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Patients diagnosed with cancer are less frequently covered by preventive measures for cardiovascular diseases. The frequent co-occurrence of these diseases makes it necessary to apply parallel diagnostics and cardiological treatment with anti-cancer therapy. Case report: We present a case of a 73-year-old former smoker with hyperlipidemia, type 2 diabetes, and arterial hypertension, after a partial right nephrectomy in 2005 due to kidney cancer, diagnosed with SARS-COV-2 infection in April 2022. Follow-up chest imaging showed a 20 mm focal lesion in the left lung further classified as a small cell neuroendocrine carcinoma. Unexpectedly the patient was hospitalized for ST-segment elevation inferior left ventricular (LV) myocardial infarction treated successfully with coronary angioplasty, however heart failure (HF) with reduced left ventricle ejection fraction was diagnosed. One month later patient required another hospitalization due to the HF decompensation and cardiological treatment was optimized with flozin addition to the standard HF therapy. After cardiological approval chemotherapy was initiated with the cisplatinum-etoposide regimen and continued for 6 months without HF decompensation and significant deterioration of renal function. After that, the patient underwent radical radiotherapy. Follow-up chest computed tomography scans showed regression of the neoplastic lesion. Conclusions: Coincidence of newly recognized cancer and infection might contribute and provoke serious cardiological events . To reduce the risk of cardiovascular complications, early periodic cardiological surveillance and optimal pharmacotherapy are required.

Lung cancer is associated with an increased risk of venous thromboembolism, including pulmonary embolism. In some situations, clinical deterioration in patients with lung cancer accompanied by elevated pressure in the right ventricle, usually measured by commonly used echocardiography, may support the diagnosis of pulmonary embolism. However, there are many other causes of increased pressure in the right ventricle in such patients, for example: progression of cancer, pre-existing lung diseases, surgical resection of pulmonary tissue, pnemotoxicity of radiotherapy or concomitant diseases of the left heart. The article presents 2 clinical cases of patients with lung cancer, in which elevated pressure in the right ventricle was resulted from other causes and accompanied the progression of cancer, despite the clinical picture suggesting a pulmonary embolism. Increased pressure in the right ventricle and usually associated pulmonary hypertension, significantly worsen already poor prognosis of patients with lung cancer. The differential diagnosis should, therefore, take into account the whole clinical picture, excluding venous thromboembolism as an important cause of pulmonary hypertension, but also take into account other potential factors to be able to make the right diagnosis and implement optimal treatment as early as possible.

Complete elimination of fluoroscopy during radiofrequency ablation (RFA) of idiopathic ventricular arrhythmias (IVAs) originating from the aortic sinus cusp (ASC) is challenging. The aim was to assess the feasibility, safety and a learning curve for a zero-fluoroscopy (ZF) approach in centers using near-zero fluoroscopy (NOX) approach in IVA-ASC. Between 2012 and 2018, we retrospectively enrolled 104 IVA-ASC patients referred for ZF RFA or NOX using a 3-dimensional electroanatomic (3D-EAM) system (Ensite, Velocity, Abbott, USA). Acute, short and long-term outcomes and learning curve for the ZF were evaluated. ZF was completed in 62 of 75 cases (83%) and NOX in 32 of 32 cases (100%). In 13 cases ZF was changed to NOX. No significant differences were found in success rates between ZF and NOX, no major complications were noted. The median procedure and fluoroscopy times were 65.0 [45–81] and 0.0 [0–5] min respectively, being shorter for ZF than for NOX. With growing experience, the preference for ZF significantly increased—43% (23/54) in 2012–2016 vs 98% (52/53) in 2017–2018, with a simultaneous reduction in the procedure time. ZF ablation can be completed in almost all patients with IVA-ASC by operators with previous experience in the NOX approach, and after appropriate training, it was a preferred ablation technique. The ZF approach for IVA-ASC guided by 3D-EAM has a similar feasibility, safety, and effectiveness to the NOX approach.

Background An increasing experience in zero- (ZF) or near-zero fluoroscopy catheter ablation (CA) supports the implementation of early, fluoroless approach for recurrent, symptomatic arrhythmias in pregnancy. Purpose The aim of the study was to evaluate the feasibility, efficacy, and safety of CA with a standardized ZF approach during pregnancy. Methods Data were derived from a large prospective multicenter registry (ELEKTRO-RARE-A-CAREgistry). Between 2012 and 2019, more than 2655 CA procedures were performed in women in intention-to-treat using a ZF fluoroscopy approach. The procedures were performer using: 1) femoral access, 2) double-catheter technique, without intracardiac echocardiography, 3) electroanatomic mapping system (Ensite, Abbott, USA) for mapping and navigation, 4) conscious, light sedation. Shared decision making approach was applied, including a pregnancy heart team consultations. Results The study group consisted of 18 pregnant women (mean age: 30.3±5.0 years; range: 19–38 years; mean gestational age during CA: 21.4±9.2 weeks; range: 7–36 weeks). All pregnant women had no overt structural heart disease. Among women in reproductive age, pregnant women referred for ZF-CA approach accounted for approximately 2% of procedures. In the study group, the major indications for CA included: AVNRT (n=10); OAVRT/WPW (n=2); focal idiopathic ventricular arrhythmia (n=4), AT (n=1) and AF (n=1). Five women had double substrate for CA. In AF case general anesthesia and transesophageal echocardiography were used to monitor ZF-transseptal puncture and right-sided pulmonary vein isolation. All procedures were successfully completed without fluoroscopy, and without serious maternal or fetal complications. The procedure and ablation application times were 55.0±30.0 min and 394±338 s, respectively. In one patient second procedure for idiopathic ventricular arrhythmia was postponed after delivery. Conclusion Implementation of pregnancy heart team and a standard fluoroless protocol for CA in daily electrophysiological practice allowed an early, safe, and effective CA of maternal supraventricular tachycardia and idiopathic ventricular arrhythmias in pregnancy. Funding Acknowledgement Type of funding source: None

Drobnocząsteczkowe inhibitory kinaz tyrozynowych stanowią skuteczną opcje terapeutyczną dla pacjentow z nowotworami hematologicznymi i guzami litymi. Z drugiej strony, podkreśla sie znaczenie sercowo-naczyniowych dzialan niepoządanych związanych z ich stosowaniem, takich jak: nadciśnienie tetnicze, niewydolnośc serca, choroba wiencowa/ostre zespoly wiencowe i wydluzenie odstepu QT. W niniejszej pracy omowiono mechanizmy lezące u podloza zdarzen sercowo-naczyniowych związanych z terapią inhibitorami kinaz tyrozynowych oraz przedstawiono mozliwości ich prewencji i leczenia w praktyce klinicznej. Świadomośc mozliwych powiklan sercowo-naczyniowych, regularne monitorowanie, wczesna diagnoza i wdrozenie odpowiedniego leczenia w polączeniu ze ścislą wspolpracą z kardiologami moze zwiekszyc korzyści z dlugoterminowej terapii tą grupą lekow.

The diagnosis of acute coronary syndrome (ACS) in patients with cancer constitutes a therapeutic challenge. We aimed to assess the clinical presentation and management of ACS as well as 1-year survival in patients hospitalized for cancer.This retrospective study included patients hospitalized between 2012 and 2018 in a nonacademic center. The inclusion criteria were diagnosis of active cancer and ACS recognized using standard criteria. Patients were assessed with respect to invasive or conservative ACS strategy. The primary endpoint was all-cause mortality, and the secondary endpoint was cardiovascular mortality during 1-year follow-up.We screened 25,165 patients, of whom 36 (0.14%) had ACS (mean [SD] age, 71.9 [9.8] years). The most common presentation was non-ST-segment elevation myocardial infarction (61% of patients). Coronary angiography was performed in 47% of patients, while 53% were treated conservatively. Overall, the primary endpoint occurred in 67% of patients and secondary endpoint in 28% during follow-up. The predictors of better outcome in a univariate analysis were invasive strategy, lack of metastases, aspirin use, and no cardiogenic shock. Invasive treatment and aspirin use remained significant predictors of better survival when adjusted for the presence of metastases (hazard ratio [HR] 0.37, confidence interval [CI] 0.15-0.92 and HR 0.39, CI 0.16-0.94, respectively) and ineligibility for cancer treatment (HR 0.37, CI 0.15-0.93 and HR 0.30, CI 0.12-0.73, respectively).The incidence of ACS in cancer patients is low but 1-year mortality rates are high. Guideline-recommended management was frequently underused. Our results suggest that invasive approach and aspirin use are associated with better survival regardless of cancer stage and eligibility for cancer treatment.

Introduction Ablation of idiopathic ventricular arrhythmias (IVA) originating in left ventricle outflow tract (LVOT) are more challenging as compared to right ventricle outflow tract (RVOT). In recent years, several ECG algorithms predicting the site of origin (SOO) of arrhythmia for adult population have been published. There is a sparse information on their diagnostic performance in children. Purpose The aim of this study was to validate two algorithms: 1) Novel TZ index, 2) V2S/V3R and their combined application in children for predicting the appropriate SOO of IVA. Methods Two groups of children without structural heart disease, thorax anomalies and normal QRS complexes during sinus rhythm were included in the study: 1) patients with IVA with inferior axis who underwent successful RFCA using the 3D-electroanatomical system, 2) patients with paced or mechanically-induced QRS complexes from LVOT or RVOT during other procedures. ECGs were analyzed in a specially developed software for analyzing the amplitude of the QRS complex waves. Semi-automated measurements of amplitudes of QRS complexes and calculations were carried out for 2 published algorithms: 1) Novel TZ index, 2) V2S/V3R. The results of their separate and combined use were compared with SOO of acute successful RFCA and mapping or spot of pacing. Results 108 PVC morphologies (68 from the RVOT and 40 from LVOT) from 74 pediatric patients (age: 14.0±2.9, 39 female) were included into the study. The algorithm V2S/V3R predicted left-sided SOO with a sensitivity and specificity of 94%. Novel TZ-index showed sensitivity of 89% and specificity of 84%. Combined use of Novel TZ-index+V2S/V3R showed high sensitivity (92%) and very height specificity (97%) of the LVOT SOO prediction Conclusion Both algorithms allowed accurate, simple and precise identification of SOO of RVOT/LVOT IVA in children. The combined use of those algorithms may facilitate additional pharmacologic treatment, omitting RVOT mapping with direct mapping LVOT, performance of the procedure by experienced operator.

Background Complete elimination of fluoroscopy during radiofrequency catheter ablation (RFCA) of idiopathic ventricular arrhythmias (IVA) originating from aortic sinus cusp (ASC) may be challenging, requires confirmation of coronary arteries ostia and could be associated with potential risk of collateral damage and severe complications. Purpose To validate the implementation, feasibility, learning curve, safety and efficacy of zero-fluoroscopy (ZF) approach in centers using near-zero fluoroscopy (NOX) approach for RFCA of idiopathic premature ventricular complexes/ventricular tachycardias (PVCs/VTs) from ASC. Methods From 2012 to 2018, we prospectively enrolled 106 consecutive patients (age: 49±19, males: 58%, children: 7%, 108 PVC/VT focuses from ASC, PVCs/24h: 23808±22006) with ASC-IVA. Patients were unselected and referred for ZF or NOX approach using three dimensional electroanatomic system- 3D EAM without intracardiac or transesophageal echocardiography. The choice of ZF and NOX was based on the first operator experience and from 2014 three experienced operators and three fellows performed ZF as an intention-to-treat approach. The peri-procedural, short-term outcome as well as learning curve of ZF in ASC were evaluated with documentation of reasons for cross-over to NOX approach. Results Out of 108 focuses there were majority of left coronary cusps and left/right junctions sites of origin [other rare locations: right coronary cusp (n=7); non-coronary cusp, n=6)]. On intention-to-treat 61/76 (80%) cases were completed without fluoroscopy in ZF-approach. Additionally, 30/30 (100%) cases were completed with NOX. The main reasons for fluoroscopy use in ZF approach (conversion to NOX) were: the need for elective valsalvography plus coronary angiography (n=6), urgent coronary angiography due to validation of transient uncomplicated coronary spasms and ST elevation (n=2), catheter stability checking (n=2), femoral access site confirmation (n=1) and navigation problem (n=1). No significant differences were found in the acute and short-term success rates between ZF and NOX (90% vs 88%, P=NS) and no major complications occurred. The procedure time, fluoroscopy time and ablation time were 66.8±26.9; 3.6±7.2 and 7.3±5.5 min, respectively. The gathering experience of ZF approach, computer-assisted ECG analysis and 3D-EAM reconstruction of aortic root and coronary artery ostia resulted in significant reduction of NOX approach between early and late period [median (n=53): 2012–2016 vs 2017–2018, 40/53 (76%) vs 5/53 (8%), p Conclusion ZF can be completed in majority of patients with ASC-IVA especially after appropriate training and operators' experience with NOX. ZF approach guided by 3D-EAM is feasible, safe, and effective for treatment of ASC-IVA with importance of training and preprocedural imaging for exclusion of coronary anomalies or validation of coronary arteries ostia by 3D-EAM.

Introduction Radiofrequency ablation (RFA) of outflow tract ventricular arrhythmia (VA) that originates from the aortic cusps can be challenging. Data on long‑ term efficacy and safety as well as optimal technique after aortic cusp ablation have not previously been reported. Objectives This aim of the study was to determine the short- and long‑ term outcomes after RFA of aortic cusp VA, and to evaluate aortic valve injuries according to echocardiographic screening. Patients and methods This was a prospective multicenter registry (AVATAR, Aortic Cusp Ventricular Arrhythmias: Long Term Safety and Outcome from a Multicenter Prospective Ablation Registry) study. A total of 103 patients at a mean age of 56 years (34-64) from the "Electra" Registry (2005-2017) undergoing RFA of aortic cusps VA were enrolled. The following 3 ablation techniques were used: zero‑fluoroscopy (ZF; electroanatomical mapping [EAM] without fluoroscopy), EAM with fluoroscopy, and conventional fluoroscopy‑ based RFA. Data on clinical history, complications after RFA, echocardiography, and 24‑ hour Holter monitoring were collected. The follow up was 12 months or longer. Results There were no major acute cardiac complications after RFA. In one case, a vascular access complication required surgery. The median (interquartile range [IQR]) procedure time was 75 minutes (IQR, 58-95), median follow‑ up, 32 months (IQR, 12-70). Acute and long term procedural success rates were 93% and 86%, respectively. The long‑ term RFA outcomes were observed in ZF technique (88%), EAM with fluoroscopy (86%), and conventional RFA (82%), without differences. During long‑ term follow‑up, no abnormalities were found within the aortic root. Conclusions Ablation of VA within the aortic cusps is safe and effective in long‑ term follow up. The ZF approach is feasible, although it requires greater expertise and more imaging modalities.

Aims Ablation procedures for the treatment of atrial fibrillation lead to changes in autonomic heart control; however, there are insufficient data on the possible association of these changes with atrial fibrillation recurrence. The study aim was to assess the effects of pulmonary vein isolation (PVI) on cardiac autonomic modulation and atrial fibrillation recurrence. Methods We screened 52 patients with atrial fibrillation referred for PVI, of whom 20 patients met inclusion and exclusion criteria, and were enrolled in the study and followed over 6 months. Beat-to-beat blood pressure monitoring was performed 1–2 days before PVI, 1 and 6 months after PVI. We estimated pulse interval variability and spontaneous baroreflex sensitivity (BRS) both in the time and frequency domains, and performed the Valsalva manoeuvre assessing the Valsalva ratio. Results During 6 months after PVI, atrial fibrillation recurrence was observed in six patients. One month after PVI, pulse interval variability and BRS (sequence method) significantly decreased in all patients, returning to preintervention values by 6 months. Patients without atrial fibrillation recurrence at 1 month showed a transient reduction in pulse interval variability (frequency domain) and in BRS (both methods) in contrast to those with atrial fibrillation recurrence. A significant decrease in the Valsalva ratio observed at 1 month was maintained at 6 months after PVI in both groups. Conclusion Successful PVI may lead to transient autonomic alterations reflected by a reduction in pulse interval variability and BRS, with more prolonged changes in the Valsalva ratio. The efficacy of PVI in preventing atrial fibrillation recurrence seems to be related to transient parasympathetic atrial denervation.

Background. Slow breathing training (SBT) has been proposed as a new non-pharmacological treatment able to induce favorable effects in patients with chronic heart failure (CHF). However, no information is available regarding its effects on orthostatic blood pressure (BP) changes in these patients, an issue of practical relevance given the reported BP-lowering effect of SBT. The aim of this study is to evaluate the influence of SBT on BP and whether SBT induces orthostatic hypotension (OH) or changes in quality of life (QoL) in CHF patients. Methods. The analysis was performed as part of an ongoing crossover open trial aimed at assessing the clinical effectiveness of SBT in treated patients with CHF. The patients underwent 10-12 weeks of SBT with the RESPeRATE device and 10-12 week follow-up under usual care. Patients were randomly divided into two groups: group I began with SBT, followed by usual care; group II began with usual care, followed by SBT. Patients undergoing SBT were asked to perform each day two separate 15 min sessions of device-guided SBT at a breathing frequency of 6 breaths/min. In all patients, before the enrollment and after each study phase, clinical data collection and BP measurements in sitting, supine and standing position were performed. OH was defined as a decrease of ≥ 20 mmHg in systolic blood pressure (SBP) or ≥ 10 mmHg in diastolic blood pressure (DBP) within 3 min of standing. QoL was assessed three times at the beginning, and after each phase of the study by the Minnesota Living with Heart Failure (MLHF) questionnaire. Results. Forty patients (two equal groups) completed the study, with the following baseline characteristics: 32 males/eight females, age 63.3 ± 13.4 years, 25 with ischemic CHF, 37 in New York Heart Association class II and three in class III, left ventricular ejection fraction 30.8 ± 6.7%, mean BP 138.7 ± 16.5/83.1 ± 11.5 mmHg, 23 with arterial hypertension and four with a history of stroke. There were no significant differences between the groups in clinical characteristics, SBP and DBP at rest, while seated and before and after standing up. OH prevalence was low and did not change during the study (10% vs 10%). No significant difference in average SBP and DBP changes secondary to body position were found when comparing the two study phases. Decrease in MLHF score was observed in group I during SBT (p = 0.002), but not in group II. Conclusions. Our data indicate that SBT is safe, does not affect the prevalence of OH in CHF patients and shows a non-significant tendency to improve QoL. These results should be confirmed in a larger sample of patients to support the safety of SBT and its possible benefits as a novel component of cardiorespiratory rehabilitation programs in CHF.

Objective:Colon cancer (CC) and cardiovascular (CV) diseases are highly coprevalent due to major risk factors common to both conditions. Hypertension is the most frequent comorbidity in oncologic patients with significant incidence of new onset hypertension associated with chemotherapy, leading to w

INTRODUCTION: Slow breathing training (SBT) has been proposed as a new nonpharmacologic treatment in patients with chronic heart failure (CHF). OBJECTIVES: The aim of this study was to assess the effects of SBT on exercise capacity, hemodynamic parameters, and sleep respiratory patterns in a relatively large sample of CHF patients. PATIENTS AND METHODS: A crossover open study was conducted. Patients completed, in a random order, 10- to 12-week SBT, with 2 15-minute sessions of device-guided SBT each day, reaching 6 breaths/min, and a 10- to 12-week follow-up under standard care. Clinical data collection, polysomnography, echocardiography, 6-minute walk test (6MWT), and laboratory tests were performed. RESULTS: A total of 96 patients (74 men, 22 women) in New York Heart Association classes I-III, with an average age of 65 years and an ejection fraction (EF) of 31%, completed the study. Home-based SBT was safe. After training, EF and 6MWT distance improved (EF: 31.3% ±7.3% vs 32.3% ±7.7%; P = 0.030; 6MWT: 449.9 ±122.7 m vs 468.3 ±121.9 m; P

Background: Little is known about the effects of cardiovascular drugs at high altitude. Objective: To assess 24-h blood pressure (BP) and heart rate (HR) during short-term altitude exposure in healthy normotensive persons treated with carvedilol or nebivolol. Methods: Participants were randomized in double-blind to placebo, nebivolol 5 mg once daily or carvedilol 25 mg b.i.d. Tests were performed at sea level (baseline and after 2 weeks treatment) and on second to third day at altitude (Monte Rosa, 4559 m), still on treatment. Data collection included conventional BP, 24-h ambulatory BP monitoring (ABPM), oxygen saturation (SpO2), Lake Louise Score and adverse symptoms score. Results: Twenty-four participants had complete data (36.4 ± 12.8 years, 14 men). Both beta-blockers reduced 24-h BP at sea level. At altitude 24-h BP increased in all groups, mainly due to increased night-time BP. Twenty-four-hour SBP at altitude was lower with carvedilol (116.4 ± 2.1 mmHg) than with placebo (125.8 ± 2.2 mmHg; P < 0.05) and intermediate with nebivolol (120.7 ± 2.1 mmHg; NS vs. others). Rate of nondipping increased at altitude and was lower with nebivolol than with placebo (33 vs. 71%; P = 0.065). Side effects score was higher with carvedilol than with placebo (P = 0.04), and intermediate with nebivolol. SpO2 at altitude was higher with placebo (86.1 ± 1.2%) than with nebivolol (81.7 ± 1.1%; P = 0.07) or carvedilol (81.1 ± 1.1%; P = 0.04). Conclusions: Both carvedilol and nebivolol partly counteract the increase in BP at altitude in healthy normotensive individuals but are associated with a lower SpO2. Carvedilol seems more potent in this regard, whereas nebivolol more effectively prevents the shift to a nondipping BP profile and is better tolerated. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Background Ascending aortic blood pressure-derived indices were shown to be related to coronary atherosclerosis. Unfortunately, most studies published so far included patients with preserved left ventricular function. Therefore, the aim of the present study was to investigate the relation between ascending aortic blood pressure-derived indices and the extent of coronary atherosclerosis in patients with impaired left ventricular function. Methods The study group consisted of 375 patients (302 men and 73 women; mean age: 59.0 ± 10.1 years) with angiographically confirmed coronary artery disease and ejection fraction ≤55%. Invasive ascending aortic blood pressure during catheterization and conventional sphygmomanometer measurements were taken. Results None of the brachial or aortic blood pressure-derived indices differed between patients with one-, two- and three-vessel coronary artery disease. They were not independently related to the risk of having three-vessel coronary artery disease in none of the constructed models in logistic regression analysis. Moreover, none of the studied indices was correlated with Gensini or severity scores. We also did not find any significant correlation between blood pressure-derived indices and extent of coronary atherosclerosis in patients with ejection fraction ≤25%, 25–40% or >40%. Conclusion Ascending aortic blood pressure-derived indices are not correlated with the severity of coronary atherosclerosis in patients with coronary artery disease and impaired left ventricular function.

The incidence of chronic heart failure (CHF) increases with the aging of the population and with the improvement in survival of patients with hypertension, coronary heart disease and diabetes, diseases which constitute the most common causes for the development of CHF. Despite the significant improvement in the treatment of patients with CHF, mortality in recent years has improved slightly. The primary treatment method for chronic heart failure is pharmacotherapy, but it has limitations. The existing data encourages to look for new treatment methods for CHF, replacing or enhancing traditional ones while constituting a low nuisance for patients. New non-pharmacological methods, including therapies based on the use of stem cells, molecular therapy, modern devices supporting the heart such as cardiac contractility modulation, spinal cord stimulation, carotid sinus nerve stimulation, cervical and intracardiac atrioventricular nodal vagal stimulation, implantable monitoring devices and wearable cardioverter-defibrillator or the treatment of comorbid diseases such as hypertension and sleep dis- orders could be of particular importance.

Aim Many hypertensive subjects travel to high altitudes, but little is known on ambulatory blood pressure (ABP) changes and antihypertensive drugs' efficacy under acute and prolonged exposure to hypobaric hypoxia. In particular, the efficacy of angiotensin receptor blockers in this condition is unknown. This may be clinically relevant considering that renin–angiotensin system activity changes at altitude. The HIGHCARE-HIMALAYA study assessed changes in 24 h ABP under acute and prolonged exposure to increasing altitude and blood pressure-lowering efficacy and safety of an angiotensin receptor blockade in this setting. Methods and results Forty-seven healthy, normotensive lowlanders were randomized to telmisartan 80 mg or placebo in a double-blind, parallel group trial. Conventional and Ambulatory BPs were measured at baseline and on treatment: after 8 weeks at sea level, and under acute exposure to 3400 and 5400 m altitude, the latter upon arrival and after 12 days (Mt. Everest base camp). Blood samples were collected for plasma catecholamines, renin, angiotensin, and aldosterone. In both groups, exposure to increasing altitude was associated with: (i) significant progressive increases in conventional and 24 h blood pressure, persisting throughout the exposure to 5400 m; (ii) increased plasma noradrenaline and suppressed renin–angiotensin–aldosterone system. Telmisartan lowered 24 h ABP at the sea level and at 3400 m (between-group difference 4.0 mmHg, 95% CI: 2.2–9.5 mmHg), but not at 5400 m. Conclusion Ambulatory blood pressure increases progressively with increasing altitude, remaining elevated after 3 weeks. An angiotensin receptor blockade maintains blood pressure-lowering efficacy at 3400 m but not at 5400 m.

Based on the SYMPLICITY studies and CE (Conformité Européenne) certification, renal denervation is currently applied as a novel treatment of resistant hypertension in Europe. However, information on the proportion of patients with resistant hypertension qualifying for renal denervation after a thorough work-up and treatment adjustment remains scarce. The aim of this study was to investigate the proportion of patients eligible for renal denervation and the reasons for noneligibility at 11 expert centers participating in the European Network COordinating Research on renal Denervation in treatment-resistant hypertension (ENCOReD). The analysis included 731 patients. Age averaged 61.6 years, office blood pressure at screening was 177/96 mm Hg, and the number of blood pressure-lowering drugs taken was 4.1. Specialists referred 75.6% of patients. The proportion of patients eligible for renal denervation according to the SYMPLICITY HTN-2 criteria and each center's criteria was 42.5% (95% confidence interval, 38.0%-47.0%) and 39.7% (36.2%-43.2%), respectively. The main reasons of noneligibility were normalization of blood pressure after treatment adjustment (46.9%), unsuitable renal arterial anatomy (17.0%), and previously undetected secondary causes of hypertension (11.1%). In conclusion, after careful screening and treatment adjustment at hypertension expert centers, only ≈40% of patients referred for renal denervation, mostly by specialists, were eligible for the procedure. The most frequent cause of ineligibility (approximately half of cases) was blood pressure normalization after treatment adjustment by a hypertension specialist. Our findings highlight that hypertension centers with a record in clinical experience and research should remain the gatekeepers before renal denervation is considered. ispartof: Hypertension vol:63 issue:6 pages:1319-25 ispartof: location:United States status: published

An increased 24-h blood pressure variability, expressed as SD of 24-h average ambulatory blood pressure values, is associated with target organ damage and cardiovascular risk in hypertension, while a physiological nocturnal blood pressure fall has been associated with reduced cardiovascular risk. Nocturnal blood pressure fall, however, may contribute markedly to the overall blood pressure variability. The aim of our study was to quantitatively assess the contribution of nocturnal blood pressure fall to 24-h blood pressure variability, and to propose,a new method for computing 24-h blood pressure variability correcting for nocturnal blood pressure fall. From a large database of ambulatory blood pressure recordings obtained in two hypertension centres (Milan, Italy and Krakow, Poland), we selected 1995 re cordings of a sufficiently high quality (>= 70% valid readings, >= 1 measure/h). We calculated (1) blood pressure variability, as SD of 24-h mean blood pressure, both directly from all 24-h individual readings and as a weighted mean of separately computed daytime and night-time blood pressure SD; and (2) the size of nocturnal blood pressure fall. The weighted mean SD of 24-h blood pressure was significantly lower than the corresponding direct 24-h SD of blood pressure. The size of the difference between direct SD and weighted mean SD was strongly correlated with the absolute size of nocturnal blood pressure fall (SD: r=0.89 and 0.86 for systolic and diastolic blood pressures, respectively, P

In recent years, radical changes have been observed in the treatment of disturbances in cardiac rhythm. Multicenter clinical studies have allowed for better understanding of the pathogenesis of rhythm disturbances. Treatment options have been aimed at reducing mortality and improving health-related quality of life (HRQoL). Despite advances in pharmacotherapy and electrotherapy, many patients with rhythm disturbances experience various symptoms which often do not allow them to participate in everyday activities. Though the circumstances surrounding the occurrence of arrhythmia are unpredictable, the QoL of patients is influenced by the frequency and duration of attacks as well as the degree to which symptoms are exacerbated. Sudden and frequent hospitalizations due to arrhythmia as well as the side effects of antiarrhythmic drugs also constitute a severe burden for patients.

Slow deep breathing improves blood oxygenation (Sp(O2)) and affects hemodynamics in hypoxic patients. We investigated the ventilatory and hemodynamic effects of slow deep breathing in normal subjects at high altitude. We collected data in healthy lowlanders staying either at 4559 m for 2-3 days (Study A; N = 39) or at 5400 m for 12-16 days (Study B; N = 28). Study variables, including Sp(O2) and systemic and pulmonary arterial pressure, were assessed before, during and after 15 minutes of breathing at 6 breaths/min. At the end of slow breathing, an increase in Sp(O2) (Study A: from 80.2±7.7% to 89.5±8.2%; Study B: from 81.0±4.2% to 88.6±4.5; both p

Sleep-related breathing disorders are common in patients with chronic heart failure (CHF) and contribute to exacerbation of CHF. The effects of biventricular stimulation (CRT) seem to exceed the improvement of mechanical heart performance and are likely to affect other aspects of CHF pathophysiology. The aim of the study was to assess the influence of CRT on subjective and objective sleep features.Twenty seven consecutive patients (aged 67.7 +/- 8.7 years, 23 men - 85%) with chronic heart failure (62.9% with ischaemic background and 37.1% of non-ischaemic etiology) in stable for at least 3 months NYHA class III - IV despite optimized pharmacotherapy, with left ventricular end-diastolic diameter (LVEDd)55 mm, left ventricular ejection fraction (LVEF)or = 35% and wide QRS complex (or = 120 ms) were appraised before and 12-16 weeks after CRT introduction clinically (including 6-minute walk test--6-MWT), echocardiographically and in polisomnography. The apnea-hypopnea index (AHI) and apnea indexes (AI) of central, obstructive and mixed types were calculated. The sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), daytime sleepiness with the Epworth Sleepiness Scale (ESS).LVEF increased, 6-MWT distance rose. Left ventricular diameters and left ventricular end-systolic volume decreased. PQSI and ESS fell (9.3 +/- 4.2 vs 6.2 +/- 3.2, p0.001 and 8.4 +/- 4.1 vs 7.0 +/- 3.4, p0.001, respectively). AHI, obstructive AL and mixed AL did not alter but significant reduction of central AL was noted (9.6 +/- 13.0 vs 3.7 +/- 6.2, p = 0.023).CRT decreases central sleep apnea and improves quality of sleep and daytime sleepiness in patients with CHF.

Autonomic nervous system plays an important role in the pathogenesis of chronic heart failure (CHF). Increasing sympathetic nervous activity and decreasing parasymphatetic activity has been observed in the course of CHF. Physical training modulates the activity of the autonomic nervous system and restores the sympathovagal balance, hence it may improve the prognosis in CHF.The aim of the study was to assess the influence of a 6-month physical training in patients with chronic ischaemic heart failure on the indices of autonomic nervous system activity--blood pressure and heart rate variability.The study group consisted of 42 patients with CHF, NYHA class II and III. Patients were divided into three groups: Group I--patients who were not trained at all, Group II--patients with interval training, Group III--patients who were trained according to model with progressive increase of workload. At baseline groups did not differ according to age, clinical parameters and biochemical parameters. In all subjects 24-hr ECG monitoring was performed (with time domain heart rate variability assessment), as well as 24-hr blood pressure monitoring to analyse blood pressure variability.After 6 months we observed significant improvement in HRV parameters in Group III--those trained with progressive increase of workload (delta SDNN + 88.2 ms, p0.05). In Group II (interval training) HRV parameters remained unchanged after 6 months of training (delta SDNN + 2.5 ms, NS). Group I (without training) revealed deterioration in HRV parameters (delta SDNN--12.9 ms, p0.05). There were no differences in the mean blood pressure and blood pressure variability in all examined groups after 6 months of follow-up compared to baseline.In the examined group of patients with chronic heart failure, 6 months physical training with progressive increase of workload significantly improves autonomic function assessed by means of heart rate variability.

Although the differences between central and peripheral blood pressure (BP) values have been known for decades, the consequences of decision making based on peripheral rather than central BP have only recently been recognized. There are only a few studies assessing the relationship between intraaortic BP and cardiovascular risk. In addition, the relationship between central BP and the risk of cardiovascular events in a large group of coronary patients has not yet been evaluated. Therefore, the aim of the study was to determine the prognostic significance of central BP-derived indices in patients undergoing coronary angiography. Invasive central BPs were taken at baseline, and study end points were ascertained during over a 4.5-year follow-up in 1109 consecutive patients. The primary end point (cardiovascular death or myocardial infarction or stroke or cardiac arrest or heart transplantation or myocardial revascularization) occurred in 246 (22.2%) patients. Central pulsatility was the most powerful predictor of the primary end point (hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.14 to 1.48). Central pulse pressure was also independently related to the primary end point (HR 1.25, 95% CI 1.09 to 1.43). Central mean BP as well as peripheral BP parameters were not independently related to the primary end point risk. Central pulsatility was also related to risk of cardiovascular death or myocardial infarction or stroke. The pulsatile component of BP is the most important factor related to the cardiovascular risk in coronary patients. It is more closely associated with cardiovascular risk than steady component of BP.

BACKGROUND: At sea level, ventilation kinetics are characterized during a ramp exercise by three progressively steeper slopes, the first from the beginning of exercise to anaerobic threshold, the second from anaerobic threshold to respiratory compensation point, and the third from respiratory compensation point to peak exercise. In the second ventilation phase, body CO2 stores are used to buffer acidosis owing to lactate production; it has been suggested that this extra CO2 production drives the ventilation increase. At high altitude, ventilation increases owing to hypoxia. We hypothesize that ventilation increase reduces body CO2 stores affecting ventilation kinetics during exercise. DESIGN: In eight healthy participants, we studied the ventilation kinetics during an exercise performed at sea level and at high altitude (4559 m). METHODS: We used 30 W/2 min step incremental protocol both at sea level and high altitude. Tests were done on a cyclo-ergometer with breath-by-breath ventilation and inspiratory and expiratory gas measurements. We evaluated cardiopulmonary data at anaerobic threshold, respiratory compensation point, peak exercise and the VE/VCO2 slope. RESULTS: At high altitude: (a) peak VO2 decreased from 2595±705 to 1745±545 ml/min (P

OBJECTIVES: To assess quantitatively the relationship between nocturnal blood pressure (BP) fall and 24-h BP variability; to propose a new method for computing 24-h BP variability, devoid of the contribution from nocturnal BP fall; and to verify the clinical value of this method. METHODS AND RESULTS: We analysed 3863 ambulatory BP recordings, and computed: (1) the standard deviation (SD) of 24-h BP directly from all individual readings and as a weighted mean of daytime and night-time SD (wSD); and (2) the size of nocturnal BP fall. Left ventricular mass index (LVMI) was assessed by echocardiography in 339 of the patients. The 24-h SD of BP was significantly greater than the 24-h wSD. Nocturnal BP fall was strongly and directly related to 24-h SD, the relationship with 24-h wSD being much weaker and inverse. The difference between SD and wSD was almost exclusively determined by the size of nocturnal BP fall. wSD of systolic BP was significantly related to LVMI, while 24-h SD was not. CONCLUSION: Conventional 24-h SD of BP is markedly influenced by nocturnal BP fall. The weighted 24-h SD of BP removes the mathematical interference from night-time BP fall and correlates better with end-organ damage, therefore it may be considered as a simple index of 24-h BP variability superior to conventional 24-h SD. © 2007 Lippincott Williams & Wilkins, Inc.

Radiofrequency ablation is a standard tool for treatment of cardiac arrhythmias. It is most frequently performed in patients with nodal tachycardia, atrial flutter, and accessory atrioventricular pathway. The site for effective ablation is selected using an anatomical or electrophysiological method or both. In patients with nodal tachycardia slow pathway ablation is preferable due to lower risk of atrioventricular block and lower frequency of recurrent tachycardia as compared with fast pathway ablation. The factors determining the site of ablation and its efficacy are Jackman's and Haissaguerre's potentials and the type of extrasystoles during the procedure. The presence of residual slow pathway conduction is not a major prognosticator of late arrhythmia recurrence. In patients with the accessory pathway ablation can be performed by destructing the ventricular entry of the accessory pathway from the femoral approach or the atrial entry from the transseptal approach. The choice of the technique depends on the experience and preferences of the operator. The localization of an effective ablation site is related to the following electrophysiological parameters: accessory pathway potential, VA interval, V-Delta interval, stability of the electrode and electrogram.

Restenosis after coronary angioplasty is still a significant problem despite the dynamic development of intervention cardiology. Homocysteine causes endothelial dysfunction and disorders of the coagulation system, increases in platelets aggregation and stimulates the proliferation of the vascular smooth cell. These were the reasons for investigating the relation between homocysteine level and the risk of restenosis. Some studies indicate that higher homocysteine levels increase the risk of restenosis after coronary angioplasty, while it has not been proven in other studies. The results of the only one randomized trial demonstrated that pharmacological lowering of the homocysteine level decreased the risk of restenosis after coronary angioplasty. At this time there are some studies which started focusing on the role of lowering homocysteine level in cardiovascular risk. These investigations may explain the importance of homocysteine level in the development of cardiovascular diseases. There is a need of a large prospective multicenter trial assessing the relationship between increased homocysteine level and the frequency of restenosis after coronary angioplasty. Using intravascular ultrasonography could be especially helpful in assessing the role of decreasing homocysteine level on neo-intima formation and arterial remodeling after intervention.

A recent study has demonstrated that pulse pressure (PP) measured in the ascending aorta is related to the extent of coronary artery disease in patients undergoing coronary angioplasty. However, no study so far has analyzed the relation between pulsatility of the ascending aorta and the extent of coronary artery disease in consecutive patients undergoing coronary angiography. Therefore, we investigated the relation between ascending aorta pulsatility and the extent of coronary atherosclerosis in unselected patients with angiographically confirmed coronary artery disease. The study group consisted of 423 consecutive patients (334 men and 89 women; mean age: 58.6+/-9.7 years) with angiographically confirmed coronary artery disease and ejection fractionor =60% PP, fractional pulse pressure (the ratio of pulse pressure to mean pressure, FPP), and the ratio of pulse pressure to diastolic pressure (pulsatility index, PI) derived from intraaortic measurements differentiated patients with one-, two- and three-vessel coronary artery disease (PP, 63.0+/-16.0 versus 64.2+/-18.3 versus 71.8+/-19.1 mmHg (P0.0001); FPP, 0.68+/-0.14 versus 0.69+/-0.15 versus 0.76+/-0.17 (P0.0001); PI 0.89+/-0.25 versus 0.92+/-0.27 versus 1.04+/-0.32 (P0.0001)). After multivariate stepwise adjustment, the odds ratio (OR) and confidence interval (CI) of having three-vessel disease was: PP per 10 mmHg OR 1.15 (95% CI 1.02-1.31); FPP per 0.1 OR 1.18 (95% CI 1.02-1.37); and PI per 0.1 OR 1.11 (95% CI 1.03-1.21). None of brachial blood pressure indices was independently related to the extent of coronary atherosclerosis.Pulse pressure, fractional pulse pressure, and pulsatility index of the ascending aorta are related to the risk of three-vessel disease in patients with coronary artery disease and preserved left ventricular function.

Arterial hypertension has an important functional and morphological influence on the arterial system. The evaluation of functional and morphological changes is based upon such terms as compliance, stiffness, distensibility in the former and intima-media thickness (IMT), number and kind of atheromatous plaques in the latter case. Functional changes in the large arteries can be modified by antihypertensive and hypolipemic agents. The IMT as a non-invasive marker of vascular wall injury is increasingly frequently used in the studies. It has been identified as a significant predictor of coronary and cerebral vascular complications. Most studies on hypolipemic therapy demonstrate that the progression of IMT is slowed down. Ca-antagonists, ACE inhibitors and beta blockers are the most frequently studied agents with respect to their influence on IMT in the following patient populations: hypertensives, patients with coronary artery disease, at high cardiovascular risk and asymptomatic subjects with carotid plaque. The present paper summarises the results of these studies. The findings of the ELSA trial, the largest study evaluating the effects of therapy on IMT are noteworthy. It has been demonstrated that lacidipine has a better antiatheromatous effect than atenolol, which is independent of its hypotensive properties. Non-invasive, relatively easy ultrasound measurement of IMT in the carotid artery is an important tool to detect atheromatous lesions and because of its prognostic value. It may also serve as a predictor of cardiovascular complications, which helps in the process of therapeutic decision-making.