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Alessia Riglietti,1,* Francesco Fanfulla,2,* Massimo Pagani,3 Daniela Lucini,3,4 Mara Malacarne,3,4 Mauro Manconi,5– 7 Guido Ferretti,8,9 Fabio Esposito,10,11 Carlo W Cereda,12 Marco Pons1 1Department of Pulmonology, Regional Hospital of Lugano (EOC), Lugano, 6900, Switzerland; 2Respiratory Function and Sleep Unit – Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy; 3Exercise Medicine Unit, Istituto Auxologico Italiano, MIlan, 20133, Italy; 4University of Milan, BIOMETRA Department, Milan, Italy; 5Sleep and Epilepsy Center, Neurocenter of the Southern Switzerland, Regional Hospital (EOC) of Lugano, Lugano, Switzerland; 6Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; 7Department of Neurology, University Hospital, Inselspital, Bern, Switzerland; 8Department APSI, University of Geneva, Geneva, Switzerland; 9Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy; 10Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy; 11IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; 12Stroke Center EOC, Department of Neurology, Neurocenter of Southern Switzerland Regional Hospital (EOC) of Lugano, Lugano, Switzerland*These authors contributed equally to this workCorrespondence: Mauro ManconiRegional Hospital of Lugano, Via Tesserete, 46, Lugano, 6903, SwitzerlandTel +41-91-8116825Email mauro.manconi@eoc.chIntroduction: Sleep-related breathing disorders are highly prevalent in patients with ischemic stroke. Among sleep-disordered breathing disorders, obstructive sleep apnea is the most represented one, but central sleep apnea, isolated or in the context of a periodic breathing/Cheyne–Stokes respiration, is frequently reported in these patients. Altered baroreflex responses have been reported in the acute phases of a cerebral event.Methods: We conducted, in a group of patients with ischemic stroke (n=60), a prospective 3-month follow-up physiological study to describe the breathing pattern during sleep and baroreflex sensitivity in the acute phase and in the recovery phase.Results: In the acute phase, within 10 days from the onset of symptoms, 22.4% of patients had a normal breathing pattern, 40.3% had an obstructive pattern, 16.4% had a central pattern, and 29.9% showed a mixed pattern. Smaller variations in the Apnea–Hypopnea Index were found in normal breathing and obstructive groups (ΔAHI 2.1± 4.1 and − 2.8± 11.6, respectively) in comparison with central and mixed patterns (ΔAHI − 6.9± 15.1 and − 12.5± 13.1, respectively; ANOVA p=0.01). The obstructive pattern became the most frequent pattern, in 38.3% of patients at baseline and 61.7% of patients at follow-up. Modification of baroreflex sensitivity over time was influenced by the site of the lesion and by the sleep disorder pattern in the acute phase (MANOVA p=0.005).Conclusion: We suggest that a down-regulation of autonomic activity, possibly related to reduced vagal modulation, may help the recovery after stroke, or a transitory disconnection from the cortical node that participates in the regulation of sympathetic outflow.Keywords: sleep-disordered breathing, baroreflex, chemoreflex, brain lesion

Aim In this study we sought to assess whether in elite athletes the physiological increase in cardiac mass attending severe long-term training leading to athlete's heart is accompanied by an improvement of autonomic performance, as assessed by post exercise vagal indices and a novel unitary Autonomic Nervous System Index for sports (ANSIs). Methods The study involved 500 elite athletes (23.9 ± 6.4 years) participating in a screening organised by the National Italian Olympic Committee. All subjects underwent a complete medical examination, rest and stand autonomic assessment (heart rate variability) as well as bicycle exercise. ANSIs was also derived as radar plot from rest, stand and heart rate recovery individual proxies of autonomic nervous system regulation. All subjects were grouped into those with left ventricular hypertrophy present (LVH(+)), or not (LVH(–)), according to recognised thresholds. Results We observed that LVH(+) athletes (24.8%) showed a marked increase of post-exercise vagal indices (p Conclusions Elite athletes with physiological cardiac hypertrophy (LVH(+)) present a selective profile of indices of autonomic nervous system performance, characterised by increases of markers of vagal recovery and of the novel unitary autonomic index for sports while RR variance and spectral indices seem to be unmodified. Athlete's heart may be characterised by a specific combination of anatomical and neurocardiac remodeling. This approach might furnish potential warning signs differentiating normal training induced physiology from pathological adaptation.

In most sports athletic performance is determined by a combination of hard and soft modifiable components, encompassing physical and psychological elements that can be assessed with modern techniques based respectively on simple friendly methods: analysis of HRV and questionnaires. Specifically a novel % rank Autonomic Nervous System Indicator (ANSI) seems particularly useful also in elite sports. In this investigation we assessed ANSI capacity to detect the expected changes in cardiac autonomic regulation induced in the Italian basketball team by the participation (18 subjects) to the yearly biweekly Alpine training summer camp. We observed that ANSI increased from 58.8 ± 32.5 to 81.7 ± 27.5 (at the end of training camp) and did not change further in the subsequent initial weeks of competition season (overall p < 0.001). Congruent changes were observed in non-linear indices. Concomitantly indices of somatic symptoms were slightly reduced just at the end of the alpine training. We conclude that analysis of HRV and questionnaires might offer a simple, useful technique to monitor changes in cardiac autonomic regulation and psychological state in elite athletes providing a convenient additional element to evaluation of training routines also in the fields.

Early obesity predicts initial modifications in cardiac and vascular autonomic regulation. The aim of this study was to assess the possible interaction between non-invasive measures of autonomic cardiovascular control and peripheral endothelium regulation in children with overweight and obesity. We involved 114 young subjects (77M/37F, 12.7 ± 2.2 years) with normal weight (NW, n = 46) to overweight or obesity (OB, n = 68). Multivariate statistical techniques utilizing a collection of modern indices of autonomic regulation, adiposity indexes and metabolic profile were employed. Resting values show substantial equivalence of data. Conversely, blood pressure variance is greater in NW/OB groups. The correlation matrix between major autonomic and metabolic/hemodynamic variables shows a clustered significant correlation between homogeneous indices. A significant correlation between metabolic indices and endothelial and autonomic control, mostly in its vascular end, was recorded. Particularly, the alpha index is significantly correlated with triglycerides (r = −0.261) and endothelial indices (RHI, r = 0.276). Children with obesity show a link between indices of autonomic and endothelial function, fat distribution and metabolic profile. The optimization of autonomic control, for instance by exercise/nutrition interventions, could potentially prevent/delay the occurrence of structural vascular damage leading to reduced cardiovascular health.

It is well recognized that regular physical activity may improve cardiac autonomic regulation preventing chronic non-communicable diseases. Accordingly, the assessment of cardiac autonomic regulation (CAR) with non-invasive techniques, such as RR interval Variability (V) might be of practical interest. We studied 56 soccer players (21.2 &plusmn, 4.2 years.) and 56 controls (22.2 &plusmn, 1.5 years.) and used a ranked Autonomic Nervous System Index (ANSI), resulting from the combination of multivariate statistical methodologies applied to spectral analysis derived indices from RRV. We hypothesized that ANSI would be higher in soccer players as compared to controls (p &lt, 0.001) and that values would be greatest in defenders and midfielders, who are known to run longer distances during competitions. Conversely in the intrinsically stationary goalkeepers ANSI would be similar to controls. Our data show that it is possible to assess the overall level of autonomic performance in soccer players as compared to the general population, using a ranked composite autonomic proxy (ANSI). This approach suggests as well that CAR is better in those players who during competitions run for a greater distance. We conclude that it is possible to highlight the differences in autonomic profile due to distinct exercise routines, using ANSI, a simple ranked, composite autonomic proxy.

Optimal autonomic regulation and stress resilience might be considered critical elements of athletic performance. We hypothesize that a novel unitary autonomic index for sports (ANSIs), together with a somatic stress related symptom score (4SQ) might help characterize athletes who were eventually selected for the Rio 2016 Olympic Games Italian team (Rio +). In this retrospective study we examined 778 athletes (age 24.4 ± 6.7 yrs) who underwent a planned yearly pre-participation screening. All athletes underwent clinical, autonomic and exercise ECG evaluation. The combination of vagal and sympathetic indices from RR variability into ANSIs was performed by radar plot and percent ranking of index variables. We assessed (Rio +) versus (Rio −) athletes also after subdivision into three sport intensity groups (low, mid and high intensity). Overall there were no significant differences between (Rio +) and (Rio −) athletes when considering individual spectral derived variables. Conversely, the unitary Index ANSIs was significantly higher in (Rio +) compared to (Rio −) athletes (respectively 54.5 ± 29.5 and 47.9 ± 28.4 p = 0.014). This difference was particularly evident (p = 0.017) in the group of athletes characterized by both high static and dynamic components. 4SQ was smaller in the (Rio +) group, particularly in the groups of athletes characterized by both low-medium static and dynamic components. ANSIs, a proxy of integrated cardiac autonomic regulation and simple assessment of resilience to stress, may differentiate Italian athletes who were eventually selected for participation in the 2016 Rio Olympic Games from those who were not, suggesting the possibility of a “winning functional phenotype”.

Background Spectral analysis of Heart Rate Variability (HRV) is a simple, non-invasive technique that is widely used in sport to assess sympatho-vagal regulation of the heart. Its employment is increasing partly due to the rising usage of wearable devices. However data acquisition using these devices may be suboptimal because they cannot discriminate between sinus and non-sinus beats and do not record any data regarding respiratory frequency. This information is mandatory for a correct clinical interpretation. Methods This study involved 974 elite athletes, all of them underwent a complete autonomic assessment, by way of Autoregressive HRV analysis. Results In 91 subjects (9% of the total population) we observed criticalities of either cardiac rhythm or respiration. Through perusal of one-lead ECG analysis we observed that 77 subjects had atrial or ventricular ectopy, i.e. conditions which impair stationarity and sinus rhythm. Running anyway autonomic nervous system analysis in this population, we observed that RR variance and raw values of LF and HF regions are significantly higher in arrhythmic subjects. In addition 14 subjects had slow (about 6 breath/min, 0.1Hz) respiration. This condition clouds the separation between LF from HF spectral regions of RR interval variability, respectively markers of the prevalent sympathetic and vagal modulation of SA node and of their synergistic interaction. Conclusions Caution must be payed when assessing HRV with non-ECG wearable devices. Recording ECG signal and ensuring that respiratory rate is higher than 10 breath/min are both prerequisites for a more reliable analysis of HRV particularly in athletes.

Lifestyle modification programs (LMP) represent a new approach to cardiometabolic/oncologic risk reduction. Successful LMP in clinical practice must be feasible, cost effective, efficacious and consider home-based exercise. Likewise, multiple mechanisms implied in cardiometabolic risk reduction such as cardiac autonomic regulation (CAR) should be easily evidenced, in spite of the computational complexity involved. This goal could be facilitated by employing novel, friendlier, simpler techniques, such as the Autonomic Nervous System Index (ANSI), which can be treated as a proxy of CAR. In this observational study, we introduce a simple LMP (based on cognitive behavioral strategies and patient-tailored prescription of nutrition and home-based exercise, managed by a single physician) into the currently existing clinical practice of secondary cardiometabolic prevention. In 26 subjects, we assessed CAR (autoregressive spectral analysis of cardiovascular variabilities), body mass composition (bioelectrical impedance analysis) and stress perception (questionnaires). After LMP, ANSI and lipid profile were improved; % of fat mass, waist circumference and stress perception were reduced. We conclude that this preliminary, proof of concept study provides significant evidence in favor of the hypothesis that it is possible to introduce a convenient, cost effective LMP into the currently existing clinical practice of secondary cardiometabolic prevention. Findings suggest a successful comprehensive behavioral change, possibly facilitated by the simplified approach employed in this study, capable of improving cardiac autonomic regulation in addition to body mass composition and stress perception.

Interests about the fine underpinnings of cardiovascular beat-by-beat variability have historical roots. Over the last decades, various aspects of the relationships between arterial pressure and heart period were taken as a proxy of the baroreflex in physiology and medicine, stimulating the interest of investigators in several interconnected scientific fields, in particular, bioengineering, neurophysiology, and clinical medicine. Studies of the overall system facilitated the emergence of a simplified negative (vagal) feedback model of the baroreflex and overshadowed the simultaneous interaction with excitatory, sympathetic positive-feedback mechanisms that would, however, better suit the model of a “paired antagonistic (parasympathetic/sympathetic) innervation of the internal organs.” From the bioengineering side, the simplicity of obtaining the series of subsequent RR intervals stimulated the analysis of beat-by-beat variations, providing a multitude of heart rate variability (HRV) indices considered as proxies of the underlying sympatho-vagal balance, and participating to the management of several important clinical conditions, such as hypertension. In this context, advanced statistical methods, used in an integrated manner and controlling for age and gender biases, might help shed new light on the relationship between cardiac baroreflex, assessed by the frequency domain index α, and the HRV indices with the varying of systolic arterial pressure (SAP) levels. The focus is also on a novel unitary Autonomic Nervous System Index (ANSI) built as a synthesis of HRV considering its three most informative proxies [RR, RR variance, and the rest-stand difference in the normalized power of low-frequency (LF) variability component]. Data from a relatively large set of healthy subjects (n = 1154) with a broad range of SAP [from normal (nNt = 778) to elevated (nHt = 232)] show that, e.g., α and ANSI significantly correlate overall (r = 0.523, p < 0.001), and that this correlation is lower in hypertensives (r = 0.444, p < 0.001) and higher in pre-hypertensives (r = 0.618, p < 0.001) than in normotensives (r = 0.5, p < 0.001). That suggests the existence of curvilinear “umbrella” patterns that might better describe the effects of the SAP states on the relationships between baroreflex and HRV. By a mix of robust, non-parametric and resampling statistical techniques, we give empirical support to this study hypothesis and show that the pre-hypertensive group results at the apex/bottom in most of the studied trends.

Since the seminal studies by Sayers (Ergonomics 16:17–32, 1973) and Akselrod et al. (Science 213:220–222, 1981) a few decades ago, it became clear that beat-by-beat oscillations in RR interval length (i.e. heart-rate variability [HRV]) contain information on underlying neural-control mechanisms based on the instantaneous balance between parasympathetic and sympathetic innervation. Over the years, the number of studies addressing HRV has increased markedly and now outnumbers 23,000. Despite such a large interest, there is still a continuing debate about interpretation of indices produced by computer analysis of HRV.

The study proposes an extension of cardiac baroreflex (cBR) sequence analysis, traditionally performed over spontaneous fluctuations of heart period and systolic arterial pressure, to typify peripheral resistance baroreflex (prBR) from spontaneous variations of peripheral resistances and diastolic arterial pressure. The prBR baroreflex sensitivity (BRS prBR ) and percentage of prBR sequences (SEQ% prBR ) were computed along with analogous quantities assessed over cBR (i.e. BRS cBR and SEQ% cBR ). The cBR and prBR were typified in healthy subjects at rest (REST) and during light bicycle ergometer exercise at 10 percent of the maximal effort (EXE). Both cBR and prBR were affected by EXE: indeed, BRS cBR and SEQ% prBR were significantly reduced. Moreover, while BRS cBR and BRS prBR were not significantly associated, SEQ% cBR and SEQ% prBR were, and the correlation coefficient was positive. This study suggests that prBR can be typified from spontaneous variabilities along with the more traditional cBR, thus enlarging the possibility of monitoring human cardiovascular control mechanisms.

Background This study addresses whether a unitary cardiac autonomic nervous system index (ANSI), obtained combining multiple metrics from heart rate variability (HRV) into a radar plot could provide an easy appreciation of autonomic performance in a clinical setting. Materials and Methods Data are standardized using percentile ranking of autonomic proxies from a relatively large reference population (n = 1593, age 39 ± 13 years). Autonomic indices are obtained from autoregressive spectral analysis of (ECG derived) HRV at rest and during standing up. A reduced ANSI (using RR, RR variance and rest–stand difference of LFnu) is then constructed as a radar plot, quantified according to its combined area and tested against different risk subgroups. Results With growing risk profile, there is a marked reduction of the rank value of ANSI, quantified individually by the radar plot area. The practical usefulness of the approach was tested in small groups of additional subjects putatively characterized by elevated or poor autonomic performance. Data show that elite endurance athletes are characterized by elevated values of ANSI (80·6 ± 14·9, P < 0·001) while subjects with either Type 1 or Type 2 diabetes show lower values (DM1 = 37·0 ± 18·9 and DM2 = 26·8 ± 23·3, P = 0·002), and patients with coronary artery disease (CAD) represent a nadir (17 ± 20, P < 0·001). Conclusions This observational study shows the feasibility of testing simpler metrics of cardiac autonomic regulation based on a multivariate unitary index in a preventive setting. This simple approach might foster a wider application of HRV in the clinical arena, and permit an easier appreciation of autonomic performance.

Aim: Given the time spent at work, the workplace represents an ideal setting to implement preventive programs for non-communicable diseases, the major cause of mortality and morbidity in Western and developing countries. We sought to verify if an ecological approach based on corporate culture, employees’ education and concrete modifications of workplace environment, offering easy opportunity to assume healthy lifestyle, could be associated with reduced cardiometabolic risk. Methods: The study involved 1089 workers in two multinational companies following different workplace health promotion policies. Company A offered to all employees the opportunity to access a web platform dedicated to general information on health and diseases. Company B implemented an ecological model encompassing company culture, employees’ education and concrete modifications of workplace environment, giving to all employees the opportunity to adopt healthy solutions throughout daily living at workplace. Participants volunteered self-reported clinical information using an IT tool. Numbers of Metabolic Syndrome components (MetS) were taken as proxy of cardiometabolic risk. Results: MetS probability obtained via statistical modeling was lower in company B as compared to company A, and absenteeism was also lower in company B. Our study shows that a work environment favoring assumption of healthy lifestyle, as in company B, is associated with a lower percentage of employees with MetS components and lower absenteeism. Moreover, statistical modeling shows that individual probabilities of being without MetS elements, controlling for age and gender, is remarkably higher in company B. Conclusions: Our data suggest that ecological approaches might be useful in worksite prevention policies.

OBJECTIVES This study addressed the relationship between spontaneous baroreflex sensitivity and carotid mechanical properties in a clinical setting. METHODS In 191 normal volunteers (age range 20-60 years, mean 44 ± 13), spontaneous indices of baroreflex regulation were obtained noninvasively in the time (baroreflex slope, BRS) and frequency domains (α index and systolic arterial pressure-RR interval transfer gain) as well as using an exogenous autoregressive causal model (A.XAR); carotid mechanical properties were estimated by ultrasound. The link between mechanical measures and spontaneous baroreflex indices was explored by multivariate analysis and linear modeling. RESULTS Participants were divided into five groups according to age decades. With advancing age we observed a decrease in spontaneous baroreflex indices (BRS from 31.2 to 16.3; α index from 27.4 to 13.6; RR-SAP gain at high frequency from 31 ± 3.0 to 14 ± 3.0 ms/mmHg all P

To focus on early cardiac and vascular autonomic dysfunction that might complicate type 1 diabetes mellitus in children, we planned an observational, cross-sectional study in a population of 93 young patients, under insulin treatment, subdivided in 2 age subgroups (children: 11.5±0.4 years; adolescents: 19.3±0.2 years). Time and frequency domain analysis of RR interval and systolic arterial pressure variability provided quantitative indices of the sympatho-vagal balance regulating the heart period, of the gain of cardiac baroreflex, and of the sympathetic vasomotor control. Sixty-eight children of comparable age served as a reference group. At rest, systolic arterial pressure and the power of its low-frequency component were greater in patients than in controls, particularly in children (14.0±2.3 versus 3.1±0.3 mm Hg 2 ). Moreover, baroreflex gain was significantly reduced in both subgroups of patients. Standing induced similar changes in the autonomic profiles of controls and patients. A repeat study after 1 year showed a progression in low-frequency oscillations of arterial pressure and a shift toward low frequency in RR variability. Data in young patients with type 1 diabetes mellitus show a significant increase in arterial pressure, a reduced gain of the baroreflex regulation of the heart period, and an increase of the low-frequency component of systolic arterial pressure variability, suggestive of simultaneous impairment of vagal cardiac control and increases of sympathetic vasomotor regulation. A repeat study after 1 year shows a further increase of sympathetic cardiac and vascular modulation, suggesting early progression of the autonomic dysfunction.

Chronic non-communicable diseases represent the major drivers of disease burden, being responsible for the majority of health care cost and deaths. Almost half of premature deaths is due to behaviors amenable to change. Accordingly, addressing behavior might represent a strategic change in the health delivery system. Improving lifestyle requires a specific strategy embedding the active collaboration of individuals with a multilevel team-oriented medical practice. With the present study we sought to assess whether the implementation of cognitive-behavioral strategies, following the principles of lifestyle medicine in an outpatient clinic provides better results in weight reduction as compared to simpler strategies as presently executed in General Practitioners' offices.This is an observational study on 173 subjects (age 53.1 ± 11.5), comparing three different groups of preventive practice: a personalized lifestyle medicine, combining cognitive behavioral strategies with patient tailored prescription of exercise and nutrition (Group A); a semi-structured approach with generic counseling (Group B); and an unstructured advice (Group C).At the end of the intervention period (17-20 months), group A showed an average weight loss of 5.4 ± 5.1 kg, which was significantly (p0.001)more than observed in group B (2.8 ± 5.1 kg) and group C (1.2 ± 4.8 kg). Likewise BMI and waist were progressively more reduced from A to C.It is possible to implement preventive cognitive-behavioral lifestyle strategies in outpatient internal medicine clinics. This methodology appears more efficacious in inducing weight reduction after more than a year as compared to usual family medicine approaches.

Background Autonomic nervous system (ANS) regulation may be altered in functional diseases, including irritable bowel syndrome (IBS), but published data are not clear to date. The aim of the study was to analyze ANS function in IBS subjects classified by Rome III criteria and healthy controls using standardized technique. Methods ANS activity was evaluated by autoregressive spectral analysis of RR interval and systolic arterial pressure variabilities, to obtain indices of sympatho-vagal modulation of the heart and of spontaneous cardiac baroreflex (α index). A symptom list was used to score 18 somatic complaints (score 0–180) (4SQ). Fatigue and stress were assessed through the use of a global scoring index (0–10). Key Results We enrolled 41 IBS subjects (29 F, age 40 ± 2 years) and 42 healthy matched controls. Heart rate was higher in IBS than control subjects (69 ± 2 vs 61 ± 1; p

Aerobic fitness seems to provide extra protection to the cardiovascular system beyond changing the traditional risk factors, a phenomenon referred to as the risk factor gap model. Aerobic fitness may possibly lead to improved autonomic regulation. The Task Force of the American Heart Association supports a national campaign to reach specific cardiovascular health goals considering various metrics, including recommended physical activity (PA) volumes. It may be clinically relevant to assess whether autonomic remodeling occurs in those who adhere to the PA recommendations. We studied 39 healthy subjects (22 males and 17 females), subdivided into two groups, according to whether they were meeting or not meeting PA recommendations (150 min/week of moderate aerobic activity, or 75 min/week of vigorous aerobic activity, or a combination of both). For each group, we evaluated aerobic capacity (VO2 Peak), body composition (Fat Mass) and autonomic nervous system profile, by way of mono and bivariate spectral analysis of cardiovascular beat by beat variability. Subjects following PA recommendations show higher RR period, higher RR variance, greater absolute power of the respiratory component of RR variability (HFRR) and higher index alpha (a measure of spontaneous baroreflex). Moreover, as expected, the group that was meeting or exceeding current PA recommendations had higher VO2 peak, less fat mass and greater weekly energy expenditure. Data show that subjects meeting current PA recommendations present a phenotype suggestive of enhanced parasympathetic drive to the SA node. This finding is compatible with the hypothesis that a more favorable autonomic profile is part of the mechanisms of the risk factor gap.

Surgery and adjuvant therapy improved prognosis of breast cancer survivors. This improvement risks being offset by potential late-occurring cardiovascular toxicity of oncologic treatment and increased cardiometabolic risk profile associated with lifestyle changes. We address the hypothesis that in breast cancer survivors, multiple functional alterations might define a phenotype, characterized by vagal impairment, diminished aerobic fitness, increased metabolic risk, and reduced wellbeing. We studied 171 sedentary asymptomatic women (106 cancer survivor—65 controls) of similar age (53 ± 8.6; 51 ± 8.1 years). Autonomic regulation was evaluated by autoregressive spectral analysis of R wave to R wave (RR) interval and systolic arterial pressure variability. Aerobic fitness was directly assessed by cardiopulmonary exercise test. Body mass index (BMI) and waist circumference served as proxies of metabolism. Fatigue and stress-related symptoms were evaluated with validated questionnaire. Patients showed significantly smaller total RR variance (1644 ± 2363 vs 2302 ± 1561 msec2), smaller absolute power of low frequency (LF) (386 ± 745 vs 810 ± 1300 msec2) and high frequency (HF) (485 ± 1202 vs 582 ± 555 msec2) of RR interval variability and smaller spontaneous baroreflex sensitivity (15.0 ± 8.9 vs 21.9 ± 10 msec/mmHg), suggesting vagal impairment. VO2 peak and O2 pulse were lower in cancer survivors than in controls. Fatigue and stress-related somatic symptoms scores were higher, as was BMI and waist circumference. Breast cancer survivors show multiple dysfunctions: vagal impairment, lower aerobic fitness, signs of altered metabolism, and higher perception of fatigue. We propose that the concept of clinical phenotype, which may accommodate multiple functional disturbances, might be useful in long-term personalized prevention programs for breast cancer survivors.

During the reambulation procedure after 35-day head-down tilt bed rest (HDTBR) for 9 men, we recorded for the first time heart rate (HR; with electrocardiogram) and arterial pressure profiles (fingertip plethysmography) for 5 min in HDTBR and horizontal (SUP) positions, followed by 12 min in standing position, during which 4 subjects fainted (intolerant, INT) and were laid horizontal again (Recovery). We computed: mean arterial pressure (P¯; pressure profiles integral mean), stroke volume (SV; obtained with Modelflow method), and cardiac output (Q̇; SV × HR). All cardiovascular data remained stable in HDTBR and SUP for both groups (EXP). Taking the upright posture, EXP showed a decrease in SV and an increase in HR, becoming significantly different from SUP within 1 min. Further evolution of these parameters kept Q̇ stable in both groups until the second minute of standing. Afterward, in INT, P̄ precipitated without further HR increases: SV stopped being corrected and Q̇ reached 2.9 ± 0.4 L·min−1 at the last 15 s of standing. Sudden drop in P̄ allowed identification of a low-pressure threshold in INT (70.7 ± 12.9 mm Hg), after which syncope occurred within 80 s. During Recovery, baroreflex curves showed a flat phase (P̄ increase, HR stable), followed by a steep phase (P̄ increased, HR decreased, starting when P̄ was 84.5 ± 12.5 mm Hg and Q̇ was 9.6 ± 1.5 L·min−1). INT, in contrast with tolerant subjects, did not sustain standing because HR was unable to correct for the P̄ drop. These results indicate a major role for impaired arterial baroreflexes in the onset of orthostatic intolerance.

Overweight (OW) and obesity in children are important forerunners of cardiovascular risk, possibly through autonomic nervous system (ANS) dysregulation, while physical exercise exerts a beneficial influence. In this observational study we hypothesise that OW might influence ANS profile even in a population performing high volume of supervised exercise. We study 103 young soccer players, homogeneous in terms of gender (all male), cultural background, school, age (11.2 ± 1 years) and exercise routine, since they all belong to the same soccer club, thus guaranteeing equality of supervised training and similar levels of competitiveness. ANS is evaluated by autoregressive spectral analysis of heart rate and systolic arterial pressure (SAP) variabilities. We estimate also the accumulated weekly Metabolic Equivalents and time spent in sedentary activities. We subdivide the entire population in two subgroups (normal weight and OW) based on the International Obesity Task Force criteria. In OW soccer players (10.7% of total group) we observe an altered profile of autonomic cardiovascular regulation, characterised by higher values of SAP (113 ± 4 vs 100 ± 1 mm Hg, 39.7 ± 3 vs 66.2 ± 10%), higher Low Frequency variability power of SAP (an index of vasomotor sympathetic regulation) (12 ± 3 vs 4.5 mm Hg(2)) and smaller spontaneous baroreflex gain (an index of cardiac vagal regulation) (19 ± 3 vs 33 ± 3 ms/mm Hg) (all (p < 0.02)). Moreover Correlation analysis on the entire study population shows a significant link between anthropometric and autonomic indices. These data show that OW is associated to a clear autonomic impairment even in children subjected to an intense aerobic training.

Considering that changes in exercise routines might have relevance in treatment of adolescents with type 1 diabetes mellitus, we sought to assess whether spontaneous modifications to weekly exercise habits might occur in these patients and whether such variations would be accompanied by alterations in autonomic profile. In this observational study, we examined 77 patients (age 15.0 ± 0.6 years.) who in addition to a tailored optimal insulin treatment were invited to perform at least 1 h a day of moderate, aerobic exercise, as suggested by recent guidelines. Patients were studied at baseline (T0) and after 15.8 ± 0.7 months (T1). They were divided into three subgroups according to increased, unchanged and diminished total estimated weekly METs between T0 and T1. Autonomic profile was evaluated by assessing spontaneous baroreflex gain and low-frequency oscillation in arterial pressure, using spectral analysis of RR and systolic arterial pressure time series. Insulin therapy and biochemical data were similar among the 3 groups at T0 and T1, while body mass index standard deviation score was slightly reduced (p

Recent epidemiological evidence indicates that chronic degenerative diseases, notably cardiovascular, represent the major toll in terms of death and of impaired quality of life. Recent estimates indicate that a small increase in financial resources in a number of clinical cases may be sufficient to minimize the consequences of elevated cardiovascular risk per individual. The observation that lifestyle choices, and in particular increased physical exercise, might strongly impact cardiovascular risk, suggests a redesign of preventive strategies, based on the combination of pharmacological and behavioral interventions. Following our recent experience with the INteractive teleConsultation network for worldwide healthcAre Services (INCAS) system, we designed a simpler point-to-point telehealth infrastructure, to be employed in cardiovascular risk reduction programs, predicting a high level of acceptance from the population, at the cost of very limited investment. This model was tested on 181 subjects (ages 18-80 years) in the Italian mountain village of Esino Lario. These subjects underwent a screening test to evaluate arrhythmia and cardiometabolic risks (arrhythmias were found in 14% of subjects, systolic arterial pressure was observed in 43% of subjects above 140 mm Hg, diastolic arterial pressure in 31% above 90 mm Hg). This study demonstrates the feasibility of a scaled-down telehealth application particularly suited to cardiovascular prevention in remote areas, such as in mountain villages.

BACKGROUND: Recent epidemiological data indicate that chronic stress is an important component of cardiovascular risk, implicitly suggesting that stress management might offer a useful complement to orthodox medical treatment and prevention of hypertension. In this context, information on mechanisms, such as subclinical increases in arterial pressure and sympathetic drive, is well documented. Conversely, evidence on methodologies and comparative efficacy needs to be improved. Accordingly, this study was planned to test the autonomic and subjective effects of two popular modalities of stress management. METHODS: We studied 70 patients complaining of stress-related symptoms, avoiding any potential autonomic confounder, such as established hypertension or drug treatment. Patients were divided in three groups: group I (n ≤ 30) followed a breathing-guided relaxation training (active); group II (n ≤ 15) an oriental massage, shiatsu (passive); and group III (n ≤ 25) followed a sham intervention. Subjective effects of stress were assessed by validated questionnaires and autonomic nervous system regulation by spectral analysis of RR interval variability. Factor analysis was used to extract information simultaneously embedded in subjective and functional data. RESULTS: Although the problem of a greater quantity of treatment procedure in the active group than in the passive group existed, results showed that active relaxation, further to slightly reducing arterial pressure, might be more effective in relieving symptoms of stress and inducing an improved profile of autonomic cardiovascular regulation, as compared with passive massage or sham intervention. CONCLUSION: This active technique seems capable of beneficially addressing simultaneously the individual psychological and physiopathological dimensions of stress in clinical settings, with potentially beneficial effects on cardiovascular risk profile. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Caregiving, an important component of cancer patient treatment, may set forth a cascade of stress responses such as sympatho-adrenal activation, immuno-humoral changes and an unhealthy lifestyle, which could be hazardous to caregivers' health. In this observational study, we addressed whether autonomic nervous system (ANS) regulation and perception of stress would be altered in a group of 58 health cancer caregivers as compared to 60 controls. We employed non invasive autoregressive spectral analysis of cardiovascular variabilities and ad hoc questionnaires. Caregivers show, in addition to signs of psychological involvement, a clear autonomic imbalance, suggestive of sympathetic predominance at rest and of a reduction of vagal cardiac regulation (overall gain of baroreflex -index alpha- was respectively of 17.5+/-1.5 versus 25.1+/-1.8 msec/mmHg, p<

Alterations in lipid metabolism are a possible consequence of highly active antiretroviral therapies (HAART) for human immunodeficiency virus (HIV)-positive patients with consequent increase of cardiovascular risk. In this context we hypothesized that both acquired immunodeficiency syndrome (AIDS) and HAART might be associated to alterations in autonomic cardiovascular regulation. In this preliminary investigation we enrolled a total of 66 men, subdivided in two groups, 33 HIV-positive patients, and 33 healthy controls, and we tested the hypothesis that heart rate variability (HRV) of HIV positive patients can be assessed with a transtelephonic approach from the HIV clinic: 100% of the total of electrocardiograms (ECG) recordings that were sent from the distant site were successfully received and analyzed. Evaluation of the signal was subsequently performed in the centralized laboratory, and consisted in extracting the RR interval variability (RRV) series and afterward subjecting it to autoregressive spectral analysis. This study shows the feasibility of obtaining, from personnel without specific training, adequate RR variability data for further spectral analysis form a distant specialized autonomic laboratory. This feature is of critical importance in the context of possible large-scale application of this simple telemedicine approach.

Background. The aim of our study was to evaluate whether convective (haemofiltration, Hf) and diffusive (haemodialysis, Hd) dialysis techniques induce different patterns of long- and short-term autonomic adjustments in haemodynamically stable dialysis patients. Methods: Ten haemodynamically stable Hd patients were studied. Each patient underwent a block of six Hd sessions, then was switched to six Hf. During the last session of each dialytic treatment, continuous beat to beat measurements of systolic arterial pressure (SAP) and heart rate (HR) were performed. Spectral analysis of heart rate variability (HRV) was made before and during the treatment to evaluate the modification of autonomic nervous system activity. Results: Baseline values of plasma sodium, body weight, HR and SAP were not different for the two considered methods of dialysis, while the baseline values of normalized LF were significantly higher in Hf as compared to Hd and the opposite was observed for HF powers (P

This paper describes preliminary experience in shared clinical management of patients located in Pointe Noire, Africa, and a referral center, Sacco University Hospital, located in Milan, Italy. The employed infrastructure INteractive TeleConsultation Network for Worldwide HealthcAre Services (INCAS) jointly developed by CEFRIEL (Center of Excellence For Research, Innovation, EducationIndustrial Labs partnership) and ENI (Ente Nazionale Idrocarburi) is based on commercial off-the-shelf technology. This minimizes maintenance problems, while permitting a simple and friendly sharing of data using the telephone and e-mail for store-and-forward applications. The critical aspect of the flow of events comprising the exchange of information is discussed. In 60% of cases, only one telemedicine consultation was required. In the remainder 40%, a number of telemedicine consultations were required for appropriate management of clinical cases. The project demonstrated flexibility as documented by the wide range of pathologies that can be dealt with it. Finally the possibility of using shared clinical management as a learning tool is highlighted by the steep and rising learning curve. We conclude, however, that the patient, although handled in a "virtual" manner, should be viewed as very "real," as some of them elected to close the gap physically between Pointe Noire and Milan, and chose to be treated at the referral site.