Indications and limits of the exercise test in chronic heart failure.

Assessment of exercise capacity has been widely used in the evaluation of chronic heart failure (CHF), both to define the severity of the syndrome and to assess the changes induced by therapy. Various exercise tests and protocols can be used. The simple stress test using the exercise bicycle or the treadmill can give useful indications only in patients with severe or lower functional reductions. Maximum exercise duration usually depends on the patient's and the physician's motivation. The addition of respiratory gas exchange measurements, maximum oxygen consumption (VO(2)) or anaerobic threshold, increases the exactness of the assessment of the exercise limitation in CHF. VO(2) maximum provides an objective marker of aerobic capacity and it is biased by neither the patient nor the physician. This technique, however, requires the patient to exercise to exhaustion, and it is somewhat subjective and not indicative of normal daily exercise routine. The anaerobic threshold is a useful way of evaluating adaptability to submaximal efforts and the impact of the therapy on the daily performance. Nevertheless, it is significantly influenced by the fitness level and it has a reduced prognostic capability compared to VO(2) maximum. Submaximal exercise tests discriminate particularly between patients with severe CHF. The major limits are the influence of the patient's motivation and its limited validation in terms of reproducibility and prediction in controlled surveys.

The cardiogenic syncope in the elderly: a review on the epidemiology and social costs.

Although syncope is a common clinical problem in the elderly, little is known of its epidemiology and social costs. According to some epidemiological enquiries, syncope is responsible for 3% of emergency room visits and for 6% of the medical admissions in general hospitals. Although some types of syncope are benign and self-limited, those of traumatic origin with abrupt loss of consciousness represent a considerable morbidity, particularly in elderly patients. The prevalence in 10 years was of 23%, with an annual occurrence of 6-7% and a recurrence rate of 30%. Despite accurate investigations, syncope remains unexplained in about 50% of the patients. The first year mortality for cardiac syncope is 20-30%, against 5% for non-cardiac causes and 10% for syncope of unknown origin. Sudden death occurred in 17% of cardiac syncope cases. An approximate cost analysis can be obtained through the survey of costs relative to the length of the hospitalization and to the number of the main diagnostic tests applied. It must be underlined, however, that the clinical history and physical examination supply the most important contribution to the diagnosis in old patients, and these often are more than sufficient to suggest the suitable choice among the instrumental tests to be applied; this approach helps considerably to reduce the hospital costs.

Middle term evaluation of amlodipine vs nitrendipine: efficacy, safety and metabolic effects in elderly hypertensive patients.

The aim of the study was to evaluate, in a population of elderly hypertensives, the efficacy for 24 hours, the safety and the effects on carbohydrates and lipids metabolism of amlodipine (A) and nitrendipine (N). After a 3-week placebo wash-out, 50 patients with mild to moderate essential hypertension (HBP) or isolated systolic hypertension (ISH), were randomized in 4 groups treated with once-daily A 5,10mg or N 10,20mg increasing until patients responded to treatment. All subjects were submitted to a 24-hour non invasive ambulatory blood pressure monitoring (ABPM) at the start of the study (t0) and after four weeks of therapy (t4). It was registered a mean daily reduction in the pressure load of 15.0% in group A, 14.1% in group B, 13.9% in group C and 15.6% in group D; (p < 0.001). 82% of the patients treated with A and 85% treated with N resulted "responder". The metabolic parameters considered showed no significant changes. The overall incidence of adverse effects were temporary and extremely limited (2%). As monotherapies, amlodipine and nitrendipine are both suitable for the management of mild to moderate hypertension in elderly.

[Echocardiographic diagnosis of left ventricular myxoma. Description of a case and review of the literature. Myxomas of the left ventricle]. / Diagnostica ecocardiografica del mixoma ventricolare sinistro. Descrizione di un caso e revisione della letteratura. I mixomi del ventricolo sinistro.

A case of left ventricular myxoma diagnosed by echocardiography and successfully removed by left ventriculotomy is reported. This is a 21 year old male, with the few symptoms which simulating an hypertrophic cardiomyopathy in contrast to the large size of the tumour. It is possible that myxomas are responsible for sudden death. Therefore, in presence of new cardiac signs kind and relevance, the possibility of a myxoma should be considered. The diagnosis can be easily ruled out (or confirmed) by echocardiography, which represents a valuable tool in the diagnosis of myxomas.

[On the behavior of the atrioventricular valves in AV blocks. Polygraphic and echocardiographic study]. / Sul comportamento delle valvole atrio-ventricolari nei blocchi A-V. Studio poligrafico ed ecocardiografico.

By means of echocardiography, phonocardiography and jugular venous pulse recording, we have investigated 8 patients with atrio-ventricular conduction disturbances of various degrees: 4 with a first-degree AV block; 3 with complete heart block; 1 with type 1, 2nd degree AV block. The pattern of mitral valve motion at M-mode echocardiography suggests that the leaflets of the atrioventricular valves are definitively closed in diastole, only by the ventricular contraction. The simultaneous recording of echocardiogram and phonocardiogram in complete heart block seems to indicate that the increased intensity of the first heart sound is not always due to the increased velocity of valve closure, but also to the sudden vibration of the atrial floor, which is put under undue tension by the simultaneous atrial and ventricular contraction.