Cardiorespiratory fitness as a mediator in the relationship between lung function and blood pressure in adults

It is unclear whether physical activity and cardiorespiratory fitness (CRF) are pathways that link low pulmonary function (LPF) to increased blood pressure (BP). Therefore, we investigated the extent to which CRF and moderate-to-vigorous physical activity (MVPA) mediate the relationship between LPF and high BP in adults. We conducted a cross-sectional study with 1,362 participants that underwent cardiopulmonary exercise testing (CPET), spirometry, and wore an accelerometer to determine physical activity patterns. We performed mediation analyses using structural equations considering peak oxygen uptake (V̇O₂) and MVPA as mediators, forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) as independent variables, and systolic and diastolic blood pressure (SBP, DBP) as dependent variables. The probability of alpha error was set at 5%. We found a significant total effect of FVC on SBP and DBP considering V̇O₂ as mediator (P<0.01). Indirect effects were also significant, with 42.6% of the total effect of FVC on SBP and 77% on DBP mediated by V̇O₂ (P<0.01). We did not observe a direct effect of FVC on SBP and DBP. Considering FEV1 as an independent variable, the total effect on SBP was also significant, as were the indirect effects, mediated by V̇O₂ at 14.8% for SBP and 7.6% for DBP (P<0.01). We did not find an indirect effect of FVC or FEV1 considering the MVPA as a mediator. CRF mediates the pathway that links LPF and elevated BP. Therefore, CRF is more sensitive to variations in FVC and FEV1 than MVPA.

Classification of cardiorespiratory fitness using the six-minute walk test in adults: Comparison with cardiopulmonary exercise testing

BACKGROUND

The six-minute walk test (6MWT) distance could facilitate the assessment of cardiorespiratory fitness (CRF) in clinical practice as recommended. We aimed to develop a CRF classification using the 6MWT distance in asymptomatic adults considering the treadmill maximum oxygen uptake (V˙O_2max) as the gold standard method.

METHODS

We evaluated V˙O_2max and 6MWT distance in 1295 asymptomatic participants aged 18-80 years (60% women). Age- and sex-related CRF was classified based on the percentiles as very low (<5th percentile), low (5th-25th percentile), regular (26th-50th percentile), good (51st-75th percentile), excellent (76th-95th percentile), and superior (>95th percentile) for both V˙O_2max and 6MWT distance. We investigated the 6MWT distance cut-off (%pred.) with the highest sensitivity and specificity for identifying each V˙O_2max classification.

RESULTS

V˙O_2max declined by 8.7% per decade in both men and women. The 6MWT distance declined by 9.3% per decade in women and 9.5% in men. We formulated age- and sex-related classification tables for CRF using the 6MWT distance. Moreover, the 6MWT distance (%pred.) showed excellent ability to identify very low CRF (6MWT distance ≤ 96%; AUC=0.819) and good ability to differentiate CRF as low (6MWT distance=97%-103%; AUC=0.735), excellent (6MWT distance=107%-109%; AUC=0.715), or superior (6MWT distance>109%; AUC=0.790). It was not possible to differentiate between participants with regular and good CRF.

CONCLUSION

The CRF classification by the 6MWT distance is valid in comparison with V˙O_2max, especially for identifying adults with low CRF. It could be useful in clinical practice for screening and monitoring the cardiorespiratory risk in adults.

Tumor necrosis factor receptor 2 as a possible marker of COPD in smokers and ex-smokers

Introduction

Oxidative stress and systemic inflammation are higher in smokers and patients with COPD; however, markers that may help differentiate between smokers and patients with COPD have not yet been identified. We hypothesized that tumor necrosis factor-alpha receptor (TNFR) and soluble form of the receptor for advanced glycation end products (sRAGE) can be indicators of COPD in asymptomatic patients.

Patients and methods

We evaluated 32 smokers (smoking history >10 pack-years), 32 patients with mild/moderate COPD (smokers and ex-smokers), and 32 never smokers. Concentrations of C-reactive protein (CRP), interleukin (IL)-6, TNFR1 and TNFR2, advanced glycation end products (AGEs), and the sRAGE were measured in serum.

Results

There were higher CRP and AGEs concentrations in smokers and in patients with COPD (P<0.001 and P=0.01, respectively) compared to controls, without statistical difference between smokers and patients with COPD. Concentrations of sRAGE, IL-6, and TNFR1 did not differ between study groups. TNFR2 was significantly higher in patients with COPD than in smokers (P=0.004) and controls (P=0.004), and the presence of COPD (P=0.02) and CRP (P=0.001) showed a positive association with TNFR2. Positive associations for smoking (P=0.04), CRP (P=0.03), and IL-6 (P=0.03) with AGEs were also found. The interaction variable (smoking × COPD) showed a positive association with IL-6.

Conclusion

Our data suggest that TNFR2 may be a possible marker of COPD in asymptomatic smokers and ex-smokers. Although smokers and patients with early COPD presented other increased systemic inflammation markers (eg, CRP) and oxidative stress (measured by AGEs), they did not differentiate smokers from COPD.

Longevity, Esthetic Perception, and Psychosocial Impact of Teeth Bleaching by Low (6%) Hydrogen Peroxide Concentration for In-office Treatment: A Randomized Clinical Trial

OBJECTIVE

The aim was to evaluate the color longevity after nine months of in-office bleaching with gel (6% hydrogen peroxide), to compare this to a control concentration of 35% in a split-mouth study model, and to assess the dental confidence and psychosocial impact on patients.

METHODS AND MATERIALS

Twenty-seven patients were assessed at the nine-month recall. The bleaching procedure with 6% or 35% hydrogen peroxide gel was performed randomly in the upper hemi-arch of each patient. The color was measured at baseline and at one week, one month, and nine months after the procedure, using the Vita Easyshade spectrophotometer, the Vita classical shade guide organized by value, and Vita Bleach Guide 3DMaster. Moreover, two surveys, OHIP-Esthetics and PIDAQ, were used to assess the esthetic self-perception and psychosocial impact of the bleaching procedure. During the nine-month recall, the color was assessed before and after dental prophylaxis.

RESULTS

Twenty-seven patients participated in the nine-month recall. There was a significant difference in ΔE between the two groups at all times assessed (p<0.011). The ΔL, Δa, and Δb showed a difference between the two groups at all times assessed (p<0.038), except for ΔL from the baseline vs nine-month after prophylaxis value (p>0.20). There was no significant difference in ΔSGU at all times (p>0.05). There was a significant difference in OHIP-Esthetics and PIDAQ sums compared with baseline scores (p<0.03).

CONCLUSION

The two compounds remained effective at nine months, with a slight rebound of color, and maintained their objective color difference but not the subjective color difference. Patients were satisfied with the bleaching procedure, and this had a positive impact on esthetic perception and a positive psychosocial impact at the nine-month recall.

Effect of three exercise programs on patients with chronic obstructive pulmonary disease

We compared the effect of three different exercise programs on patients with chronic obstructive pulmonary disease including strength training at 50_80% of one-repetition maximum (1-RM) (ST; N = 11), low-intensity general training (LGT; N = 13), or combined training groups (CT; N = 11). Body composition, muscle strength, treadmill endurance test (TEnd), 6-min walk test (6MWT), Saint George's Respiratory Questionnaire (SGRQ), and baseline dyspnea (BDI) were assessed prior to and after the training programs (12 weeks). The training modalities showed similar improvements (P > 0.05) in SGRQ-total (ST = 13 +/- 14%; CT = 12 +/- 14%; LGT = 11 +/- 10%), BDI (ST = 1.8 +/- 4; CT = 1.8 +/- 3; LGT = 1 +/- 2), 6MWT (ST = 43 +/- 51 m; CT = 48 +/- 50 m; LGT = 31 +/- 75 m), and TEnd (ST = 11 +/- 20 min; CT = 11 +/- 11 min; LGT = 7 +/- 5 min). In the ST and CT groups, an additional improvement in 1-RM values was shown (P < 0.05) compared to the LGT group (ST = 10 +/- 6 to 57 +/- 36 kg; CT = 6 +/- 2 to 38 +/- 16 kg; LGT = 1 +/- 2 to 16 +/- 12 kg). The addition of strength training to our current training program increased muscle strength; however, it produced no additional improvement in walking endurance, dyspnea or quality of life. A simple combined training program provides benefits without increasing the duration of the training sessions.

Relationship between disease severity and quality of life in patients with chronic obstructive pulmonary disease

Few studies have evaluated the relationship between Airways Questionnaire 20 (AQ20), a measure of the quality of life, scores and physiological outcomes or with systemic markers of disease in patients with chronic obstructive pulmonary disease (COPD). The aim of the present study was to investigate the relationship of forced expiratory volume in 1 s (FEV1), body mass index, fat-free mass index, 6-min walk test (6MWT) results, dyspnea sensation and peripheral oxygen saturation (SpO2) with the quality of life of COPD patients. Ninety-nine patients with COPD (mean age: 64.2 +/- 9.2 years; mean FEV1: 60.4 +/- 25.2% of predicted)were evaluated using spirometry, body composition measurement and the 6MWT. The baseline dyspnea index (BDI) and the Modified Medical Research Council (MMRC) scale were used to quantify dyspnea. Quality of life was assessed using the AQ20and the St. George's Respiratory Questionnaire (SGRQ). The Charlson index was used to determine comorbidity. The body mass index/airflow obstruction/dyspnea/exercise capacity (BODE) index was also calculated. AQ20 and SGRQ scores correlated significantly with FEV1, SpO2, 6MWT, MMRC and BDI values as did with BODE index. In the multivariate analyses,MMRC or BDI were identified as predictors of AQ20 and SGRQ scores (P < 0.001 in all cases). Thus, the relationship between AQ20 and disease severity is similar to that described for SGRQ. Therefore, the AQ20, a simple and brief instrument, can be very useful to evaluate the general impact of disease when the time allotted for measurement of the quality of life is limited.

Effects of Isolated Cycle Ergometer Training on Patients with Moderate-to-Severe Chronic Obstructive Pulmonary Disease

BACKGROUND

Pulmonary rehabilitation (PR) programs are beneficial to patients with chronic obstructive pulmonary disease (COPD), and lower-extremity training is considered a fundamental component of PR. Nevertheless, the isolated effects of each PR component are not well established.

OBJECTIVE

We aimed to evaluate the effects of a cycle ergometry exercise protocol as the only intervention in a group of COPD patients, and to compare these results with a control group.

METHODS

25 moderate-to-severe COPD patients were evaluated regarding pulmonary function, respiratory muscle strength, exercise capacity, quality of life and body composition. Patients were allocated to one of two groups: (a) the trained group (TG; n = 13; 6 men) was submitted to a protocol of 24 exercise sessions on a cycle ergometer, with training intensity initially set at a heart rate (HR) close to 80% of maximal HR achieved in a maximal test, and load increase based on dyspnea scores, and (b) the control group (CG; n = 12; 6 men) with no intervention during the protocol period.

RESULTS

TG showed within-group significant improvements in endurance cycling time, 6-min walking distance test, maximal inspiratory pressure and in the domain 'dyspnea' related to quality of life. Despite the within-group changes, no between-group significant differences were observed.

CONCLUSION

In COPD patients, the results of isolated low-to-moderate intensity cycle ergometer training are not comparable to effects of multimodality and high-intensity training programs.

Neutral endopeptidase and angiotensin I converting enzyme insertion/deletion gene polymorphism in humans

Neutral endopeptidase (NEP) hydrolyses angiotensins (Ang) I and II and generates angiotensin-(1-7) [Ang-(1-7)]. In humans, the insertion/deletion (I/D) angiotensin-I converting enzyme (ACE) gene polymorphism determined plasma ACE levels by 40%. In rats, a similar polymorphism determines ACE levels which are inversely associated to NEP activity. The objective of this study is to evaluate the relationship between ACE expression and plasma NEP activity in normotensive subjects and in hypertensive patients. In total, 58 consecutive patients with hypertension, evaluated in our Hypertension Clinic, were compared according to their ACE I/D genotypes with 54 control subjects in terms of both plasma ACE activity and NEP activities. Plasma ACE activity was elevated 51 and 70% in both DD ACE groups (normotensives and hypertensives) compared with their respective ID and II ACE groups (P<0.001). A significant effect of the ACE polymorphism and of the hypertensive status on ACE activity was observed (P<0.001). In normotensive DD ACE subjects, NEP activity was 0.30+/-0.02 U/ml, whereas in the normotensive II ACE and in the normotensive ID ACE subjects NEP activity was increased 65 and 48%, respectively (P<0.001). In the hypertensive DD ACE patients, NEP activity was 0.47+/-0.03 U/mg. An effect of the I/D ACE genotypes on NEP activity (P<0.04) and an interaction effect between the I/D ACE genotype and the hypertensive status were also observed (P<0.001). These results are consistent with a normal and inverse relationship between the ACE polymorphism and NEP activity in normotensive humans (as is also observed in rats). This normal relationship is not observed in hypertensive patients.

Cytokines and dietary energy restriction in stable chronic obstructive pulmonary disease patients

Tumour necrosis factor (TNF)-alpha has been found to be increased in malnourished chronic obstructive pulmonary disease (COPD) patients; however, the main cause of this phenomenon remains undetermined. In normal subjects, TNF-alpha production may be induced by dietary energy deprivation. The aim of this study was to investigate if stable COPD patients present alterations of inflammatory mediators after 48 h of dietary energy restriction. Fourteen COPD patients were admitted to the hospital while receiving an experimental diet with an energy content of approximately one-third of their energy needs. Clinical evaluation, nutritional assessment and serum levels of interleukin (IL)-6, TNF-alpha and C-reactive protein, and secretion of TNF-alpha by peripheral blood monocytes were assessed on admission and after the experimental diet. For reference values of the laboratory parameters, blood was collected from 10 healthy, elderly subjects. COPD patients showed significantly higher serum concentrations of IL-6 than control subjects, however, the experimental diet was not associated with statistically significant changes in the inflammatory mediators. The findings of this study, although preliminary because of the limited degree and duration of the energy restriction, suggest that the elevated levels of tumour necrosis factor-alpha, previously described in undernourished or weight-losing chronic obstructive pulmonary disease patients, may not be linked to a decrease of dietary energy intake.

Is chronic hypoxemia in patients with chronic obstructive pulmonary disease associated with more marked nutritional deficiency? A study of the fat-free mass evaluated by anthropometry and bioelectrical impedance methods

In order to determine wheter blood gases abnormalities, specially hypoxemia, are associated with more marked changes in fat-free mass in patients with chronic obstructive pulmonary disease (CPOD), nutritional assessment was performed on 16 normoxemic (PaO2 > 55 mm Hg) and 16 hypoxemic (PaO2 < 55 mm Hg) COPD patients in stable clinical condition. Body weight was expressed as percentage of the ideal body weight. Fat-free mass was estimated by anthropometry (FFM-Anthr) and by bioelectrical impedance (FFM-BI). Handgrip-strength was assessed as a measure of peripheral skeletal muscle strength. Patients were age-matched and presented similar degree of airway obstruction. Malnutrition, defined as body weight less than 90% of the ideal, was observed in 19% of the normoxemic patients and in 25% of the hypoxemic patients (p>0,05). FFM values in hypoxemic patients, estimated by both methods, were not different from those observed in normoxemic patients. No significant difference was observed on handgrip values between the two groups. No correlation was found between nutritional indices and pulmonary function and gases exchange parameters. FFM correlated positively with values of peripheral muscle function in normoxemic and hypoxemic patients. These data add further evidence to the hypothesis that hypoxemia is not a primary cause of the nutritional deficiency observed in COPD patients.

[Humoral rejection in heart transplantation. Report of 2 cases]

Heart transplantation is a therapeutic alternative for selected patients with refractory heart failure. Acute allograft rejection is one of the main causes of early death after transplantation. The cellular rejection is characterized by cellular infiltrates with or without myocyte necrosis. However, some patients develop left ventricular dysfunction due to rejection without evidence of cellular infiltration. In these patients, the rejection is mediated by antibodies and complement. Humoral rejection is a relative rare but potentially fatal form of acute allograft rejection. We report two patients with left ventricular dysfunction secondary to humoral rejection, shortly after cardiac transplantation. Both patients were treated with methylprednisolone, and azathioprine was substituted by cyclophosphamide. One patient underwent plasmapheresis. The clinical outcome was satisfactory and the left ventricular function returned to normal in both cases. The diagnostic and therapeutic strategies for the management of humoral rejection are reviewed.

Idiopathic pulmonary hemosiderosis with cystic lesions: a rare presentation

This report describes a case of a 49-year-old man with cough, recurrent hemoptysis, and dyspnea during 18 months, presenting with radiological findings of alveolar infiltrate and cystic lesions in left upper lobe. Laboratory studies revealed normocytic hypochromic anemia and normal coagulation tests. C-reactive protein and mucoproteins were negative. Serum protein electrophoresis and complement, urinalysis, serum creatinine, creatinine clearance, and 24-hour urine protein were normal. Tests for antineutrophil cytoplasmic antibodies and anti-glomerular-basement membrane antibodies were negative. Tests for connective tissue diseases were all negative. Histological findings were consistent with those of idiopathic pulmonary hemosiderosis. Radiological findings are discussed.

The role of echocardiographic harmonic imaging and contrast enhancement for improvement of endocardial border delineation

Despite advances in imaging technology, many myocardial segments remain poorly visualized with echocardiography; however, both contrast enhancement and harmonic imaging have shown promise for improving endocardial definition. Fifty subjects with technically limited echocardiograms were studied with fundamental and harmonic imaging as well as during echocardiographic contrast injection. Overall endocardial visualization scores improved with both techniques compared with fundamental imaging. Harmonic imaging improved endocardial visualization in 43% of all segments and in 57% of segments nonvisualized with fundamental imaging. The benefit of harmonic imaging was seen in all segments. Contrast echocardiography had similar overall improvements in visualization (42% of all segments, 67% of segments nonvisualized with fundamental imaging) but was not helpful in all regions. Harmonic imaging outperformed contrast in 9 of 22 segments, whereas contrast was superior in 4 of 22. In a subgroup of patients with very poor images, contrast enhancement was superior, with a greater increase in overall score and a higher salvage rate than harmonic (68% vs 40%).

Cor triatriatum in a 70-year-old woman: role of transesophageal echocardiography and dynamic three-dimensional echocardiography in diagnostic assessment

In this report we describe a 70-year-old woman with unrecognized nonobstructive cor triatriatum (CT). She had concomitant mitral regurgitation and coronary artery disease. Diagnosis of CT and its hemodynamic assessment were accomplished by transesophageal echocardiography. Dynamic three-dimensional echocardiography demonstrated multiple fenestrations in the left atrial membrane. Intraoperative findings confirmed the diagnostic accuracy of three-dimensional echocardiography. To our knowledge, this is the first case of CT that has anatomic correlation with three-dimensional echocardiography.

Enalapril restores depressed circulating insulin-like growth factor 1 in patients with chronic heart failure

BACKGROUND

Congestive heart failure (CHF) is characterized by increased activity of the renin-angiotensin system. Recent experimental studies have shown that infusion of angiotensin II results in depressed plasma levels of insulin-like growth factor 1 (IGF-1) and weight loss. We have previously reported that stable patients with CHF have decreased activity of the growth hormone (GH)-IGF1 axis. We have hypothesized, therefore, that angiotensin-converting enzyme (ACE) inhibition therapy should restore GH-IGF1 activity in CHF patients.

METHODS AND RESULTS

Nine patients with stable CHF who were taking digitalis and diuretics, New York Heart Association functional class III were studied before and after 8 weeks of therapy with Enalapril (10 mg twice daily). We measured IGF1 levels, radionuclide left ventricular ejection fraction (EF) and peak oxygen consumption (PVO2). We found that 7 of 9 patients had abnormally low levels of IGF1 (0.2-0.5 mU/ml). IGF1 levels reverted to normal after Enalapril therapy (0.36 +/- 0.03 to 0.8 +/- 0.14 mU/ml, P = .004). This was associated with a significant increase in EF (27.4 +/- 1.1 to 31.4 +/- 0.9%) and PVO2 (14.8 +/- 1.2 to 18.6 +/- 1.5 ml/kg/min) values (P < .05).

CONCLUSION

Chronic ACE inhibition therapy restored previously reduced IGF1 plasma levels in patients with CHF, most likely by reducing angiotensin II activity.

[Comparison of low-molecular-weight heparin and unfractionated heparin in the treatment of unstable angina]

BACKGROUND

Low molecular weight heparin can be administered by the subcutaneous route and has a stable and prolonged antithrombotic effect. These features have prompted clinical essays about its use as an alternative to unfractionated heparin in the treatment of unstable angina.

AIM

To compare the clinical effects of low molecular weight heparin and unfractionated conventional heparin in patients with unstable angina or non Q infarction.

PATIENTS AND METHODS

Seventy patients (47 male) admitted to the hospital with the diagnosis of unstable angina or non Q acute myocardial infarction were randomly assigned to receive unfractionated intravenous heparin or subcutaneous low molecular weight heparin bid. All received aspirin p.o. and i.v. nitroglycerin. The incidence of recurrent angina, acute myocardial infarction or a need for emergency surgical revascularization during hospital stay were assessed in both groups.

RESULTS

Compared to patients with low molecular weight heparin, patients receiving unfractionated heparin had a higher incidence of recurrent resting angina (23 and 47.5% respectively, p < 0.04) and higher need for emergency surgical revascularization (3.3 and 17.5% respectively, p < 0.06). Patients treated with unfractionated conventional heparin had a 3 times higher risk of having an adverse cardiovascular event than patients receiving low molecular weight heparin (O.R. 0.33, confidence intervals 0.11-0.58).

CONCLUSIONS

Low molecular weight heparin is superior to unfractionated conventional heparin in the treatment of unstable angina and non Q acute myocardial infarction.

[Effects of ramipril and spironolactone on ventricular remodeling after acute myocardial infarction: randomized and double-blind study]

BACKGROUND

Studies have shown that angiotensin converting enzyme (ACE) inhibition prevents left ventricular remodeling and cardiovascular events after an acute myocardial infarction. The role of aldosterone in ventricular remodeling after a myocardial infarction has not been addressed.

AIM

To compare the effects of an ACE inhibitor, an aldosterone receptor antagonist and placebo on left ventricular remodeling after a first episode of transmural acute myocardial infarction.

PATIENTS AND METHODS

Patients hospitalized for a first episode of acute myocardial infarction were blindly and randomly assigned to receive ramipril (2.5 mg bid), spironolactone (25 mg tid) or placebo. Ejection fraction, left ventricular end diastolic and end systolic volumes were measured by multigated radionuclide angiography, at baseline and after six months of treatment.

RESULTS

Twenty four patients were assigned to placebo, 31 to ramipril and 23 to spironolactone. Age, gender, Killip class, treatment with thrombolytics, revascularization procedures and use of additional medications were similar in the three groups. After six months of treatment, ejection fraction increased from 34.5 +/- 2.3 to 40.2 +/- 2.4% in patients on ramipril, from 32.6 +/- 2.9 to 36.6 +/- 2.7% in patients on spironolactone, and decreased from 37 +/- 3 to 31 +/- 3% in patients on placebo (ANOVA between groups p < 0.05). Basal end systolic volume was similar in all three groups, increased from 43.4 +/- 3.4 to 61.4 +/- 6.0 ml/m2 in patients on placebo and did not change in patients on spironolactone or ramipril (ANOVA p < 0.05). End diastolic volume was also similar in the three groups, increased from 70.6 +/- 4.3 to 92.8 +/- 6.4 ml/m2 in patients on placebo and did not change with the other treatments.

CONCLUSIONS

Ramipril and spironolactone had similar effects on ventricular remodeling after acute myocardial infarction, suggesting that aldosterone contributes to this phenomenon and that inhibition of its receptor may be as effective as ACE inhibition in its prevention.

[Vasodilator hormonal agents in chronic heart failure: effect of angiotensin-converting enzyme inhibitors]

BACKGROUND

Administration of angiotensin converting enzyme (ACE) inhibitors to patients with congestive heart failure (CHF) is associated to a decrease in the abnormal vasoconstrictor neurohormonal activity. This contributes to the sustained benefits of these drugs on symptoms and survival of patients with CHF. There is little information, however, regarding the effects of ACE inhibition on vasodilator and natriuretic hormones.

AIM

To evaluate the chronic effects of enalapril, in addition to digitalis and diuretics in patients with chronic cardiac failure.

PATIENTS AND METHODS

Nine patients with an idiopathic dilated cardiomyopathy (8 male, aged 48 to 76 years old) under treatment with digitalis and diuretics, received enalapril 20 mg bid during eight weeks. Before and after this treatment period resting left ventricular ejection fraction, functional class, plasma levels of atrial natriuretic factor and bradykinins (BK) and urinary excretion of kalikreins (BK) and prostaglandin E2 (PGE2) were measured.

RESULTS

After enalapril therapy, there was a significant increase in maximal O2 consumption (14.8 +/- 1.2 to 18.6 +/- 1.5 ml/kg/min, p < 0.05) and radionuclide LV ejection fraction (27.4 +/- 1.1 to 31.4 +/- 0.9% p < 0.05). This was associated with a significant decrease in plasma ANP levels (559 +/- 158 to 178 +/- 54.8 pg/ml) and UK (391 +/- 112 to 243 +/- 92 Cu/24 h).

CONCLUSIONS

The decrease in ANP levels, which is a well known marker of prognosis in CHF, could contribute to explain the sustained clinical benefits observed with ACE inhibitors in patients with CHF.

[Growth hormone deficiency in patients with chronic heart failure]

BACKGROUND

Experimental and preliminary clinical data in patients with dilated cardiomyopathy show that growth hormone has a positive inotropic effect and contributes to peripheral vasodilatation. However, there is little information about the activity of growth hormone-IGF-1 axis in patients with chronic heart failure.

AIM

To measure growth hormone and IGF-1 levels in patients with chronic heart failure.

PATIENTS AND METHODS

Nine patients, aged 49 to 76 years old, 7 male, were studied. Seven had an idiopathic dilated cardiomyopathy and 2 a coronary heart disease. All had a stable cardiac failure, in functional capacity II or III and were receiving digoxin, furosemide and potassium supplements. Thyroid hormone levels, basal and exercise growth hormone and IGF-1 levels were measured and compared with reference values for American populations. Left ventricular ejection fraction was measured with an isotopic technique and nutritional status using anthropometry and indirect calorimetry.

RESULTS

Anthropometric measures, basal and post-prandial oxygen consumption were within normal limits. Thyroid hormone levels were normal. During maximal exercise, growth hormone levels were 2.56 +/- 4.1 ng/ml and IGF-1 levels were 0.56 +/- 0.61 mU/ml. These values were significantly lower than expected for age and sex.

CONCLUSIONS

These patients with chronic cardiac failure have lower than normal growth hormone and IGF-1 levels.

Assessment of vitamin A status in chronic obstructive pulmonary disease patients and healthy smokers

The relation between vitamin A status and the degree of lung airway obstruction was examined in a cross-sectional study of 36 male subjects aged 43-74 y who were assigned to five groups as follows: healthy nonsmokers (n = 7), healthy smokers (n = 7), mild chronic obstructive pulmonary disease (COPD-mild) patients (n = 9), COPD-moderate-severe patients (n = 7), and COPD-moderate-severe patients with exacerbation (+ex; n = 6). Smoking habits, pulmonary function tests, energy-protein status were assessed; serum concentrations of retinyl esters, retinol, retinol binding protein, and transthyretin and relative dose responses were measured. In addition, 12 male smokers aged 45-61 y with mild COPD were randomly assigned to two groups for a longitudinal study: six subjects consumed vitamin A (1000 RE/d; COPD-vitamin A) and six subjects received placebo for 30 d. Lowered serum retinol concentrations were found in the COPD-moderate-severe and COPD-moderate-severe+ex groups. Measurements of vitamin A status in healthy smokers and in COPD-mild patients were not different from those in healthy nonsmokers. The improvement of pulmonary function test results after vitamin A supplementation [mean increase for 1-s forced expiratory volume (FEV1) = 22.9% in the COPD-vitamin A group] may support the assumption of a local (respiratory) vitamin A deficiency in patients with this disease.

[Noncardiogenic pulmonary edema associated with hydrochlorothiazide use]

A 54 years old female patient with a mitral valve prolapse and a rheumatoid arthritis treated with steroids was admitted with dyspnea and hypotension, that started 30 min after taking a pill containing enapril and hydrochlorothiazide. Hemodynamic monitoring with a Swan-Ganz catheter showed a pulmonary capillary pressure of 5 mm Hg, a systemic vascular resistance of 887 (dyn sec)/cm5 and a cardiac output of 10 l/min. The patient had a history of adverse reactions to thiazides and responded to volume replacement, dopamine and steroids.

Cyclic AMP-dependent protein kinase and mechanical heart function in ventricular hypertrophy induced by pressure overload or secondary to myocardial infarction

The role of cyclic AMP-dependent protein kinase (PKA) and systolic function during the development of left ventricular hypertrophy (LVH) still remain uncertain. The aim of this work is to study PkA activity and mechanical heart function in two experimental heart hypertrophy models: specifically, one induced by pressure overload (Goldblatt model: two kidneys, one clamped, Gb); and another secondary to myocardial infarction (MI) generated by ligation of the left coronary artery. Hypertension in the Gb group becomes evident by the third and fourth week after surgery without any significant change in the corresponding sham group. The myocardial infarction group did not show any change in systolic pressure. Different degrees of LVH for the two experimental models were observed. Relative cardiac mass (RCM) and relative ventricular mass (RVM) increased 23 and 16%, respectively, above the sham-operated rats in MI group (P < 0.05). For the pressure overload model, the increase values were 42 and 44%, respectively (P < 0.05). Left ventricular hypertrophy was also evaluated through quantitative changes in cardiac beta-myosin heavy chain which agreed with morphometric studies in Goldblatt rats. Ventricular PKA activity did not show any significant difference with respect to the sham-operated group after induction of pressure overload. For the MI model, ventricular PKA activity changed only at day 7 post-infarction with a 289% increase above the sham-operated group (P < 0.05). The absence of activation of ventricular PKA after constriction of renal artery or myocardial infarction was also corroborated by the patterns of PKA-dependent phosphorylated proteins. While force-generating capacity was increased, there was no change in ventricular PKA activity, indicating that there is no relation between this enzyme and systolic stress-strain regression lines in either pressure overload or myocardial infarction conditions. Cyclic AMP-dependent protein kinase activity had no relation with development of cardiac hypertrophy in the two experimental models of LVH. These findings contribute to the hypothesis for a multifactorial interaction of different intracellular biochemical and molecular mechanisms in the genesis of cardiac hypertrophy.

[Non-invasive intermittent mechanical ventilation: usefulness in treatment of chronic severe heart failure]

BACKGROUND

The higher respiratory work and less inspiratory muscle strength of patients with cardiac failure may contribute to decrease their functional capacity.

AIM

To assess the effects of non invasive intermittent mechanical ventilation on clinical parameters, peripheral perfusion, cardiac and inspiratory muscle function.

PATIENTS AND METHODS

Patients with chronic cardiac failure, functional capacity III-IV were subjected to 6 sessions of nasal non invasive intermittent ventilation during 4 hours or to simulated ventilation (controls).

RESULTS

Fifteen ventilated patients and six controls completed the protocol. Ventilated patients improved the Mahler transition score for dyspnea by 4 +/- 1.6 points. They also improved their aerobic capacity, increasing the exercise duration from 10.9 +/- 4 to 12.7 +/- 5 min and their maximal oxygen consumption from 14.6 +/- 4 to 16.4 +/- 5.7 ml/kg/min. These patients also decreased their O2 and CO2 ventilatory equivalents. Maximal inspiratory pressure increased from 67.9 +/- 23.6 to 80.19 +/- 21.4 cm H2O, sustained maximal inspiratory pressure increased from 101.4 +/- 48 to 133 +/- 53 cm H2O and maximal endurance increased from 132 +/- 52 to 162 +/- 58 g in ventilated patients. None of these variables was modified in control patients. No changes were observed in renal function, blood volume, arterial gases, spirometry or plasma catecholamine levels in any group.

CONCLUSIONS

Intermittent nasal ventilation or other measures to improve inspiratory muscle function may be beneficial for patients with severe cardiac failure.

[Cardiopulmonary exercise test in patients with chronic cardiac failure: comparison with normal subjects and reproducibility of measurements]

The aim of this work was to measure oxygen consumption and carbon dioxide production during exercise in 21 subjects with cardiac failure and 13 normal subjects. During the resting period, subjects with cardiac failure had higher ventilatory frequency and respiratory quotient than normals. During maximal exercise, the former achieved higher ventilatory frequency and oxygen ventilatory equivalent than normals. In subjects with cardiac failure and normals, anaerobic thresholds were 14.4 +/- 0.9 and 28.8 +/- 2.2 ml/kg/min respectively and peak oxygen consumptions 17.1 +/- 1 and 34.4 +/- 1.7 ml/kg/min respectively. There were less than 10% differences in parameters when tests were repeated in 10 subjects with cardiac failure. It is concluded that gas exchange testing may be a reliable and objective assessment method in patients with cardiac failure.

[Tilt test: hemodynamic responses in patients with syncope or presyncope of unknown etiology]

The aim of this work was to assess the hemodynamic responses to the tilt test of 51 patients with syncope (n = 31) or presyncope (n = 20) of unknown etiology. A protocol with an inclination of 70 degrees (20 min) with or without isoproterenol (mean dose of 3.6 +/- 0.3 ug/min), was used. Forty five percent of patients had a positive test, 18 with isoproterenol at 70 degrees (group 1A) and 5 without isoproterenol (group 1B); 28 patients had a negative test (group 2). These groups did not differ in age or sex distribution. Basal heart rate was 76.2 +/- 2x'. At the end of the test it was 73.4 +/- 5.7 in group 1A, 78.0 +/- 7.5 in group 1B and 120.4 +/- 3.3 in group 2 (p < 0.01). Systolic blood pressure decreased to 78.1 +/- 4.8 mmHg in group 1A, to 76.2 +/- 9.9 in group 1B and did not decrease in group B (130.0 +/- 5.7 mmHg, p < 0.01). The required dose of isoproterenol was higher in group 1A than in group 2 (4.4 +/- 0.3 vs 3.1 +/- ug/min, p < 0.01). It is concluded that the tilt test reproduced symptoms and accompanying hemodynamic mechanisms in a high proportion of patients with syncope of unknown etiology. This test should be incorporated in the diagnostic workup of these patients.

Changes in cyclic AMP dependent protein kinase and active stiffness in the rat volume overload model of heart hypertrophy

OBJECTIVE

The aim was to clarify the role of cyclic AMP dependent protein kinase (PKA) and changes in mechanical heart function during development of cardiac hypertrophy induced by volume overload.

METHODS

Protein and DNA contents, PKA activity, and peak systolic stress-strain relationships in hearts from animals submitted to aortocaval shunt were assessed as a function of time. Sham operated (control) rats were used as controls.

RESULTS

Heart weight to body weight ratio and cardiac protein content per heart increased from d 7 (p < 0.005 and p < 0.01, respectively) reaching their highest values by d 56; the same occurred with cardiac DNA content. PKA activity.g-1 tissue in soluble extracts of hearts from rats with aortocaval shunt increased by 2.7-fold on d 2 (p < 0.005), reached a ninefold peak increase by d 7 (p < 0.0001) and declined to fourfold by d 56 with respect to control values. The end peak systolic stress-strain relation slopes were: control, 368(SEM 14) g.cm-2 (n = 16); aortocaval shunt values: 2 d, 514(28) g.cm-2 (n = 6); 7 d, 579(10) g.cm-2 (n = 7); and 56 d, 554(28) g.cm-2 (n = 7). The force generating capacity at 0% strain was also significantly higher in the shunt groups as compared to sham operated controls (p < 0.01). Early activation of PKA was also confirmed through endogenous cardiac protein phosphorylation. SDS-PAGE gel electrophoretogram and autoradiography showed more heavily phosphorylated bands in aortocaval shunt hearts than in the control group.

CONCLUSIONS

PKA activity and the slope of systolic stress-strain regression line followed a similar trend throughout the study, with an early increase in both variables by d 2 in the shunt group, reaching a peak at d 7, and decreasing thereafter but remaining higher than in controls. PKA activity appears to be related to increased force generating capacity rather than to hypertrophy or increased cardiac protein content. Thus PKA activation is an early biochemical event after aortocaval shunt, followed later by cardiac hypertrophy. Changes in PKA activity showed a similar trend to mechanical heart function over time. These findings help to explain the changes in the mechanical properties of the heart preceding the development of cardiac hypertrophy in the rat model of volume overload.

[Evaluation of the effect of enalapril, a converting enzyme inhibitor, on lymphocytic beta-adrenergic receptors of patients with chronic cardiac insufficiency]

We have previously corroborated that lymphocyte beta-adrenergic receptor density is significantly reduced in patients with chronic heart failure. It is well known that angiotensin converting enzyme inhibitors normalize the function of sympathetic nervous system. We have assessed the effect of enalapril on lymphocyte beta-adrenergic receptor system from patients with chronic heart failure (n = 14) using a random, cross and double blind protocol. Our results show that the improvement in clinical score and ventricular function were not related with changes in the number and affinity of beta-adrenergic receptor nor cyclic AMP content in lymphocytes obtained from these patients.