Presentazione sul tema: "Reflusso e Aritmie Lo sport come mezzo di prevenzione"— Transcript della presentazione:
1Reflusso e Aritmie Lo sport come mezzo di prevenzione 14 Settembre 2013Reflusso e AritmieDr. Paolo PieragnoliSOD AritmologiaFirenze
2EpidemiologiaIncidenza e prevalenza della fibrillazione atriale (FA) aumentano con l’aumentare dell’etàIncidenza (n • 103/2 anni)Benjamin EJ, et al. JAMA 1994UominiDonneEtà (anni)2040806055-6475-8465-7485-94Framingham study2
3Prevalenza di fibrillazione atriale per età e sesso nello Studio ATRIA 2468101217,974 soggetti con FA (0.95%) inuna popolazione USA (California)di 1.89 milioni di personeRifUominiDonnePrevalenza (%)<5555-6460-6470-7465-6980-8475-79>85Gruppi di età (anni)Go AS et al, JAMA 20013
4AF in the general population 1.6% prevalence of AF in general population(Framingham study, AHJ 1983)3.2% people aged yrs develop AF during the subsequent 24 years (Framingham study, AHJ 1983)5.5% people >65 yrs have AF (Furberg, AJC 1994)41% paroxysmal, 59% chronic (Framingham study, AHJ 1983)
5Stima dei soggetti con FA 16Stima NON conservativa – Continuo aumento di incidenza12Stima dei soggetti con FA(N, milioni)8Stima conservativa – Nessun ulteriore aumento di incidenza4200020102020203020402050AnnoMiyasaka Y. Circulation, 20065
6Fibrillazione atriale: cause CardiacaNon cardiaca“Lone” atrial fibrillation
7“Lone” Atrial Fibrillation The Olmsted County Study “Lone” Atrial Fibrillation The Olmsted County Study. N Engl J Med 1987; 317:Absence of identifiable cardiovascular, pulmonary, or precipitating illness, age <60 yrs2.7% of patients with atrial fibrillationMean 15 yrs follow-up1.3% incidence of stroke94% survival
8Fibrillazione atriale: cause cardiache Malattia cardiaca ipertensivaMalattia cardiaca ischemicaMalattia cardiaca valvolareReumatica: stenosi della mitraleNon reumatica: stenosi dell’aorta, rigurgito mitralePericarditeTumori cardiaciSick sinus syndromeCardiomiopatiaIpertroficaIdiopatica dilatativaChirurgia post bypass coronarico
9Fibrillazione atriale: cause non cardiache PolmonareMetabolicaIpertiroidismoDisordine elettroliticoTossica: alcol (‘holiday heart’ syndrome)
23Acid reflux causes a local inflammatory process that may alter the autonomic innervations of the esophageal mucosa, and may also penetrate the esophageal wall and affect the adjacent vagal nerves due to the close juxtaposition of the esophagus and atria, especially the left atrium, where most triggers associated with atrial fibrillation have been described, affecting myelination and thus propagation of stimuli.Inflammation of the esophagegal mucosa affects local receptors that may induce afferent-efferent reflex mechanisms of the cardiac rhythm which can lead to secondary stimulation of the vagal nerves inducing AF.
27Hiatal hernia is a condition in which parts of the abdominal contents, mainly the GEJ and the stomach, are proximally displaced above the diaphram through the esophageal hiatus into the mediastinum.Hiatal hernia (10% in patients younger than 40 years to 70% in patients older than 70 years) may predispose to GERD or worsen existing GERD in a few individuals
29Possible mechanisms are : Atrial arrhythmias may be induced by a mechanical effect on the left atrial wall that is related to the passage of foodA large hiatal hernia may also cause compression of the left atrium and may result in an area of relative ischemia and anatomical block resulting in reentry and arrhythmias
31Reflux esophagitis in the pathogenesis of paroxysmal atrial fibrillation: results of a pilot studyN° of patientsMethodologyResultsConclusionWeilg et al, 2003
32Thirty-two patients (13 women and 19 men, age years) with a combination of dysrhytmias and GERD, and 9 patients (5 women and 4 men, age years) with GERD only underwent simultaneous 24-hours pH and ECG monitoringPower spectrum analysis of heart rate variability was obtained woth both low-frequency (LF) (symptathetic modulation) and high-frequency (HF) (vagal modulation) components.Hourly mean esophageal pH and LF/HF ratio (esophagus-heart) were correlated.A 3-month regimen of esomeprazole 40 mg/day was prescrived.In 18 patients with dysrhythmias and in none with GERD only, a significant correlation between esophageal pH and LF/HF ratio was observed.A significatn reduction of cardiac symptoms after PPI therapy was observed only in these patients (13/16 vs 4/11, p<0.01)
33The study concluded that there could be a subgroup of patients with heart dysrhythmias in whom esophageal acid stimulus elicited cardiac autonomic reflexes, and acid suppression in this subgroup may improve both GERD and cardiac symptoms.Although this study demonstrated a reduction or disappearance of the dysrhythmias in patients with a cardiac response to esophageal acid exposure, it had some limitations.
35multicenter questionnaire survey Relationship between atrial fibrillation and gastroesophageal reflux disease:multicenter questionnaire surveyN° of patientsMethodologyResultsConclusionShimazu et al, 2011
36Pulmonary veins isolation: pathophysiology M. Gulizia et al “Diagnosi e terapia del Flutter e della Fibrillazione atriale” 2009
37Choice between ablation and antiarrhythmic drug therapy for patients with and without structural heart diseaseEuropean Heart Journal (2010) 31, 2369–2429
50CONCLUSION 1The association between AF and GERD is still debated, predominantly because of shared confounding factors such as obesity, diabetes and sleep apnea.However, there is a mounting body of evidence that suggests an association between the two; therefore, a large randomized clinical trial is warranted.Currently, the most likely potential mechanism for GERD-induced AF is local release of cytokines secondary to esophageal injury, which creates a proarrhythmogenic environment. Perhaps the most compelling evidence that supports this association is that proton pump inhibitors seem to reduce the incidence and the duration of AF.
51CONCLUSION 2At present, few clinicians outside the field of cardiac electrophysiology and gastroenterology are aware of the possible association of GERD, hiatal hernia and AF. As more patients with these disorders are treated and studied, our insights into the pathogenesis will be elucidated. It will be interesting to see whether AF causes GERD reciprocally, thus creating a cycle.Increasing awareness that GERD and/or hiatal hernia may be independent risk factors for AF may result in physicians being more aggressive in treating patients with proton pump inhibitors and hiatal hernia repair, since both of these therapies have shown a reduction in the incidence and duration of AF.