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Twenty-four subjects aged 70 and older were retrospectively selected from our archives and screened for symptoms of cardiovascular disease. Baseline exercise test was negative for myocardial ischemia in all subjects. All subjects had completed an 8-week program, performed for a variety of indications and consisting of an aerobic physical training program including 30 minutes of cycling three times per week at 65% to 75% of maximum heart rate achieved at peak exercise test performed at enrollment, an educational intervention, dietary advice, and psychological support. All subjects underwent a cardiopulmonary exercise test (CPX) before and at the end of exercise training. At the end of each CPX, peak oxygen uptake (VO2peak), the rate of increase of ventilation per unit of increase of carbon dioxide production (VE/VCO2slope), and HRR were recorded. Twenty-five healthy subjects younger than 60 with no evidence of exercise-induced myocardial ischemia and not enrolled in any exercise training program were also retrospectively selected from our archives and used as a control group for analyzing HRR. These patients performed two exercise tests several weeks apart. Several studies have shown that changes in vagal tone can be used as an outcome tool that helps identify patients or subjects with or without cardiovascular disease at risk for a cardiovascular event, although the evidence of a prognostic value of HRR in older subjects without cardiovascular disease is rather poor. In this study, exercise training resulted in HRR improvement in healthy elderly subjects, suggesting that exercise training improves vagal/sympathetic balance in older subjects without cardiovascular disease as well. Whether the observed improvement in HRR may have long-term beneficial prognostic effects was not the aim of the study, although a beneficial effect might be postulated, in light of the Framingham data

We report a case of a 38-years-old HIV-positive patient, undergoing in the last 18 months therapy with three antiretroviral drugs including a protease inhibitor (nelfinavir). The patient was admitted in our Department with acute anterior myocardial infarction and was submitted to PTCA on the left anterior descending coronary artery. The patient, a 30 cigarettes/day smoker, with family history of hypertension and high levels of trygliceride and cholesterol, was subsequently admitted to our Cardiac Rehabilitation Unit. Cardiac Rehabilitation Program was composed of cycle aerobic training 4 times/week, dietary education, psychologic support and therapy with pravastatin, aspirin, nitrate, enalapril, and carvedilol. At the end of the 8 week Rehabilitation Program we observed a normalization of cholesterol and trygliceride levels and an improvement of cardiac functional capacity and mental health.

Introduction. Erectile dysfunction (ED) affects about 50% of males aged 40-70 years old. ED shares with atherosclerotic disease several common risk factors; therefore, it may be considered a surrogate marker of atherosclerosis. Sincephosphodiesterase-5 inhibitors are well known pharmacologic agents capable of significant improvement in ED, we designed this study to evaluate whether exercise training is of added value in patients with ED who are already on PDE-5 inhibitors. Methods. We recruited 20 male patients affected by ED with metabolic syndrome.At baseline, all patients underwent Cardio-Pulmonary Exercise Testing (CPET) and the International Index of Erectile Function (IIEF) test.After the initial evaluation, patients were subdivided into two groups: tadalafil group (group T, n=10), who were maintained only on tadalafil therapy, and a tadalafil/exercise training group (T/E group, n=10)who continued tadalafil but in addition underwent a2-month structured exercise training program. Results. Basal anthropometric characteristics of study population showed no significant differences. Although bothgroups showed at 2 months an improvement of the IIEF score, thiswas more evident in the T/E group (T group: 11.2 vs 14.2, P=0.02; T/E group: 10.8 vs 20.1, P

Introduction. Even though an overwhelming amount of evidence supports the clinical efficacy and safety of the implantable cardioverter defibrillator (ICD), inappropriate shocks for atrial arrhythmias with rapid ventricular conduction or for abnormal sensing results in multiple adverse effects Presentation. In this study we present the case of a 59- year-old woman who was admitted to hospital for ICD implantation with a past medical history that was positive for non-ischemic dilated cardiomyopathy, congestive heart failure (NYHA class III), atrial fibrillation, essential hypertension and a recent episode of syncope. Since in the 18 months follow-up the patient suffered many inappropriate shocks, we investigated the association of the presence of a PTSD (Post- Traumatic-Stress-Disorder) prior to implantation and a specific profile of cognitive processing emotions, with the effectiveness of the ICD. Emotional distress states and cognitive thoughts preceding ICD shock inappropriate episode were recorded by structured mobile diary (eMotional-ICDiary©). We outlined how the presence of a highly traumatic event which had occurred 6 years previously was related to a recurrence of a combination of moderate distress and cognitive thoughts, associated with episodes of Inappropriate Shock. A psycho-diagnostic examination and the administration of the Emotional Processing Scale (EPS-25) and Emotional Regulation Questionnaire (ERQ) outlined that the patient presented a profile of cognitive processing of emotions characterized by elevated levels of unprocessed emotions, low appraisal and high suppression emotional regulation strategy. Conclusion. The observations gathered in this single case are a good starting point for further research in order to check if the post-traumatic stress disorder and a specific cognitive profile connected to the processing of emotions are associated with the presence of inappropriate ICD shocks. Further larger sample studies are required in this area.

CONTEXT: A reduced activity of the GH/IGF-I axis in chronic heart failure (CHF) has been described by several independent groups and is associated with poor clinical status and outcome. OBJECTIVE: The aim of the current study was to investigate the prevalence of GH deficiency in a patient population with CHF and evaluate the cardiovascular effects of GH replacement therapy. DESIGN AND SETTING: The randomized, single-blind, controlled trial was conducted at the Federico II University. PARTICIPANTS: One hundred fifty-eight patients with CHF, New York Heart Association class II-IV, underwent a GH stimulation test. Sixty-three patients satisfied the criteria for GH deficiency, and 56 of them were enrolled in the trial. INTERVENTION: The treated group (n = 28) received GH at a replacement dose of 0.012 mg/kg every second day (approximately 2.5 IU). MAIN OUTCOMES MEASURES: Changes in physical performance and various cardiovascular indexes were measured. RESULTS: GH replacement therapy improved quality of life score (from 46 +/- 5 to 38 +/- 4; P < 0.01), increased peak oxygen uptake and exercise duration (from 12.9 +/- .9 to 14.5 +/- 1 ml/kg x min and from 520 +/- 36 to 586 +/- 43 sec, respectively; P < 0.01), and flow-mediated vasodilation (from 8.8 +/- 1.3 to 12.7 +/- 1.2%; P < 0.01). GH increased left ventricular ejection fraction (from 34 +/- 2 to 36 +/- 2%; P < 0.01) and reduced circulating N-terminal pro-brain natriuretic peptide levels (from 3201 +/- 900 to 2177 +/- 720 pg/ml; P = 0.006). No significant changes from baseline were observed in controls. CONCLUSIONS: As many as 40% of patients with CHF are GH deficient. GH replacement therapy in these patients improves exercise capacity, vascular reactivity, left ventricular function, and indices of quality of life.

Cardiac rehabilitation includes interventions aimed at facilitating physical, psychological and emotional recovery following the acute phase of myocardial infarction (AMI). To date, optimal cardiac rehabilitation program duration and frequency of patient contact has yet to be identified.The present study was performed to evaluate the effects of two different strategies of secondary prevention (2 years, multifactorial continued educational and behavioral intervention versus usual care) implemented into a cardiac rehabilitation setting on several cardiovascular endpoints indicating cardiovascular functional exercise capacity and coronary risk profile in patients with recent AMI.This was a prospective randomized study including 52 postinfarction patients. Initially, all patients were enrolled in a 3-month outpatient cardiac rehabilitation program. Thereafter, they were randomly subdivided into two groups (I = intervention group; C = control group), each composed of 26 patients, and followed for 24 months.At the end of the 3-month outpatient cardiac rehabilitation program, both groups showed a significant (P0.05) improvement in cardiopulmonary parameters (maximal oxygen consumption, maximal workload) and in cardiovascular risk profile (BMI, lipid profile). During the 24-month study period, group I showed stabilization or even improvement (P0.05) of both cardiopulmonary parameters and cardiovascular risk profile, whereas group C patients showed a deterioration or significant impairment (P0.05) of the same parameters. Clinical events occurred in 27% of patients in the control group (n = 7) and in 11% in the training group (n = 3) (P0.05).Long-term, multifactorial educational and behavioral intervention maintained for 2 years in a multicomprehensive cardiac rehabilitation setting represents a valid strategy for improving long-term cardiovascular functional capacity and cardiovascular risk profile in postinfarction patients.

To investigate the effects of exercise training (ET) on left ventricular (LV) volumes, cardiopulmonary functional capacity and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in postinfarction patients with moderate LV dysfunction.Sixty-one postinfarction patients were randomized into two groups: group T [n=30, LV ejection fraction (EF) 41.6+/-11.3%, mean+/-SD] entered a 6-month ET programme, whereas group C (n=31, EF 42.0+/-7.6%, P=NS) did not. NT-proBNP assay, Doppler-echocardiography and cardiopulmonary exercise test were performed upon enrolment and at sixth months.At sixth months, trained patients showed an improvement in workload (+26%, P0.001), Vo2peak (+31%, P0.001), LV end-diastolic volume index (LVEDVI; -9%, P0.001), a reduction in NT-proBNP (-71%, P0.001) and a significant correlation between changes in NT-proBNP and in LVEDVI (r=0.858, P0.001). Baseline NT-proBNP correlated with changes in LVEDVI in both trained (r=0.673, P0.001) and untrained (r=0.623, P0.001) patients. Group C showed unfavourable LVEDVI dilation (+8%, P0.001; T vs. C group, P0.001) and a smaller reduction in NT-proBNP (-40%, P0.001; T vs. C group, P0.001).Six month ET induced a favourable LV remodelling and a marked fall in NT-proBNP that could predict LV remodelling in postinfarction patients with moderate LV dysfunction.

A large number of studies investigated the link between psychosocial risk factors and atherosclerosis or cardiac events. They found that emotional factors and chronic stressors strongly influence the course of coronary artery disease, by promoting the same pathophysiological mechanisms responsible for atherosclerosis. Thus, cardiologists often find in cardiac practice patients that presents psychosocial risk factors, needing the development of interventions aimed to management of these factors. Some of these interventions are the same that are traditionally used in clinical practice, such as exercise training and nutritional counselling, while others are more specific, and require the presence of psychologists (behavioral strategies, relaxation training, social support, etc.). Behavioral cardiology is an emerging field of clinical practice based on the recognition that psychosocial risk factors can promote atherosclerosis and adverse cardiac events. It requires the development of practical solutions aimed at the management of adverse lifestyle behaviours, emotional factors, and chronic stress.

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.

Introduction N-terminal-pro-brain (B-type) natriuretic peptide (NT-pro-BNP) is a peptide hormone released from ventricles in response to myocyte stretch. The aim of the study was to investigate the influence of exercise training on plasma NT-pro-BNP to verify if this parameter could be used as a biological marker of left ventricular remodelling in myocardial infarction patients undergoing an exercise training programme.Methods Forty-four patients after myocardial infarction were enrolled into a cardiac rehabilitation programme, and were randomized in two groups of 22 patients each. Group A patients followed a 3-month exercise training programme, while group B patients received only routine recommendations. All patients underwent NT-pro-BNP assay, and cardiopulmonary exercise test before hospital discharge and after 3 months.Results In Group A, exercise training reduced NT-pro-BNP levels (from 1498 +/- 438 to 470 +/- 375pg/ml, P = 0.0026), increased maximal (V-O2peak +4.3 +/- 2.9 ml/kg per min, P < 0.001; Power(max) +38 +/- 7, P < 0.001) exercise parameters and work efficiency (Power(max)/V-O2peak + 1.3 +/- 0.4 Power/ml per kg per min, P < 0.001); there was also an inverse correlation between changes in NT-pro-BNP levels and in V-O2peak (r = -0.72, P < 0.001), E-wave (r = -0.51, P < 0.001) and E/A ratio (r = 0.59, P < 0.001). In group B, at 3 months, no changes were observed in NT-pro-BNP levels, exercise and echocardiographic parameters.Conclusion Three months exercise training in patients with moderate left ventricular systolic dysfunction after myocardial infarction induced a reduction in NT-pro-BNP levels, an improvement of exercise capacity and early left ventricular diastolic filling, without negative left ventricular remodelling. Whether the reduction of NT-pro-BNP levels could be useful as a surrogate marker of favourable left ventricular remodelling at a later follow-up remains to be further explored.

Background: regional or global impairment of left ventricular (LV) systolic or diastolic function leading to increased LV wall stress results in increased circulating levels of N-terminal pro-brain natriuretic peptide (NT-pro-BNP). Objective: this study aims at evaluating the effect of exercise training (ET) on NT-pro-BNP plasma levels in older patients recovering from acute myocardial infarction (AMI). Design: prospective randomised study. Setting: Academic Medical Centre. Subjects: forty older patients (33 males and 7 females) who experienced AMI. Methods: patients were randomised into two groups, each composed of 20 patients: Group A were enrolled in a 3-month exercise-based cardiac rehabilitation (CR) programme and Group B were discharged home with generic instructions to continue physical activity. NT-pro-BNP, cardiopulmonary and Doppler-echocardiographic parameters were measured at baseline and at 3-month follow-up. Results: in Group A, ET reduced NT-pro-BNP levels (from 1446 ± 475 to 435 ± 251 pg/ml, P

Heart rate recovery (HRR) is a marker of vagal tone that is a powerful predictor of mortality in patients with coronary artery disease.This study aims at evaluating the effects of long-term exercise training on HRR after acute myocardial infarction (AMI), in order to clarify whether prolonged exercise training could maintain a long-term improvement of HRR.Forty-four patients after AMI were enrolled in a 3-month hospital-based exercise training programme. At the end, patients were subdivided into two groups: group A (n=22), patients discharged with a specific home-based exercise training programme and instructions for improving leisure-time physical activity; group B (n=22), patients discharged with generic instructions to maintain physical activity. All patients underwent a cardiopulmonary exercise test before, at the end of 3 months exercise training and at 6 months follow-up.At the end of the hospital-based exercise training programme we observed an increase in peak oxygen consumption [VO2peak; from 13.9+/-3.6 to 18+/-2.7 ml/kg per min (A) and from 14.1+/-3.9 to 17.9+/-2.1 ml/kg per min (B), P0.001] and in HRR [from 17.1+/-1.8 to 23.4+/-1.4 beats/min (A), and from 18.8+/-2.1 to 24.3+/-1.9 beats/min (B), P0.001]. At 6 months' follow-up we observed a further improvement in VO2peak (from 18.0+/-2.7 to 20.3+/-2.7 ml/kg per min, P0.001) and in HRR (from 23.4+/-1.4 to 27.8+/-2.1 beats/min, P0.001) in group A, but a significant decrease in VO2peak and in HRR in group B (P0.001).Long-term exercise training is useful for maintaining or improving the beneficial results of the standard 3-month exercise training programme on cardiovascular capacity and HRR. This observation may bear beneficial prognostic effects on patients after AMI.

Objects: This study aims to evaluate the influence of household smokers and of a prolonged, comprehensive home-based Cardiac Rehabilitation Program (CRP) on patient’s long term smoking behaviour after AMI. Methods: 164 male post-AMI patients, all smokers until the day of AMI, were subdivided into three groups: Group A (n=54): patients with recent AMI, discharged from hospital without enrolment in CRP; Group B (n=55): similar to Group A but enrolled in an 8 weeks hospital-based CRP and then discharged home with routine care; Group C (n=55) enrolled in an 8 weeks hospital-based CRP followed by a further 10 months of formal home-based CRP, with scheduled hospital follow-up visits. Results: Smoking resumption at 12 months was influenced by the presence of household smokers (HS): 38% of patients with HS resumed smoking compared to 27% of patients without HS (p