Exercise stress testing in clinical practice

Exercise stress testing is an important diagnostic tool for evaluating patient’s cardiovascular performance. The present review describes the accuracy and the value of exercise stress testing in different settings: after an acute coronary event, after percutaneous coronary intervention or coronary artery bypass graft; in patients risk assessment before non-cardiac surgery; in diabetic population; in patients with baseline electrocardiographic abnormalities. Moreover, this review provides insights relating to test accuracy in women and geriatric patients. Finally, this review explores new variables/parameters (dyspnea, chronotropic incompentence, heart rate recovery, functional capacity, integrated scores) that in the last few years added an incremental value to conventional analysis of exercise-induced angina or electrocardiographic changes

Takotsubo syndrome in a young woman during puerperium: case report

Introduction. Takotsubo syndrome is a reversibile cardiomyopathy that often occurs during an emotional stress and is more frequent in post-menopausal women. Case presentation. We describe a clinic case of a 42 years old woman, admitted to our emergency unit because of a thoracic pain. The ECG showed ST-T elevation in V1- V4, the echocardiography revealed akinesia of apical segment of left ventricle. Coronary arteries were free from significant stenosis and ventriculography showed akinesia of apical segment of left ventricle. In the following days, ECG evolved toward a normalization of ST-T segment with appearance of negative T wave in V2-V6, and also the echocardiography showed a normalized LV wall motion. The patient was discharged and ECG and echocardiography were normal at two months follow up. Conclusion. In this case report, a young woman during puerperium presented with a Takotsubo syndrome. We speculate that the high Prolactin level and her emotional state contributed to the clinical manifestation of the syndrome

Vulnerable personality and Takotsubo cardiomyopathy consequent to emotional stressful events: a clinical case report

Introduction: Although the onset of Takotsubo cardiomyopathy (TTC) can be triggered by an acute, intense emotional stress, the exact pathogenic mechanisms still remain undefined. Presentation: A 58-year-old female was sent by ambulance to the Emergency Department (ED) for chest pain and ST elevations on ECG. Her chest pain began 3 hours before on admission after a domestic argument. Transthoracic echocardiogram showed severe systolic dysfunction with an ejection fraction of 20%. Cardiac catheterization revealed no significant coronary artery disease. The left ventriculogram showed apical ballooning with hyperdynamic proximal segments. A diagnosis of Takotsubo Cardiomyophaty (TTC) was made according to the Mayo Clinic 2008 criteria. The patient evolved with improvement of her condition and, therefore, was discharged from the hospital. Follow-up echocardiogram seven days later showed normal LV size and function with ejection fraction (EF) of 43%. Paykel Life Stress Event Scale identified as emotional trigger a domestic argument occurred 3 hours before symptom onset. History showed a major life stress event, death of a loved one, six months before symptoms. The patient underwent psychological assessment after hospital discharge by Emotional Regulation Questionnaire and BDI showing high suppression/ low reappraisal profile and moderate depression. Conclusion: This case highlights the hypothesis of a possible link between cognitive emotional processing and vulnerability to Takotsubo syndrome

Exercise stress testing in clinical practice

Exercise stress testing is an important diagnostic tool for evaluating patient's cardiovascular performance. The present review describes the accuracy and the value of exercise stress testing in different settings: after an acute coronary event, after percutaneous coronary intervention or coronary artery bypass graft; in patients risk assessment before non-cardiac surgery; in diabetic population; in patients with baseline electrocardiographic abnormalities. Moreover, this review provides insights relating to test accuracy in women and geriatric patients. Finally, this review explores new variables/parameters (dyspnea, chronotropic incompentence, heart rate recovery, functional capacity, integrated scores) that in the last few years added an incremental value to conventional analysis of exercise-induced angina or electrocardiographic changes

Atrial fibrillation detection using a novel three-vector cardiac implantable monitor: the atrial fibrillation detect study.

Aims Continuous rhythm monitoring is valuable for adequate atrial fibrillation (AF) management in the clinical setting. Subcutaneous leadless implantable cardiac monitors (ICMs) yield an improved AF detection, overcoming the intrinsic limitations of the currently available external recording systems, thus resulting in a more accurate patient treatment. The study purpose was to assess the detection performance of a novel three-vector ICM device equipped with a dedicated AF algorithm. Methods and results Sixty-six patients (86.4% males; mean age 60.4 ± 9.4 years) at risk to present AF episodes, having undergone the novel ICM implant (BioMonitor, Biotronik SE&Co. KG, Berlin, Germany), were enrolled. External 48-h ECG Holter was performed 4 weeks after the device implantation. The automatic ICM AF classification was compared with the manual Holter arrhythmia recordings. Of the overall study population, 63/66 (95.5%) had analysable Holter data, 39/63 (62%) showed at least one true AF episode. All these patients had at least one AF episode stored in the ICM. On Holter monitoring, 24/63 (38%) patients did not show AF episodes, in 16 of them (16/24, 67%), the ICM confirmed the absence of AF. The AF detection sensitivity and positive predictive value for episodes' analysis were 95.4 and 76.3%, respectively. Conclusion Continuous monitoring using this novel device, equipped with a dedicated detection algorithm, yields an accurate and reliable detection of AF episodes. The ICM is a promising tool for tailoring individual AF patient management. Further long-term prospective studies are necessary to confirm these encouraging results

Presence of carbepenemase-producing Enterobacteriaceae in the River Lambro basin, Italy: might sediment represent an important resistance reservoir?

In the last years, the rapid spread in anthropized ecosystems of pathogens which are resistant to carbapenem antibiotics has raised great concern. In this study, KPC-producing Klebsiella pneumoniae was found in the River Lambro in June 2019, whereas KPC-producing Klebsiella oxytoca and Citrobacter braakii were identified in untreated wastewaters. Susceptibility profiles indicated resistance to imipenem, ertapenem and meropenem. Different carbapenamase genes (blaKPC, blaNDM, blaVIM, blaOXA-48) were also found in the River Lambro, although not associated to living bacteria. The presence of a wide set of carbapenemase genes and resistant pathogens show that river sediments could act as a reservoir of antibiotic resistance potentially threatening human health

efficacy of telecardiology in improving the results of cardiac rehabilitation after acute myocardial infarction

Background: This study was addressed to verify if Telecardiology (TC) improves the results of Cardiac Rehabilitation in patients following a home-based Cardiac Rehabilitation Program (CRP) after acute myocardial infarction (AMI). Materials and Methods: We studied three groups of patients after AMI: Group A (control group): 15 patients, who followed a standard in-hospital CRP of 3 weekly sessions of 2 months duration; Group B (study group): 15 patients, who were enrolled in a home-based CRP of similar duration and were monitored by TC with the aid of an ecg-device (Sorin Life Watch CG 6106); Group C (second control group): 15 patients, who followed a home-based CRP without ecgmonitoring by TC. All patients performed a symptom-limited exercise testing at the beginning of the CRP. Psychometric data (STAI-Y1, STAI-Y2, BDI) were also evaluated. At the end of the CRP all patients underwent repeated exercise testing and psychometric evaluation. Results: TC applied to the home-based CRP was associated with a good compliance to the program. Compared to Group C, in Group B we observed an increase of maximal heart rate, exercise duration, maximal work-load, and an improvement of anxiety, a trend to reduction of depression, and an improvement of quality of life. These results were very similar to Group A patients following a hospital-based CRP. Conclusions: TC improves compliance, functional capacity and psychological profile of patients undergoing a home-based CRP, compared to patients enrolled in a homebased CRP without ecg-monitoring by Telecardiology

Integrative epigenomics in Sjögren´s syndrome reveals novel pathways and a strong interaction between the HLA, autoantibodies and the interferon signature

Primary Sjögren's syndrome (SS) is a systemic autoimmune disease characterized by lymphocytic infiltration and damage of exocrine salivary and lacrimal glands. The etiology of SS is complex with environmental triggers and genetic factors involved. By conducting an integrated multi-omics study, we confirmed a vast coordinated hypomethylation and overexpression effects in IFN-related genes, what is known as the IFN signature. Stratified and conditional analyses suggest a strong interaction between SS-associated HLA genetic variation and the presence of Anti-Ro/SSA autoantibodies in driving the IFN epigenetic signature and determining SS. We report a novel epigenetic signature characterized by increased DNA methylation levels in a large number of genes enriched in pathways such as collagen metabolism and extracellular matrix organization. We identified potential new genetic variants associated with SS that might mediate their risk by altering DNA methylation or gene expression patterns, as well as disease-interacting genetic variants that exhibit regulatory function only in the SS population. Our study sheds new light on the interaction between genetics, autoantibody profiles, DNA methylation and gene expression in SS, and contributes to elucidate the genetic architecture of gene regulation in an autoimmune population