Increased sympathetic activity and plasma levels of norepinephrine (NE), parasympathetic withdrawal and impaired baroreflex gain have been reported in chronic heart failure (CHF). It is still debated whether, and if so, to what extent, the marked sympathetic activity influences the survival. Very little data is available on the prognostic implications of baroreflex sensitivity (BRS) and heart rate variability (HRV). Both BRS and HRV have been shown to be markedly reduced in CHF and significantly associated with the degree of ventricular dysfunction and with a further progression of the severity of the disease. Only small studies involving a limited number of patients have correlated these indices to an increased risk of death in CHF. We studied 119 consecutive sinus rhythm patients with mild to severe CHF. It was found that time and frequency parameters of HRV were not different between deceased and surviving patients, while BRS at univariate analysis was significantly associated with mortality; however, this prognostic information was not confirmed in a multivariate model. Although further analyses are necessary, our data and those of the literature do not confirm in CHF the important role which has been attributed to HRV and BRS in post-myocardial infarction risk stratification. In this paper some methodological limitations concerning the measure of these indices in CHF and possible different interpretative keys of the results are discussed to explain the discrepancies.

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PubMedDate not supplied

Aspirin does not interact with ACE inhibitors when both are given early after acute myocardial infarction: results of the GISSI-3 Trial.

Aspirin (ASA) and angiotensin-converting enzyme inhibitor (ACEi) therapy reduce mortality when administered early after the onset of myocardial infarction. ASA can antagonize some effects of ACEi therapy by inhibiting the synthesis of vasodilating prostaglandins; however, the evidence for this effect from large controlled trials is contradictory. The authors analyzed a database of 18,895 patients of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardio-3 (GISSI-3) Trial in which patients were allocated either to receive lisinopril or not to receive lisinopril within 24 hours of the onset of symptoms of myocardial infarction. The aim of the study was to verify the possible negative interaction between ASA and the ACEi lisinopril in the postacute phase of acute myocardial infarction. Of 18,895 analyzable patients, 15,841 received ASA at entry. Overall lisinopril reduced 42-day mortality from 7.1% to 6.3%. In patients receiving ASA, mortality was reduced by lisinopril from 6.0% to 5.4%, and from 13.0% to 10.8% in patients not receiving ASA. The difference in proportional reductions of mortality corresponds to the fact that a more marked lisinopril effect is seen in patients at higher baseline risk across all study subgroups, one of which coincides with the no-ASA group. The analysis of the inhospital incidence of major clinical events did not reveal a potentially negative interaction between ASA and lisinopril. The same findings were obtained from the analysis of reinfarction at 42 days. The interaction between ASA and lisinopril was also tested by multivariate analysis adjusted for confounding variables at entry, and the interaction tests were not statistically significant. Serum creatinine levels at 42 days were significantly higher in lisinopril group than in the control group. Systolic and diastolic blood pressures in lisinopril group were significantly lower than controls at 42 days. The effect of lisinopril on creatinine and blood pressure did not differ between the ASA and no-ASA groups. ASA does not decrease the mortality benefit of early lisinopril after myocardial infarction, nor does it increase the risk of major adverse events. Lisinopril is safe and effective when given early after the onset of myocardial infarction, regardless of a concomitant administration of ASA started early and continued over a 6-week period.

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PubMedDate not supplied

Clinical epidemiology of heart failure.

Heart failure (HF) is rapidly becoming one of the most prevalent cardiovascular disorders; the incidence of HF is expected to continue to increase in the years to come. The peculiarities of the syndrome require special approaches from the point of view of both clinical management and research methodology. As far as clinical management, new models based on a multidisciplinary approach and continuity of care should be implemented. The methodology of epidemiological research should take into account the complexity of the syndrome, the high frequency of comorbid conditions, the advanced age of typical patients, and the spreading of HF patients among different health care providers and specialists. In this paper, a general epidemiological view of HF is reported and studies of clinical epidemiology carried out in Italy in the area of HF are described. (c) 1999 by CHF, Inc.

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PubMedDate not supplied

[Rehabilitation of the worker with heart disease].

The physical, metabolic and psychological advantages of cardiac rehabilitation and its effects on secondary prevention and mortality are discussed. The importance of functional assessment of the patient with postacute myocardial infarction (MI) is emphasized in order to define the prognostic and therapeutic approaches. The methods of assessment are described, ith particular regard to Echocardiography, ambulatory ECG and exercise test. The echocardiographic location and extension of left ventricular asynergy, which are often unpredictable with conventional ECG, have important functional implications. In our experience, on the basis of these data, subsets of patients with different degrees of left ventricular dysfunction, both at rest and during exercise, can be identified. The ambulatory ECG can reveal ventricular arrhythmias in 60% of infarcted patients, while during exercise test the incidence of ventricular premature beats (VPB) is 20%. Both in post-acute evaluations and in evaluations performed 1 year later, poor correlations were found between VPB and ECGraphic and hemodynamic parameters either at rest or during exercise; however during the first postinfarction year ventricular arrhythmias tend to decrease. Hemodynamic and ECGraphic patterns during exercise were analyzed in about 600 patients with recent MI: the left ventricular filling pressure (PWP) was greater than 20 mm Hg in 54% of the patients and greater than 30 mm Hg in 28%. The MI site is predictive of hemodynamic left ventricular dysfunction both at rest and during exercise: anterior MIs are more impaired than inferior MIs. Good correlations were found between the ST-segment elevation (increased ST) during exercise and left ventricular function; in particular, in anterior MI the ventricular function is generally normal in patients without increased ST, abnormal in those with increased ST (the increased ST increment during exercise, if present at rest, has no hemodynamic implications). In inferior MI the increased ST does not seem to have nay hemodynamic significance. The ST-segment depression (decreased ST) too, is of important functional significance: in anterior MI it is usually associated with increased ST and a more evident left ventricular dysfunction. In inferior MI, ventricular function is generally better in patients without decreased ST than in those with increased ST.(ABSTRACT TRUNCATED AT 400 WORDS)

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