Atrial fibrillation and cognitive disorders: An overview on possible correlation.

Atrial Fibrillation is the most common cardiac arrhythmia affecting people of all ages, principally the elderly. Cognitive decline and dementia are also prevalent diseases in elderly. The scientific community always showed interest in the possible association between these two pathological entities, both implicating social and economic burden. This has been confirmed by several longitudinal population-based studies. Some studies also revealed that the association between atrial fibrillation and dementia may be not related to history of stroke. Therefore, other pathophysiological mechanisms are likely implicated, so far unclear or undefined. The aim of the present review is to analyse the possible mechanisms underlying the frequent association between atrial fibrillation and cognitive impairment.

[Transient left ventricular apical ballooning with dynamic outflow tract obstruction complicated by persistent hypotension]. / Sindrome tako-tsubo con transitoria ostruzione dinamica del tratto di efflusso del ventricolo sinistro, complicata da persistente ipotensione.

The pathogenesis of tako-tsubo syndrome remains, nowadays, unclear: it is likely that the relevance of the different proposed mechanisms differs among specific clinical contexts. In this paper, we describe the case of a 61-year-old woman admitted to the intensive cardiac care unit for pre-syncope and persistent hypotension. Clinical and echocardiographic data were suggestive of tako-tsubo syndrome with severe dynamic left ventricular outflow tract (LVOT) obstruction and severe mitral regurgitation. Coronary angiography was normal. Inotropic agents were not administered, because absolutely contraindicated in the presence of LVOT obstruction: indeed, they may worsen the dynamic gradient with further hemodynamic compromise. The patient was, therefore, initially treated with intravenous fluid infusion and, later on, with beta-blockers; the patient had a regular clinical recovery, with progressive disappearance of ECG and echocardiographic abnormalities. This case confirms that an early echocardiographic diagnosis of LVOT obstruction is essential for therapeutic decision-making, especially in the setting of tako-tsubo syndrome presenting with compromised hemodynamic status.

Impact of ''off-label'' use of ivabradine on exercise capacity, gas exchange, functional class, quality of life, and neurohormonal modulation in patients with ischemic chronic heart failure.

BACKGROUND: epidemiologic studies indicate that elevated heart rate (HR) is an independent risk factor for mortality and morbidity in patients (pts) with chronic heart failure (CHF). Clinical trials with ß-blockers suggest that HR reduction is an important mechanism of their benefit in pts with stable CHF. Pharmacologic inhibition of the I(f) current now provides the opportunity of pure HR reduction. The purpose of this study was to evaluate the impact of ''Off-Label'' use of ivabradine on exercise capacity, gas exchange, functional class, quality of life, and neurohormonal modulation in pts with ischemic CHF. METHODS: between January 2008 and June 2008, a graded maximal exercise test with respiratory gas analysis and an endurance test with constant workload corresponding to 85% of the peak VO(2) at the baseline and after 3 months were performed, and at the same times, N-terminal probrain natriuretic peptide (NT-proBNP) levels were also measured, in 60 pts (45 M, 15 F, mean age 52.7 ± 5.3 years), with stable ischemic CHF, New York Heart Association (NYHA) functional classes II (n = 35)-III (n = 25), with left ventricular ejection fraction (LVEF) ≤ 40%, randomized to a ''off-label'' ivabradine use (n = 30) and a control group (n = 30). RESULTS: the exercise capacity increased from 14.8 ± 2.5 to 28.2 ± 3.5 min (P < .0001) and the peak oxygen consumption tended to improve from 13.5 ± 1.3 to 17.9 ± 2.4 mL/kg per minute (P < .0001) in ivabradine group. Oxygen consumption at the anaerobic threshold (AT) increased from 11.9 ± 1.4 to 15.3 ± 1.4 mL/kg per minute (P < .0001). NTproBNP levels decreased from 2356 ± 2113 pg/mL to 1434 ± 1273 pg/mL (P = .045). No significant differences were found in control group at 3 months. The positive ivabradine effects were also associated with an improvement in the NYHA functional class and quality of life. CONCLUSION: the ''Off-Label'' use of ivabradine significantly improves the exercise capacity, gas exchange, functional heart failure class, quality of life, and neurohormonal modulation in pts with ischemic CHF.

Differentiation of hypertrophic cardiomyopathy from other forms of left ventricular hypertrophy by means of three-dimensional echocardiography.

In clinical practice, differential diagnosis among different forms of left ventricular (LV) hypertrophy is not always easy, and hypertrophic cardiomyopathy (HC) can be misdiagnosed. In this study, it was hypothesized that a 3-dimensional echocardiographically derived index of LV regional mass distribution could be useful in differentiating HC from other forms of LV hypertrophy. Sixty-eight subjects underwent 2- and 3-dimensional echocardiography; of these, 20 were healthy volunteers, 18 were top-level athletes, 15 had essential hypertension, and 15 had HC. In off-line analysis, a 12-segment model was generated for segmental mass measurement. A mass dispersion index (MDI) was calculated as the average of the SDs of segmental mass values at the basal, middle, and apical layers. The ratio of ventricular septal thickness to posterior wall thickness was also calculated using 2-dimensional echocardiography. Patients with HC had significantly higher MDI values (1.75 +/- 0.43) than healthy volunteers (0.39 +/- 0.13) (p <0.0001), athletes (0.49 +/- 0.12) (p <0.0001), and patients with hypertension (0.38 +/- 0.10) (p <0.0001). The ratio of ventricular septal thickness to posterior wall thickness was significantly higher in patients with HC (1.31 +/- 0.23) than normal subjects (1.04 +/- 0.05) (p <0.0001), highly trained athletes (1.03 +/- 0.06) (p = 0.001), and patients with hypertension (1.06 +/- 0.06) (p = 0.002). However, receiver-operating characteristic analysis showed a higher sensitivity for MDI (93.3% for the cut-off value of 1.13) than the ratio of ventricular septal thickness to posterior wall thickness (66.7% for the cut-off value of 1.20), with excellent specificity for both (100%) in identifying patients with HC. In conclusion, the 3-dimensional echocardiographically derived MDI could be considered a useful and reliable additional tool in differentiating HC from other forms of LV hypertrophy.

Relation of left atrial maximal volume measured by real-time 3D echocardiography to demographic, clinical, and Doppler variables.

Left atrial (LA) enlargement is a negative prognostic factor for survival in patients with stroke, congestive heart failure, and myocardial infarction. In the absence of mitral valvular disease it is also a marker of chronic elevated left ventricular filling pressures. The aim of our study was to examine whether the currently considered factors such as demographic, clinical, and Doppler parameters fully correspond to LA maximal volume measured by real time three-dimensional echocardiography (RT3DE). Two-hundred-twenty-four patients (age 58+/-12 years) were studied. Of these, 66 were healthy volunteers and 158 were patients with more than 2 cardiovascular risk factors (109), documented coronary heart disease (CHD) and normal LV function (33), and patients with (10) and without (6) IHD and LV systolic dysfunction. Two-dimensional Doppler and tissue Doppler (TDI) echocardiographic parameters and LA maximal volume, assessed by RT3DE were analyzed. LA maximal volume values were positively and highly significantly associated, after adjustment for age and sex, with LV mass, mitral flow peak E velocity and E/A ratio, TDI E'/A' ratio and E/e' ratio (P<0.001). There were highly significant inverse associations of LA maximal volume and ejection fraction and peak A' velocity detected by TDI (P<0.0001). LA maximal volume was significantly correlated with the progression of diastolic dysfunction from normal to grade III. In particular, there was a clear difference between the normal and pseudonormal filling patterns (p<0.001) in terms of LA maximal volume. In conclusion, progressive LA volume increase is directly correlated with age, LV mass, and LV diastolic dysfunction, and inversely correlated with LV systolic function.

[Clinical use of a new class of anticoagulant drugs: the direct thrombin inhibitors]. / L'impiego clinico di una nuova classe di farmaci anticoagulanti: gli inibitori diretti della trombina.

The coagulation cascade, and particularly thrombin, plays a very important role in arterial and venous thrombosis. Thereby, it is clear that thrombin inactivation is an optimal strategy for thrombotic disease prevention and treatment. The direct thrombin inhibitors are a new class of anticoagulant drugs directly binding thrombin and blocking its interaction with fibrinogen. The group of direct thrombin inhibitors includes recombinant hirudin (lepirudin and desirudin), bivalirudin, melagatran and its oral precursor, ximelagatran, argotraban and dabigatran. These drugs have several advantages compared to other anticoagulant drugs, and the particular pharmacokinetic properties of some of them could be very important for future management of thromboembolic prophylaxis. The efficacy and safety of these new drugs are evaluated in several clinical trials; however today only few clinical indications are available for the majority of them.

[Pharmacological treatment of depression after acute myocardial infarction]. / La terapia farmacologica della depressione dopo infarto miocardico acuto.

Depressed mood and other depressive symptoms frequently appear after acute myocardial infarction and it is known how these patients have an increased risk for morbidity and mortality compared to patients without depression. Many risk factors promote the development of clinical depression in patients with recent myocardial infarction. Although a large number of studies underline the negative prognostic impact of depression on the infarcted patient, only rarely depressed patients are appropriately diagnosed and treated. Furthermore it should be borne in mind that the use of psychotropics in medically ill patients requires attention. These compounds, in fact, may interact with the disease causing several complications. In addition since the cardiologic patient is often treated with other drugs, the risk of clinically significant pharmacological interactions is obviously improved. It seems appropriate to give some considerations about therapy and management of the infarcted patient with depression.