovagal syncope. The aim of the therapy of affected patients is to diminish the syncope prevalence, to brake the neurocardiogenic reaction on an early stage or to prolong the duration of the presyncope phase to enable the patient prevention of the injury. The lack of clear diagnostic criteria and difficulties with estimation the efficacy of any particular therapeutic intervention in many clinical studies of different authors, inclusion to the studies patients with different clinical presentation stages of the disease contribute to different conclusions, which automatic use in the clinical practice is inappropriate. There is an urgent need to clear the methodological discrepancies and to conduct good planed, large, randomized, multicentre studies to assess the efficacy of different therapeutic methods in the treatment of vasovagal syncope.

[Influence of amlodipine on serum level of some cytokines in patients with congestive heart failure]. / Wplyw amlodypiny na stezenie wybranych cytokin u chorych na przewlekla niewydolnosc krazenia.

Recent studies showed higher plasma levels of several cytokines, such as interleukines or tumour necrosis factor in patients with congestive heart failure. Cytokines play a very important role in pathogenesis of congestive heart failure, because they impair contractility of heart muscle and cause damage of endothelium and myocytes due to their proinflammatory effects. One of the treatment modalities of heart failure might be administration of drugs inhibiting production of cytokines. The study was undertaken to evaluate whether beneficial effects of amlodipine in congestive heart failure are due to inhibition of synthesis of cytokines. The plasma levels of interleukine 6 (IL-6), tumour necrosis factor (TNF-alpha), neuropeptide Y (NPY) and endothelin-1 (ET-1) were determined in patients with congestive heart failure (NYHA II and III) before and after 30 days of treatment with amlodipine. 40 patients with congestive heart failure (CHF) treated in the Department of Cardiology of Medical University in Wroclaw participated in this study. In all patients CHF developed in the course of ischaemic heart disease and coexisting hypertension. Patients were divided into 2 groups dependingly on the NYHA classification. The first group consisted of 24 patients in II NYHA class, the other one--of 16 patients in III NYHA class. At 8 am, on the second day after admission and before treatment with amlodipine blood samples were taken from examined patients to determine plasma levels of IL-6, TNF-alpha, NPY and ET-1. Then patients were administered amlodipine at the dose of 5-10 mg per day. The next blood samples were taken on 5th and 30th day of treatment. Plasma levels of TNF-alpha, IL-6, NPY and ET-1 were estimated with radioimmunoassay using Medgerix kits. Our findings showed that plasma levels of TNF-alpha, IL-6, NPY and ET-1 in patients with CHF are increased. 30-days treatment with amlodipine caused significant decrease of TNF-alpha and IL-6 levels, but did not influence the plasma levels of NPY and ET-1. Amlodipine causes improvement of circulatory efficiency assessed according to NYHA classification. Treatment with amlodipine may be an additional way of therapy in CHF.

[Infections and coronary heart diseases]. / Zakazenia a choroba niedokrwienna serca.

The role of inflammatory mechanisms in the initiation, progression and clinically expression of atherosclerosis is increasingly appreciated, and a large number of review have been published on associations between of coronary heart disease and various bacterial and viral agents. This review provides a systematic overview of the available the epidemiological and clinical studies on coronary heart disease and Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus and dental disease as well as possible mechanisms. These published prospective studies provide no good evidence to support the existence of strong epidemiological associations between coronary heart disease and Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus and dental disease but because the available evidence is still sparse, further studies of these agents are needed that can reliably investigate the possibility of associations with coronary heart disease.