Mental Workload Alters Heart Rate Variability, Lowering Non-linear Dynamics

Mental workload is known to alter cardiovascular function leading to increased cardiovascular risk. Nevertheless, there is no clear autonomic nervous system unbalance to be quantified during mental stress. We aimed to characterize the mental workload impact on the cardiovascular function with a focus on heart rate variability (HRV) non-linear indexes. A 1-h computerized switching task (letter recognition) was performed by 24 subjects while monitoring their performance (accuracy, response time), electrocardiogram and blood pressure waveform (finger volume clamp method). The HRV was evaluated from the beat-to-beat RR intervals (RRI) in time-, frequency-, and informational- domains, before (Control) and during the task. The task induced a significant mental workload (visual analog scale of fatigue from 27 ± 26 to 50 ± 31 mm, p < 0.001, and NASA-TLX score of 56 ± 17). The heart rate, blood pressure and baroreflex function were unchanged, whereas most of the HRV parameters markedly decreased. The maximum decrease occurred during the first 15 min of the task (P1), before starting to return to the baseline values reached at the end of the task (P4). The RRI dimension correlation (D2) decrease was the most significant (P1 vs. Control: 1.42 ± 0.85 vs. 2.21 ± 0.8, p < 0.001) and only D2 lasted until the task ended (P4 vs. Control: 1.96 ± 0.9 vs. 2.21 ± 0.9, p < 0.05). D2 was identified as the most robust cardiovascular variable impacted by the mental workload as determined by posterior predictive simulations (p = 0.9). The Spearman correlation matrix highlighted that D2 could be a marker of the generated frustration (R = –0.61, p < 0.01) induced by a mental task, as well as the myocardial oxygen consumption changes assessed by the double product (R = –0.53, p < 0.05). In conclusion, we showed that mental workload sharply lowered the non-linear RRI dynamics, particularly the RRI correlation dimension

0230: Effectiveness of switching Prasugrel's ‘low responders’ to ticagrelor after acute coronary syndrome

AimsThis study aimed to assess the effectiveness and safety of switching from Prasugrel to Ticagrelor patients identified as Prasugrel low-responders one month after ACS.Methods and results540 patients admitted for ACS with coronary stent implantation and discharged on Prasugrel 10mg were screened. Prasugrel response was assessed one month after discharge using Platelet Reactivity Index Vasodilatator Stimulated Phosphoprotein (PRI VASP). High on-Treatment Platelet Reactivity (HTPR) was defined as VASP>50%. Patients with HTPR were enrolled and switched to Ticagrelor 90 mg twice a day. They were re-tested a month later. Primary endpoint was defined as: comparison of degree of platelet inhibition and incidence of HTPR one month after switching to Ticagrelor in patients with HTPR on Prasugrel therapy. The safety endpoint was the incidence of bleedings under Ticagrelor as compared with Prasugrel therapy, using the Bleeding Academic Research Consensus definition.Between March 2010 and November 2013, 19 patients were defined as HTPR on Prasugrel 10 mg one month after ACS, with a mean VASP of 59,3%. Among these patients, 14 were switched to Ticagrelor 180 mg daily and, at one month, we observed a significant decrease in PRI VASP, with a mean value at 19.6% (p<0.001). No patients remained HTPR and 4 patients (28.4%) were identified as Very Low on-Treatment Platelet Reactivity (VLTPR) (VASP<10%). No ischemic events were reported after switching, while 3 patients (21%) suffered from bleeding complications (2 BARC1 and 1 BARC2 bleedings) during Ticagrelor therapy.ConclusionSwitch to Ticagrelor in Prasugrel's “low responders” patients is an effective strategy, leading to an adequate platelet inhibition in a large majority of patients. This biological tailored approach could be useful in preventing ischemic complications, in this specific high risk population, potentially increasing bleeding risk. This hypothesis needs to be confirmed in large clinical studies.Abstract 0230 – Figur

General practitioners’ perceptions on opportunistic single-time point screening for atrial fibrillation: A European quantitative survey

Atrial fibrillation; General practitioners; SurveyFibrilación auricular; Médicos de cabecera; EncuestaFibril·lació auricular; Metges de capçalera; EnquestaBackground: There is no clear guidance on how to implement opportunistic atrial fibrillation (AF) screening in daily clinical practice. Objectives: This study evaluated the perception of general practitioners (GPs) about value and practicalities of implementing screening for AF, focusing on opportunistic single-time point screening with a single-lead electrocardiogram (ECG) device. Methods: A descriptive cross-sectional study was conducted with a survey developed to assess overall perception concerning AF screening, feasibility of opportunistic single-lead ECG screening and implementation requirements and barriers. Results: A total of 659 responses were collected (36.1% Eastern, 33.4% Western, 12.1% Southern, 10.0% Northern Europe, 8.3% United Kingdom & Ireland). The perceived need for standardized AF screening was rated as 82.7 on a scale from 0 to 100. The vast majority (88.0%) indicated no AF screening program is established in their region. Three out of four GPs (72.1%, lowest in Eastern and Southern Europe) were equipped with a 12-lead ECG, while a single-lead ECG was less common (10.8%, highest in United Kingdom & Ireland). Three in five GPs (59.3%) feel confident ruling out AF on a single-lead ECG strip. Assistance through more education (28.7%) and a tele-healthcare service offering advice on ambiguous tracings (25.2%) would be helpful. Preferred strategies to overcome barriers like insufficient (qualified) staff, included integrating AF screening with other healthcare programs (24.9%) and algorithms to identify patients most suitable for AF screening (24.3%). Conclusion: GPs perceive a strong need for a standardized AF screening approach. Additional resources may be required to have it widely adopted into clinical practice.The AFFECT-EU project has received funding from the European Research Council under the European Union’s Horizon 2020 research and innovation program under the grant agreement no. 847770

Hyperoxia Improves Hemodynamic Status During Head-up Tilt Testing in Healthy Volunteers A Randomized Study

International audienceHead-up tilt test is useful for exploring neurally mediated syncope. Adenosine is an ATP derivative implicated in cardiovascular disturbances that occur during head-up tilt test. The aim of the present study was to investigate the impact of hyperoxia on adenosine plasma level and on hemodynamic changes induced by head-up tilt testing. Seventeen healthy male volunteers (mean age 35 AE 11 years) were included in the study. The experiment consisted of 2 head-up tilt tests, 1 session with subjects breathing, through a mask, medical air (FiO 2 ¼ 21%) and 1 session with administration of pure oxygen (FiO 2 ¼ 100%) in double-blind manner. Investigations included continuous monitoring of hemodynamic data and measurement of plasma adenosine levels. No presyncope or syncope was found in 15 of the 17 volunteers. In these subjects, a slight decrease in systolic blood pressure was recorded during orthostatic stress performed under medical air exposure. In contrast, hyperoxia led to increased systolic blood pressure during orthostatic stress when compared with medical air. Furthermore, mean adenosine plasma levels decreased during hyperoxic exposure before (0.31 AE 0.08 mM) and during head-up tilt test (0.33 AE 0.09 mM) when compared with baseline (0.6 AE 0.1 mM). Adenosine plasma level was unchanged during medical air exposure at rest (0.6 AE 0.1 mM), and slightly decreased during orthostatic stress. In 2 volunteers, the head-up tilt test induced a loss of consciousness when breathing air. In these subjects, adenosine plasma level increased during orthostatic stress. In contrast, during hyperoxic exposure, the head-up tilt test did not induce presyncope or syncope. In these 2 volunteers, biological study demonstrated a decrease in adenosine plasma level at both baseline and during orthostatic stress for hyperoxic exposure compared with medical air. These results suggest that hyperoxia was able to increase blood pressure during head-up tilt test via a decrease in plasma adenosine concentration. Our results also suggest that adenosine receptor antagonists are worth trying in neurocardiogenic syncope. (Medicine 95(8):e2876) Abbreviations: AR = adenosine receptor, APL = adenosine plasma level, BP = blood pressure, DBP = diastolic blood pressure, FiO 2 = fraction of inspired oxygen, HR = heart rate, HUT = head-up tilt test, LMM = linear mixed model, PO 2 = partial pressure of oxygen, SBP = systolic blood pressure

Benefit of dual-chamber pacing with Closed Loop Stimulation in tilt-induced cardio-inhibitory reflex syncope (BIOSync trial): study protocol for a randomized controlled trial

Ritme cardíac; Síncope reflex neurològic; Prova de la taula d’inclinacióRitmo cardíaco; Síncope reflejo neuromediado; Prueba de la mesa inclinadaCardiac pacing; Neuro-mediated reflex syncope; Tilt-Table testBackground: The efficacy of dual-chamber cardiac pacing in neuro-mediated reflex syncope with a cardio-inhibitory response to the Tilt-Table test (TT) has not been definitively assessed so far. The lack of reproducibility of results from previous studies may be partially explained by discrepancies in subject selection and some weaknesses in design and methods. The European Society of Cardiology (ESC) has set a class IIb indication to pacemaker implantation in this population recommending further research. Methods/design: The BIOSync study is a multicenter, patient- and outcome-assessor-blind, randomized, parallel-arm, placebo-controlled trial with the objective of assessing the clinical benefit of cardiac pacing in patients with frequently recurrent reflex syncope, suspected (but not proven) to be triggered by asystolic pauses as showing a VASIS 2B response to the TT (>3-s pause regardless of blood pressure drop). The primary and secondary endpoints are time to first post-implantation recurrence of syncope or the combination of pre-syncope or syncope, respectively. One hundred and twenty-eight consenting patients will be 1:1 randomized to dual-chamber cardiac pacing 'on' or 'off' after pacemaker implantation, and followed up until the first adjudicated primary endpoint event for a maximum of 2 years. The so-called Closed Loop Stimulation function on top of dual-chamber pacing is the pacing mode selected in the study active arm. Participating patients are asked to self-report syncopal symptoms at least every 3 months with self-administered questionnaires addressed to an independent Adjudication Committee. Patients and members of the Adjudicating Committee are blinded to randomization. The study is designed to detect a 40% relative reduction in the 2-year incidence of syncopal recurrences with 80% statistical power. Discussion: The BIOSync study is designed to definitively assess the benefit of pacing against placebo in reflex syncope patients with a cardio-inhibitory response to the TT. The study will also provide important information on the efficiency of the TT in appropriately selecting reflex syncope patients for cardiac pacing.All study-related costs are being directly supported by the sponsor of the study (BIOTRONIK SE & Co. KG, Berlin, Germany). No further funding is provided

RETRATO DE NIÑOS [Material gráfico]

Copia digital. Madrid : Ministerio de Educación, Cultura y Deporte, 201

Câncer de fígado: ameaça nova ou antiga para os jovens dos países em desenvolvimento?

Among the most frequent malignancies worldwide, hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death (1). Its incidence has doubled over the past two decades, with the greatest burden occurring in low- and middle-income countries. Malignant primary liver tumors are usually described as a pathology affecting mainly men older than 40 years with a cirrhotic liver; they have rarely been reported in younger people and usually, in those younger than 40, most commonly hepatoblastoma.Entre las neoplasias malignas más frecuentes del mundo, el carcinoma hepatocelular (CHC) es la segunda causa de muerte relacionada con el cáncer (1). Su incidencia se ha duplicado durante las dos últimas décadas y la mayor carga se produce en los países de ingresos bajos y medianos. Los tumores hepáticos primarios malignos suelen describirse como una patología que afecta principalmente a hombres mayores de 40 años con un hígado cirrótico; rara vez se han registrado en personas más jóvenes y normalmente, en menores de 40, lo más común es el hepatoblastoma.Entre as doenças malignas mais comuns no mundo inteiro, o carcinoma hepatocelular (HCC) é a segunda principal causa de morte relacionada ao câncer (1). Sua incidência dobrou nas últimas duas décadas, sendo que a maior carga ocorreu em países de baixa e média renda. Os tumores primários malignos do fígado são geralmente descritos como uma patologia que afeta principalmente homens acima de 40 anos de idade com fígado cirrótico; raramente foram relatados em pessoas mais jovens e geralmente, naqueles com menos de 40 anos, o mais comum é o hepatoblastoma

Management of asymptomatic arrhythmias: a European Heart Rhythm Association (EHRA) consensus document, endorsed by the Heart Failure Association (HFA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin America Heart Rhythm Society (LAHRS).

Asymptomatic arrhythmias are frequently encountered in clinical practice. Although studies specifically dedicated to these asymptomatic arrhythmias are lacking, many arrhythmias still require proper diagnostic and prognostic evaluation and treatment to avoid severe consequences, such as stroke or systemic emboli, heart failure, or sudden cardiac death. The present document reviews the evidence, where available, and attempts to reach a consensus, where evidence is insufficient or conflicting

2018 EHRA expert consensus statement on lead extraction: Recommendations on definitions, endpoints, research trial design, and data collection requirements for clinical scientific studies and registries: Endorsed by APHRS/HRS/LAHRS

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