Q fever can present in acute or chronic form with a wide range of clinical symptoms and presentations. Here we report severe pericarditis with cardiac tamponade due to a chronic Coxiella burnetii (C. burnetii) infection. Our report emphasizes and justifies the importance of serological testing for chronic Q fever in patients with unexplained pericarditis, particularly in areas where C. burnetii is endemic.

We evaluated the impact of irbesartan (150mg once/day for 6 months) on kidney function, echocardiographic parameters and pre-clinical atherosclerosis indexes in 33 patients with newly onset of hypertension and without overt kidney dysfunction (Hypertensive Group–HTG). 15 age- and sex-matched, normotensive, healthy individuals (Normotensive Group–NTG) served as controls, without receiving any medication. After 6 months, HTG further improved its kidney function, flow-mediated dilation, diastolic function, left ventricle mass and left atrium volume implicating a cardio and reno-protective action in patients with newly onset of hypertension.

Background/design Functional electrical stimulation of lower limb muscles is an alternative method of training in patients with chronic heart failure (CHF). Although it improves exercise capacity in CHF, we performed a randomised, placebo-controlled study to investigate its effects on long-term clinical outcomes. Methods We randomly assigned 120 patients, aged 71 ± 8 years, with stable CHF (New York Heart Association (NYHA) class II/III (63%/37%), mean left ventricular ejection fraction 28 ± 5%), to either a 6-week functional electrical stimulation training programme or placebo. Patients were followed for up to 19 months for death and/or hospitalisation due to CHF decompensation. Results At baseline, there were no significant differences in demographic parameters, CHF severity and medications between groups. During a median follow-up of 383 days, 14 patients died (11 cardiac, three non-cardiac deaths), while 40 patients were hospitalised for CHF decompensation. Mortality did not differ between groups (log rank test P = 0.680), while the heart failure-related hospitalisation rate was significantly lower in the functional electrical stimulation group (hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.21–0.78, P = 0.007). The latter difference remained significant after adjustment for prognostic factors: age, gender, baseline NYHA class and left ventricular ejection fraction (HR 0.22, 95% CI 0.10–0.46, P < 0.001). Compared to placebo, functional electrical stimulation training was associated with a lower occurrence of the composite endpoint (death or heart failure-related hospitalisation) after adjustment for the above-mentioned prognostic factors (HR 0.21, 95% CI 0.103–0.435, P < 0.001). However, that effect was mostly driven by the favourable change in hospitalisation rates. Conclusions In CHF patients, 6 weeks functional electrical stimulation training reduced the risk of heart failure-related hospitalisations, without affecting the mortality rate. The beneficial long-term effects of this alternative method of training require further investigation.

Conventional exercise programmes constitute a cornerstone in the management of patients with chronic heart failure (CHF).1, 2 Physical exercise has beneficial effects on endothelial dysfunction, neurohormonal activation, oxidative stress, inflammatory activation and depressive symptoms.2-6 As a result, according to a meta-analysis (ExTraMATCH),7 exercise training leads to a relative risk reduction of 23% for death or hospitalization. In addition, the randomized controlled trial HF-ACTION showed a reduction in cardiovascular mortality and hospitalization rate after adjustment for key prognostic factors.8 However, the compliance of CHF patients with training programmes is not satisfactory, even in the context of clinical trials.8 This poor adherence is related to limitations resulting from advanced disease state or coexistent comorbid conditions, along with the lack of proper motivation.9 In addition to conventional physical exercise, alternative modes of training have been studied in CHF patients.10, 11 In this context, neuromuscular or functional electrical stimulation (FES) of leg muscles offers an alternative mode of training and represents an attractive option for CHF patients who are unable, non-adherent or unwilling to exercise. Self-adhesive surface electrodes are positioned on the thighs (5 cm below the inguinal fold and 3 cm above the upper patella border) and calf muscles (2 cm below the knee joint and just over the proximal end of the Achilles tendon). The patient lies in supine position with their thighs slightly bent in a 120° angle to the torso that enables muscles to produce their maximal force. Electrical stimulation is performed through the surface electrodes. Skeletal muscular contractions are produced by the percutaneous stimulation of peripheral nerves, aiming to maintain muscle mass and strength and prevent muscle atrophy. The stimulator delivers a biphasic current of low frequency (10–50 Hz), with gradually increasing stimulation amplitude of 40–80 mA, maximized to pain threshold. A FES rehabilitation programme can be performed either at the hospital or at home, using a dual-channel battery-powered stimulator. A series of small clinical studies in CHF patients comparing FES with conventional exercise or sham stimulation showed that FES had beneficial effects on muscular strength, exercise capacity, quality of life, emotional stress and biomarkers of neurohormonal or immuno-inflammatory activation.12-17 Moreover, FES was safe and well tolerated, whilst the patient is sedentary and relaxed in the environment of his/her choice. Therefore, FES may be considered as a substitute for traditional rehabilitation programmes in CHF patients that are unable to perform conventional exercise, either owing to advanced heart failure with extremely poor cardio-respiratory fitness or to comorbidities, such as coexisting neuromuscular or skeletal muscular abnormalities. In those cases, FES may serve as an alternative rehabilitation programme. Otherwise, FES can defer muscle atrophy until the patient's limitations subside, thus acting as a ‘bridge’ to conventional exercise programmes. The initial participation in a FES protocol aims at improving muscle strength and endurance as well as exercise capacity up to a point where transition to conventional aerobic exercise may be feasible, with or without FES as an adjunct regimen. In fact, the incremental value of neuromuscular electrical stimulation combined with conventional exercise may be an interesting target for future research. It has been shown that FES enhanced maximal aerobic capacity not only in sedentary adults but also in a physically active healthy population, supporting the concept of bearing incremental value.18 For patients with advanced or end-stage CHF in particular, a recent position statement of an expert panel on quality of life clearly stressed the importance of non-pharmacological therapies, including exercise training.9 In this particular CHF population, who are unable to perform conventional exercise, FES may serve as an alternative mode of training. As previously emphasized, FES is an easily applicable, well-tolerated and safe modality in a wide range of HF patients, including elderly ones19 and those with severe symptoms [New York Heart Association (NYHA) class III or IV].17 In addition, it has been shown that FES might exert a greater benefit on clinical and neurohormonal parameters in NYHA III–IV patients compared with NYHA II patients.17 However, evidence on FES in advanced or end-stage CHF is lacking. It is evident that patients able to participate in conventional rehabilitation programmes should be urged to adhere to a tailored exercise regimen. Patients' compliance and uptitration of exercise in time are of great importance in order to ensure major benefits. Evaluation of the response to exercise programmes is also of key importance. The lack of improvement in exercise capacity after a conventional training programme seems to have a strong prognostic value for adverse cardiac events, independently of classical predictive factors.20 In those ‘non-responders’ to classical exercise regimens, FES may constitute a valuable alternative. Finally, one last group worth a mention are patients who, despite being able to exercise, lack the motivation to participate in training programmes or show an extremely low compliance with them. In this context, FES has two potential advantages: the amelioration of depressive feelings that often underlie patients' lack of interest or incentive, and the enhancement of compliance with training. Taking advantage of both, this unmotivated group of patients may be offered this alternative mode of training in order, on one hand, to experience the aforementioned benefits and, on the other, to be potentially motivated to undertake conventional exercise at a later stage, with or without FES. The duration of FES training seems to correlate with the magnitude of induced adaptations, with superior results elicited by increasing hours of training. However, gradually increasing FES frequency, initially targeting muscle endurance and uptitrated to target muscular strength as well, should also be tested. In addition to escalating FES protocols, future research could further focus on identifying transition thresholds from FES to conventional exercise training, facilitating complementation or replacement of FES by traditional exercise. Recently, investigators studied FES in hospitalized heart failure patients and reported an improvement in 6-min walking distance.21 If the benefit of FES during hospitalization for heart failure is confirmed by further studies, neuromuscular stimulation may potentially be part of the therapies prescribed to patients during discharge. An algorithm for the integration of FES into the care of CHF patients is outlined in Figure 1. Patients, who are able to exercise physically, should be encouraged to follow conventional training programmes. Those patients should be monitored for compliance and response. Among them, those who fail to comply with the prescribed physical training regimen and those who show a poor response, as defined by the lack of improvement in exercise capacity, quality of life and potentially other parameters (i.e. emotional stress, endothelial function) should be considered for enrolment in a FES programme. In those patients, FES may serve either as an adjunct or a ‘bridge’ to conventional training. However, patients who are unable to exercise physically because of comorbidities or advanced or end-stage CHF should also be considered for enrolment in a FES program. In those patients, FES may serve either as an alternative mode of training when no lack of improvement in clinical status that would allow physical exercise is expected or as an adjunct or a ‘bridge’ to conventional training when improvement is expected. In conclusion, FES constitutes an alternative form of exercise for patients unable or unwilling to engage in conventional exercise programmes. It may effectively substitute, promote or complement physical training and increase adherence to rehabilitation protocols. Despite its benefits for exercise capacity and quality of life, this modality remains currently underutilized. The algorithm proposed herein (Figure 1) may allow the integration of FES into the care of CHF patients provided that some missing pieces of supporting evidence, particularly in end-stage CHF patients, will become available and that the algorithm will be validated by future research. Furthermore, studies with larger sample sizes, longer duration of follow-up and ‘harder’ clinical endpoints are required to establish the value of FES in CHF. Conflict of interest: none declared.

Background Exercise training is an established modality in chronic heart failure. Functional electrical stimulation (FES) is an effective alternative mode of training in patients unwilling or unable to exercise; however, it has not been investigated in elderly patients. We sought to investigate the effects of FES on functional status, quality of life, emotional status and endothelial function in chronic heart failure patients aged 70 years or higher.Methods Thirty patients with stable systolic chronic heart failure (mean age 753 years, New York Heart Association (NYHA) class II/III, 37%/63%) randomly underwent a six-week FES training programme or placebo. Questionnaires addressing quality of life (Kansas City Cardiomyopathy Questionnaire (KCCQ), functional and overall) and emotional stress (Zung self-rating depression scale (SDS), Beck Depression Inventory (BDI)), as well as endothelial function (flow-mediated dilatation) were assessed at baseline and upon protocol completion.Results A significant improvement in NYHA class (p=0.005), KCCQ-functional (F=68.6, p for interaction<0.001), KCCQ-overall (F=66.9, p<0.001), BDI (F=66.3, p<0.001) and Zung SDS (F=95.1, p<0.001) was observed in the FES group compared to placebo. Patients in the FES group also had a significant increase in flow-mediated dilatation compared with placebo (F=59.1, p<0.01). FES-induced per cent change in flow-mediated dilatation was significantly correlated with respective per cent change in KCCQ functional (r=0.386, p=0.039).Conclusion In this pilot study, FES effectively improved functional status, quality of life, motional stress and endothelial function in elderly chronic heart failure patients and warrants further investigation in this particular group of patients.

INTRODUCTION Previous studies have shown an exercise-induced increase in circulating adhesion molecules (sICAM-1 and sVCAM-1) in patients with coronary artery disease (CAD). The aim of this study was to evaluate the diagnostic role of changes in serum adhesion molecules in the setting of a dobutamine stress echocardiogram (DSE). METHODS Thirty patients (18 men and 12 women aged 63.3 ± 10.67 years) with suspected myocardial ischemia underwent a DSE in our department's laboratory of echocardiography in order to identify inducible ischemia. Dobutamine was infused in incremental doses from 5 μg/kg/min up to 40 μg/kg/min. Blood samples were drawn at baseline as well as at peak stress and circulating adhesion molecules sVCAM-1 and sICAM-1 levels were measured by ELISA. Patients with a positive DSE underwent coronary arteriography within 2 weeks of the DSE study. RESULTS Sixteen patients had a positive DSE for inducible ischemia while 14 had a negative test. Among the patients with positive DSE, 12 had angiographically significant CAD as well as statistically significantly higher levels of sICAM-1 than DSE negative patients (n=14), both at baseline (302.57 ± 43.37 vs. 267.47 ± 28.03 ng/mL, p=0.028) and at peak stress (322.07 ± 49.64 vs. 260.43 ± 36.45 ng/mL, p=0.001). A significant increase from baseline to peak stress was also noted in this group (from 302.57 ± 43.37 to 322.07 ± 49.64 ng/mL, p=0.043). There were no statistically significant differences in the levels of sVCAM-1 between groups at baseline and there was no change from baseline to peak stress. CONCLUSION Plasma levels of sICAM-1 were found to be elevated in subjects with a positive DSE and angiographically significant CAD compared to patients with a negative DSE, both before and after inducible ischemia. In contrast, no changes were noted regarding sVCAM-1 levels.

Introduction Stress cardiomyopathy, also known as Takotsubo cardiomyopathy or left ventricular apical ballooning, has been linked to emotional or physical stress resulting in transient left ventricular dysfunction. It typically affects the mid and apical left ventricular segments. At onset, it resembles acute myocardial infarction, due to the acute onset of chest pain and ST-T segment elevation. However, there is minimal biomarker elevation and a normal coronary artery angiogram. Case presentation We report a case of a woman with transient myocardial injury after a stressful event, presenting with a variation of the affected segments. In this case, only the basal and mid portions of the left ventricle were affected, while the apex was completely spared. Coronary angiography revealed no significant occlusion and left ventricular function had recovered completely by the third day of hospitalization. Conclusion We present a variant form of stress cardiomyopathy, affecting the basal and mid segments of the left ventricle.

and endothelium-dependent vasodilation reduced (5.6±5.3 vs. 15.7±7.4%,p<0.001 ) in SX patients compared to controls.Furthermore, a significant correlation was lound between endothelium~dependenl vasodilalion and serum CRP levels in the whole population of subjects (r=-0.38,p<0.05), with a tendency to a correlation in the group of SX patients (r=-0.44,p=0.086) but not in controls (r=0.19,p=0.549), separately.No dillerences were observed in endolhelium-independenl vasodilalion results between SX patients and controls (19.5±9 vs. 19.8±5%,respectively, p=0.902).The vasodilator response to nitroglycerin was also not significantly correlated to serum CRP levels both in the whole population el subjects (r=-0.15,p=0.44) and in syndrome X patients (r=-0.37,p=0.15) and in controls (r=0.11,p=0.74), separately. Conclusion:Our data confirm the presence el peripheral endothelial dyslunclion and el higher serum CRP values in SX patients.There was, however, only a tendency to a correlation between CRP levels and flow-mediated vasodilalion, suggesting thal other mechanisms may contribute to endothelial dyslunction in these patients.