Oscillatory behavior of P wave duration and PR interval in experimental congestive heart failure: a preliminary study

Objective: The relationship between the autonomic nervous system (ANS) modulation of the sinus node and heart rate variability has been extensively investigated. The current study sought to evaluate, in an animal experimental model of pacing-induced tachycardia congestive heart failure (CHF), a possible ANS influence on the P wave duration and PR interval oscillations. Approach: Short-term (5 min) time and frequency domain analysis has been obtained in six dogs for the following electrocardiographic intervals: P wave duration (P), from the onset to peak of P wave (P p), from the onset of P wave to the q onset (PR) and from the end of P wave to the onset of q wave (P e R). Direct vagal nerve activity (VNA), stellate ganglion nerve activity (SGNA) and electrocardiogram (ECG) intervals have been evaluated contextually by implantation of three bipolar recording leads. Main results: At the baseline, multiple regression analysis pointed out that VNA was strongly positively associated with the standard deviation of PP and P e R intervals (r 2:0.997, p < 0.05). The same variable was also positively associated with high-frequency (HF) of P expressed in normalized units, of P p, and of P e R (b: 0.001) (r 2: 0.993; p < 0.05). During CHF, most of the time and frequency domain variability significantly decreased from 20% to 50% in comparison to the baseline values (p < 0.05) and SGNA correlated inversely with the low frequency (LF) obtained from P e R (p < 0.05) and PR (p < 0.05) (r 2:0.899, p < 0.05). LF components, expressed in absolute and normalized power, obtained from all studied intervals, were reduced significantly during CHF. Any difference between the RR and PP spectral components was observed. Significance: The data showed a significant relationship between ANS and atrial ECG variables, independent of the cycle duration. In particular, the oscillations were vagal mediated at the baseline, while sympathetic mediated during CHF. Whereas P wave variability might have a clinical utility in CHF management, it needs to be addressed in specific studies

Associations between depressive symptoms and disease progression in older patients with chronic kidney disease: results of the EQUAL study

Background Depressive symptoms are associated with adverse clinical outcomes in patients with end-stage kidney disease; however, few small studies have examined this association in patients with earlier phases of chronic kidney disease (CKD). We studied associations between baseline depressive symptoms and clinical outcomes in older patients with advanced CKD and examined whether these associations differed depending on sex. Methods CKD patients (&gt;= 65 years; estimated glomerular filtration rate &lt;= 20 mL/min/1.73 m(2)) were included from a European multicentre prospective cohort between 2012 and 2019. Depressive symptoms were measured by the five-item Mental Health Inventory (cut-off &lt;= 70; 0-100 scale). Cox proportional hazard analysis was used to study associations between depressive symptoms and time to dialysis initiation, all-cause mortality and these outcomes combined. A joint model was used to study the association between depressive symptoms and kidney function over time. Analyses were adjusted for potential baseline confounders. Results Overall kidney function decline in 1326 patients was -0.12 mL/min/1.73 m(2)/month. A total of 515 patients showed depressive symptoms. No significant association was found between depressive symptoms and kidney function over time (P = 0.08). Unlike women, men with depressive symptoms had an increased mortality rate compared with those without symptoms [adjusted hazard ratio 1.41 (95% confidence interval 1.03-1.93)]. Depressive symptoms were not significantly associated with a higher hazard of dialysis initiation, or with the combined outcome (i.e. dialysis initiation and all-cause mortality). Conclusions There was no significant association between depressive symptoms at baseline and decline in kidney function over time in older patients with advanced CKD. Depressive symptoms at baseline were associated with a higher mortality rate in men

Temporal dispersion of ventricular repolarization phase and autonomic nervous system control: clinical and experimental evidences

Abstract- Sudden cardiac death (SCD) is the most dreadful complication of many cardiac diseases. No study has already investigated the myocardial temporal dispersion indexes as possible tools in stratifying the overall cardiovascular mortality in patients with coronary risk factors and preserved left ventricular systolic function. Method- We retrospectively compared the short-term (5-minutes) heart rate variability (HRV), QTe variability index ( QTeVI), QTp variability index QTpVI), calculated from q to T wave peak and Te variability index calculated from T wave peak to the T wave end (TeVI) in coronary risk factor deceased (n:10) or survived (n:94) patients in two years follow-up. Results- All of the QT variability indexes and the most of HRV spectral components coherence variables differed in the two subjects groups. Multivariate logistic regression analysis identified the increase of QTeVI, QTpVI, TeVI and the decrease of SDNN, lnTP, lnLF and lnHF, predicting cardiovascular mortality. Conclusions- In a population with common coronary risk factors and normal systolic function all temporal dispersion indexes and RR spectral analysis variable seem be a risk factors for cardiovascular mortality

P wave analysis and left ventricular systolic function in chronic heart failure. possible insights form the P wave - PP interval spectral coherence

Background - Chronic increase in left ventricular filling pressure represents one of the most important mechanism underlying the structural, as well as the electrical, atrial chamber remodeling leading to atrial fibrillation. The present pilot pathophysiological study sought to investigate possible relationship between short-period cross-spectral coherence of P-Q, R-R and P-P intervals and echocardiographic indices of left ventricular and atrial function. Method and Results - Electrocardiographic single lead short-term cross-spectral analysis on P-Q and P-P intervals was performed in 31 patients with chronic heart failure (CHF). Twenty age and therapy matched hypertensive patients acted as control group. The interval between the beginning of P wave and its peak (Ppeak) was also analyzed. Patients with CHF showed a significant lower PQ → PP and Ppeak → PP coherence (p&lt;0.001) than the counterpart. At multivariate analysis only Ppeak → PP was independently associated to left ventricular ejection fraction (r2: 0.312; b: 60; β: 0.559; p&lt;0.0001) and atrial volume (r2: -0.160; b: -0.15; β:-0.400, p &lt;0.05). Conclusions - Ppeak → PP coherence might be a simple marker of left ventricular and atrial function. Whether this index could be a useful noninvasive marker of increased left ventricular filling pressure and, possibly, of atrial fibrillation risk needs to be test in larger prospective study

Giant right atrial thrombus in hepatocellular carcinoma: real-time characterization by cardiac magnetic resonance and real time three-dimensional echocardiography

Hepatocellular carcinoma (HCC) with extension to the right atrium is an uncommon form of cardiac involvement. We report a case of a 67-year-old man admitted to our Department for the incidental findings of a mass in the right atrium. Physical examination revealed leg edema, distention of external jugular vein and ascites. The anamnestic collection revealed HCC occurred on post-alcoholic liver cirrhosis 3 years earlier. Transthoracic echocardiography revealed a dilated RA containing a mass, with superficial apposition of a thrombotic material. Bi-dimensional echocardiography is the most commonly used noninvasive tool for evaluating intracardiac masses. Although MRI is considered the gold standard, real-time three-dimensional echocardiography has the capability to obtain the entire volume reconstruction of an intracardiac mass, even with an irregular shape. Moreover, it permits an hemodynamic evaluation of the potential obstructive effects visualized from different angles and planes

Myocardial repolarization dispersion and autonomic nerve activity in a canine experimental acute myocardial infarction model

BACKGROUND Evidence from a canine experimental acute myocardial infarction (MI) model shows that until the seventh week after MI, the relationship between stellate ganglion nerve activity (SGNA) and vagal nerve activity (VNA) progressively increases. OBJECTIVE The purpose of this study was to evaluate how autonomic nervous system activity influences temporal myocardial repolarization dispersion at this period. METHODS We analyzed autonomic nerve activity as well as QT and RR variability from recordings previously obtained in nine dogs. From a total of 48 short-term ECG segments, 24 recorded before and 24 recorded 7 weeks after experimentally-induced MI, we obtained three indices of temporal myocardial repolarization dispersion: QT(e) (from Q-wave to T-wave end), QT(p) (from Q-wave to T-wave peak), and T-e (from T-wave peak to T-wave end) variability index (QT(e)VI, QT(p)VI, TeVI). We also performed heart rate variability power spectral analysis on the same segments. RESULTS After MI, all the QT variables increased QT(e)VI (median [interquartile range]) (from -1.76[0.82] to -1.32[0.68]), QT(e)VI (from -1.90[1.01] to -1.45[0.78]), and TeVI (from -0.72[0.67] to -0.22[1.00]), whereas all RR spectral indices decreased (P < .001 for all). Distinct circadian rhythms in QT(e)VI (P < .05,) QT(p)VI (P < .001) and TeVI (P < .05) appeared after MI with circadian variations resembling that of SGNA/VNA. The morning QT(p)VI and TeVI acrophases approached the SGNA/VNA acrophase. Conversely, the evening QT(e)VI acrophase coincided with another SGNA/VNA peak. After MI, regression analysis detected a positive relationship between SGNA/VNA and TeVI (R-2: 0.077; beta: 0.278; p < 0.001). CONCLUSION Temporal myocardial repolarization dispersion shows a circadian variation after MI reaching its peak at a time when sympathetic is highest and vagal activity lowest

Nuova tecnica di imaging 3D CARTOSOUND applicata all'estrazione transvenosa di elettrocateteri

INTRODUZIONE. La rimozione di elettrocateteri cardiaci viene eseguita in un numero sempre maggiore di ospedali con incidenza di complicanze significativa,soprattutto nei centri a basso volume. Le attuali tecniche estrattive sono limitate dall’impossibilità di visualizzare direttamente le struttura anatomiche,provocando ansia persino negli operatori più esperti. Inoltre,nessuna tecnica di estrazione transvenosa può essere considerata standard e applicabile in tutti i pazienti. Da questo ne deriva la necessità di dover indirizzare le varie tecniche estrattive con rischio/beneficio ottimizzato al singolo paziente. METODI. Registro prospettico monocentrico in cui tutti i pazienti sottoposti ad estrazione di elettrocateteri sono stati consecutivamente arruolati. Sono stati creati e confrontati due gruppi in base all’utilizzo di tecnologia CartoSoundTM (gruppo CARTOSOUND) o sola fluoroscopia convenzionale (gruppo CONTROLLO). Una mappa 3D CartoSound delle strutture venose,delle camere cardiache destre,del tessuto fibroso e degli elettrocateteri è stata creata prima e durante la procedura. Sono state utilizzate diverse tecniche di estrazione,in linea con un approccio principalmente step-by-step nel gruppo CONTROLLO e basato sulla valutazione individuale del rischio/beneficio delle tecniche estrattive,legato prevalentemente all’entità ed alla localizzazione di aderenze,nel gruppo CARTOSOUND. Gli end-point dello studio includono complicanze periprocedurali e tempi procedurali e di esposizione a raggi X. RISULTATI. Da Novembre 2009 a Luglio 2011 sono stati arruolati 53 pazienti:36 (67.9%) nel gruppo CONTROLLO e 17 (32.1%) nel gruppo CARTOSOUND. Le complicanze procedurali sono state maggiori nel gruppo CONTROLLO: 27.8% vs 5.9% per complicanze minori e 8.3% vs 0% per complicanze maggiori. I tempi procedurali e di esposizione a raggi X non differivano significativamente tra i due gruppi: 79,5 ± 67,5 vs 73,6 ± 47,7 min (P=0.88) e 16 ± 20 vs 24,7 ± 36,8 min (P=0.28). CONCLUSIONI. In questo registro prospettico di pazienti sottoposti ad estrazione di elettrocateteri,l’utilizzo di approccio ecografico intracardiaco in tempo reale mediante modulo 3D CartoSoundTM ha mostrato un potenziale vantaggio in termini di sicurezza senza determinare allungamento dei tempi procedurali e di esposizione a raggi X. L’estrazione di elettrocateteri assistita da CartoSound trae beneficio dalla valutazione 3D delle aderenze fibrose e dall’identificazione precoce delle possibili complicanze

Kidney Failure Prediction Models: A Comprehensive External Validation Study in Patients with Advanced CKD

Background: Various prediction models have been developed to predict the risk of kidney failure in patients with CKD. However, guideline-recommended models have yet to be compared head to head, their validation in patients with advanced CKD is lacking, and most do not account for competing risks.Methods: To externally validate 11 existing models of kidney failure, taking the competing risk of death into account, we included patients with advanced CKD from two large cohorts: the European Quality Study (EQUAL), an ongoing European prospective, multicenter cohort study of older patients with advanced CKD, and the Swedish Renal Registry (SRR), an ongoing registry of nephrology-referred patients with CKD in Sweden. The outcome of the models was kidney failure (defined as RRT-treated ESKD). We assessed model performance with discrimination and calibration.Results: The study included 1580 patients from EQUAL and 13,489 patients from SRR. The average c statistic over the 11 validated models was 0.74 in EQUAL and 0.80 in SRR, compared with 0.89 in previous validations. Most models with longer prediction horizons overestimated the risk of kidney failure considerably. The 5-year Kidney Failure Risk Equation (KFRE) overpredicted risk by 10%-18%. The four- and eight-variable 2-year KFRE and the 4-year Grams model showed excellent calibration and good discrimination in both cohorts.Conclusions: Some existing models can accurately predict kidney failure in patients with advanced CKD. KFRE performed well for a shorter time frame (2 years), despite not accounting for competing events. Models predicting over a longer time frame (5 years) overestimated risk because of the competing risk of death. The Grams model, which accounts for the latter, is suitable for longer-term predictions (4 years)

The association between TMAO, CMPF and clinical outcomes in advanced CKD; results from the EQUAL study

Background Trimethylamine N-oxide (TMAO), a metabolite from red meat and fish consumption, plays a role in promoting cardiovascular events. However, data regarding TMAO and its impact on clinical outcomes are inconclusive, possibly due to its undetermined dietary source. Objectives We hypothesized that circulating TMAO derived from fish intake might cause less harm compared with red meat sources by examining the concomitant level of 3-carboxy-4-methyl-5-propyl-2-furanpropionate (CMPF), a known biomarker of fish intake, and investigated the association between TMAO, CMPF, and outcomes. Methods Patients were recruited from the European QUALity (EQUAL) Study on treatment in advanced chronic kidney disease among individuals aged &gt;= 65 y whose estimated glomerular filtration rate (eGFR) had dropped for the first time to &lt;= 20 mL/min per 1.73 m(2) during the last 6 mo. The association between TMAO, CMPF, and outcomes including all-cause mortality and kidney replacement therapy (KRT) was assessed among 737 patients. Patients were further stratified by median cutoffs of TMAO and CMPF, suggesting high/low red meat and fish intake. Results During a median of 39 mo of follow-up, 232 patients died. Higher TMAO was independently associated with an increased risk of all-cause mortality (multivariable HR: 1.46; 95% CI: 1.17, 1.83). Higher CMPF was associated with a reduced risk of both all-cause mortality (HR: 0.79; 95% CI: 0.71, 0.89) and KRT (HR: 0.80; 95% CI: 0.71, 0.90), independently of TMAO and other clinically relevant confounders. In comparison to patients with low TMAO and CMPF, patients with low TMAO and high CMPF had reduced risk of all-cause mortality (adjusted HR: 0.49; 95% CI: 0.31, 0.73), whereas those with high TMAO and high CMPF showed no association across adjusted models. Conclusions High CMPF conferred an independent role in health benefits and might even counteract the unfavorable association between TMAO and outcomes. Whether higher circulating CMPF concentrations are due to fish consumption, and/or if CMPF is a protective factor, remains to be verified