Background: With the outbreak of Coronavirus disease 2019 (COVID-19), many studies’ attention to this world’s complexity increased dramatically. Different views on sports and physical activities have been presented, which have addressed the advantages and disadvantages of sports activities in this period differently. The purpose of this review was to investigate the physiological and psychological effects of physical activity during the COVID-19 pandemic. Methods: Using PubMed, Science Direct, Medline, and Web of Science electronic databases, this review summarizes the current knowledge of direct and indirect effects of physical activity during the COVID-19 pandemic, evaluating the advantages and drawbacks of specific exercise physiology conditions. All types of studies were assessed, including systematic reviews, case-studies, and clinical guidelines. The literature search identified 40 articles that discussed COVID-19, immune system, the relation between immune system and exercise or diet, and psychological impacts of physical activity. Results: Forty articles review showed that the immune system depends on the type, frequency, intensity, and duration of the exercise. Intense or prolonged exercise with short recovery periods can progressively weaken the immune system and increase the risk of COVID-19. One of the acute responses after moderate-intensity training is improved immune function and a decrease in inflammatory cytokines. Paying attention to dietary intakes of micro-and macronutrients in conjunction with exercise can strengthen the condition to fight against coronavirus. Exercise can also affect the psychological dimensions of the COVID-19 pandemic, including depression, anxiety, and stress, which improve community mental health during the quarantine. Conclusion: Setting appropriate physical activity based on individuals’ properties and proper diet plan may enhance the physiological and psychological body’s condition to fight against coronavirus.

Background: Rotation of the femoral component in total knee replacement (TKR) is very important for good long-term results. Malrotation of the femoral component usually requires subsequent reimplantation. We performed X-ray projections of the knee at 90° to determine proper rotation of the femoral component without use of computed tomography. Methods: The axial projection of the distal femur was measured in post-TKR cases. During the TKR operation, Whiteside’s method had been used to provide symmetrical flexion space. The exact outer rotation of the femoral component was measured by x-ray determination of the middle condylar twist angle, from the central epicondylar axis and posterior condylar axis. Results: The middle condylar twist angle was in outer rotation, with an average of 3.36° (range: 1-7.6), similar to the literature. Six of the patients underwent bilateral TKR. In total, the case series included 18 women and 15 men, with average age of 71.34 years-old (range: 56-85). As a clinical evaluation we used Knee Society Score (2011). From results 2 patients were not very satisfied with the instability TKR. Axially X-ray seemed to be only which could distribute these patients. Summary: X-ray values have the same evaluation as computed tomography. The results were 2 patients in pattern of 48, which were sufficient to extrapolate to whole population according to the statistical methods. This corresponds to 4% which we can add to evaluate satisfaction of all patients after TKR and eventually lower the total of unsatisfactory patients which is total of ¼ of total. It is also forensic reason for all patients. Our recommendation to have good results and patient satisfaction in TKR is to do x-rays before and after operation. Important are x-rays antero-posterior, lateral, and Kanekasu projection to know the rotation after TKR. Other cases without stability in flexion are nor very rarely planed for revision surgery, which is much more expensive, and burdens overall health system. 

Introduction: Acupuncture is a practice that has been used to treat multiple medical conditions for thousands of years and is one of the most popular alternative treatments applied in Western medical practice. Acupuncture is a modality that has significant potential for further integration into the treatment of sports medicine conditions. Methodology: The search strategy in this review included electronic databases-MEDLINE, Cochrane Library, PubMed, Web of Science, and Science Direct. Randomized controlled trials and systematic reviews were preferred for article inclusion, but other study types were included when the number or quality of evidence was limited. Results: Back pain, neck pain, shoulder pain, and knee pain related to OA tend to respond well to acupuncture treatment. There is evidence to support the use of acupuncture for the short-term treatment of plantar fasciitis, although long-term efficacy data is lacking. Acupuncture may be a useful treatment modality for epicondylitis and Achilles tendinopathy, but the current data is limited. While acupuncture may improve athletic performance and prevent Delayed-Onset Muscle Soreness (DOMS) symptoms, there is little current evidence to support this use. Conclusion: Further studies are needed to assess the usefulness of acupuncture in sports medicine. However, there is good evidence for the current use of acupuncture in treatment of multiple pain conditions.

The Sit-to-Stand test (STST) involves comparing the change in a person’s non-weight-bearing and weight-bearing foot posture to quickly classify a person’s overall foot mobility. Despite the simplicity of the test, its reliability and validity has not been established. The purpose of this study is to determine the intra-rater and inter-rater reliability of the STST as well as its validity. Ninety-seven subjects with a mean age of 25 years (±3.7) participated in the study. Each subject’s foot posture from non-weight-bearing to weight-bearing was evaluated by two different raters. Each rater classified each subject’s change in foot posture as “Hypomobile”, “Normal” or “Hypermobile”. This same procedure was repeated approximately one week later without the raters being able to review what their original classification for that subject had been. The subjects also had their foot mobility quantified by measuring the height and width of their dorsal arch in both non-weight-bearing and weight-bearing. These quantitative measures of foot mobility were then classified as “Hypomobile”, “Normal”, or “Hypermobile” using quartiles. A series of Cohen’s Kappa coefficients were used to assess the amount of agreement between the visual classifications by each rater as well as the classification between the observational and objective classifications. The between-day Kappa coefficients ranged from 0.613 to 0.719 and the inter-rater Kappa coefficients ranged from 0.473 to 0.531. The Kappa coefficients between the visual and quantitative classifications ranged from 0.281 to 0.436. The STST should therefore be used with caution because of its moderate between-rater reliability and validity.

Time-efficient screening of lower extremity biomechanics to identify potential injurious movement patterns is crucial within athletic medicine settings. When considering biomechanical risk factors for anterior cruciate ligament injuries, several screening tests have been used to assess dynamic knee valgus. Current methods involving 3-dimensional motion capture systems are considered gold standard for such assessment; however, these methods are time consuming and require expensive materials. This study investigated the use of 2-dimentional kinematic evaluation during a standardized vertical jump athletic assessment to screen for potential lower extremity risk of injury. 50 collegiate athletes, 25 male and 25 female, from various sports participated in the study. The vertical jump was chosen because it is a common performance evaluation test that is regularly performed several times a year, providing consistent opportunities for screening while not creating additional obligations for the student athletes. Results showed that the 2-dimentional evaluation method had strong correlations (P<0.0001) with the gold standard 3-dimensional evaluation, suggesting that an accelerated 2-dimentional screening process can be used as a first step to screen for potential injurious lower extremity movement patterns.

High blood pressure under medical palance is associated with a variety of circulatory diseases, and it has been estimated that over 12% of all deaths in the world is directly or remotely connected with hypertension. It is said that one out of every five persons, can expect to have high blood pressure at one time or the other, during one’s life time. Based on hemodynamic equation, the mean arterial pressure is equal to cardiac out-put, times resistance (p means=Q x R). Hence hypertension is usually as a result of either an increased cardiac output and/or an increased resistance. The most common form of high blood pressure in humans is called “essential hypertension”, while is said to have no known cause. However this research aims at showing how a 12-week moderate exercise with bicycle egometer (i.e., use of non-pharmacologic approach to reduce the resting heart rate and blood pressure of 6 volunteer retired civil servants from Anambra state civil service and 6 retired academic staff of Nnamdi Azikiwe university in Awka. The paired T-test analysis of data obtained revealed a statistical significant effect of the moderate 12-week exercise on bicycle egometer, on the resting heart rate and blood pressure of the experimental group of the respondents. Hence it could be concluded that the administration of moderate exercise on bicycle egometer could be an effective use of non-pharmacologic intervention in the control and prevention of high blood pressure or hypertension among the elderly.

Sustained isometric contractions of skeletal muscles produce intramuscular pressures that leads to blood flow restriction. In result an active muscle feels deficit of oxygen what bring to muscle fatigue. In another side during exercise we have physiological contradiction between raising of oxygen demand by working muscle and restriction of blood flow due to vessel pressing. To clarify this issue many research has been performed based mainly on measurement of blood flow in muscle tissue. The purpose of this study was to assess real-time changes in muscle oxygenation during a sustained isometric contractions of dorsiflexor muscle of low (30%), moderate (60%) and submaximal (90%) intensity. Experiments were conducted using the subject’s dominant (right) leg. Volunteers was recruited from eight male students of USIPC (age: 19±2 years, weight: 75±6 kg). Tissue oxygenation index (StO2) were recorded from the tibialis anterior using NIRS device (NONIN). Saturation was higher at 30% compared with both 60% and 90% MVC at all time points after start exercise and higher at 60% than 90%. Oxygen consumption (VO2) permanently increased from slow (30%) to moderate (60%) and submaximal contractions. After cessation of the each contraction there was a large and immediate hyperemic response. Rate of StO2 increasing after effort cessation what reflects the resaturation of hemoglobin which depend on integrity and functionality of vascular system and reflects blood vessel vasodilation. StO2 restoration rate permanently increased from slow (30%) to moderate (60%) and submaximal contractions too. At last on final stage of experiment arterial occlusion test has been performed to determine the minimal oxygen saturation value in the dorsiflexors. Oxygen saturation reached a 24±1.77% what is significantly higher than StO2 after 60 and 90%MVC. So, we can conclude that oxygen saturation at 60% and 90% MVC are similar and sharply decreased after start of exercise. It means that after 60% MVC take place occlusion of blood vessels due to intramuscular pressure. Oxygen consumption of active muscle increased depend on intensity of exertion according to increasing of oxygen demand. StO2 resaturation rate (Re) permanently increased from slow (30%) to moderate (60%) and to submaximal contractions. Re increasing after effort cessation reflects the resaturation of hemoglobin which depend on integrity and functionality of vascular system and reflects blood vessel vasodilation.

Context: Shoulder pain is one of the most frequent reported complaints in intensive competitive swimming. The so-called ‘swimmers’ shoulder’ has been widely explored and has been reported sometimes without specific reference to contributing mechanisms or structures. Somatic dysfunction is defined as an impaired or altered function of related components of the somatic system and may appear in the early stage of pain feeling. Aim: To evaluate somatic dysfunctions in a group of young competitive swimmers with and without shoulder pain and its relationship with the shoulder’s mobility along with the efficacy of an osteopathic manipulative treatment (OMT) on shoulder’s mobility, pain, and comfort of swimming. Material and method: 20 competitive swimmers (14.6 ± 1.3 ys; 11.6 ± 2.4 hs.wk-1) were divided into two groups, with and without shoulder pain (SPG/CG). Before and after light touch/OMT, and 1 week later, somatic dysfunctions, shoulder’s range of mobility, pain, and swimming comfort were assessed by 2 independent osteopaths. Results: Somatic dysfunctions were observed in both groups without significant differences in the number or localization and were independent of severity of pain. In the SPG, pain decreased significantly after OMT (6.1 ± 1.9 vs. 3.9 ± 1.8; p = 0.001) and remained stable 1-week later (P = NS). Shoulder’s mobility was lower on the aching shoulder in the “shoulder pain” group when compared to the control group on flexion and abduction tests but not on extension or adduction tests. Following OMT, only abduction improved when compared to light touch. Comfort in swimming was reported as “better” in both OMT/light touch groups. Conclusion: There is no difference between light touch and OMT as both decreased pain and increased comfort in swimming but abduction range of motion only improved in the OMT group.

The anthropometric characteristics are decisive for an optimal physical level and, therefore, a good level in the game; and they can be different depending on the game position. The aim of this study was to identify the physical characteristics, body composition and somatotype of professional soccer players and to verify differences according to their playing positions: goalkeepers, defenders, forwards and midfielders. The measurements were performed on 57 male players of a soccer team of the Spanish Football League One. Twenty seven anthropometric variables were measured (height and body weight, four bone breadths, eleven girths and ten skinfolds) and the Bioelectrical Impedance Analysis was also performed. The percentage of body fat has been determined from 11 different equations. Goalkeepers showed the highest weight (80.2 ± 3.2 kg), supraespinal (10.5 ± 3.8 mm) and abdominal (15.6 ± 3.5 mm) skinfolds than others positions. In relation to body fat percentages, similar results were obtained from the equations of Jackson-Pollock (from 3 and 7 skinfolds), Carter, Withers, and Heyward and Stolarczyk (mean value 7.8 ± 1.5%). Higher results were obtained from the other equations applied. Differences among positions were also found concerning body composition; goalkeepers showed the highest body fat percentage (9.4 ± 1.4%). Mean somatotype was also different among positions; goalkeepers and forwards presented a balanced mesomorph somatotype while defenders and midfielders showed an ecto-mesomorph one. The differences in morphological characteristics according to the team position were notice only in goalkeepers, especially regarding their weight, abdominal and supraespinale skinfolds and the percentage of fat tissue.

Background: Left atrial volume (LAV) has been established as a sensitive marker of left ventricular (LV) diastolic function and as an independent predictor of mortality in patients with acute myocardial infarction (AMI). LA remodeling and its determinants in the setting of AMI have not been much studied. Methods: We studied 53 patients with anterior AMI and a relatively preserved LV systolic function, who underwent complete reperfusion and received guidelines guided antiremodeling drug management. LA and LV remodeling were assessed using 2D echocardiography at baseline and 6 months. LAV indexed for BSA (LAVi) was used as the index of LA size and further LA remodeling. Results: LAVi increased signifi cantly at 6 months compared to baseline [28.1 (23.0-34.5) vs 24.4 (19.5- 31.6) ml/m2, p=0.002] following LV end diastolic-volume index change [56.8 (47.6-63.9) vs 49.5 (42.0-58.4) ml/m2, p=0.0003]. Other standard LV diastolic function indices did not show any signifi cant change. Univariateanalysis showed a strong positive correlation of LAVi change with BNP levels at discharge, LV mass index and LV volumes indices change, throughout the follow up period. Multivariate regression analysis revealed that BNP plasma levels was the most important independent predictor of LA remodeling (b-coef.=0.630, p=0.001). Conclusions: Despite current antiremodeling strategies in patients with AMI, LA remodeling is frequently asssociated with LV remodeling. Additionally LAVi change in the mid-term reflects better than standard echocardiographic indices LV diastolic filling impairment.

Introduction: Coronary angioplasty is a safe therapeutic method for coronary disease. However, its major obstacles remain the occurrence of stent thrombosis (ST) and in-stent restenosis (ISR). The aim of this study was to evaluate the short-term and medium-term results of coronary angioplasty patients in the cardiology department of Aristide Le Dantec hospital in Dakar. Methodology: It was a longitudinal, descriptive and analytical study over a period of 12 months (April 2014 to April 2015) with a follow-up at 6 months. Was included any patient who had a coronary angioplasty with stent placement. Results: Thirty-eight patients had been included with a male predominance and a sex ratio of 5.32. The average age was 57.94 years. Cardiovascular risk factors were mainly smoking (57.9%) and coronary heredity (42.1%), followed by hypertension (39.5%) and diabete (34.2%). The indications for angioplasty were acute coronary syndromes TS(+) and TS(-) respectively (50%) and (23.7%) and stable angina (26.3%). The right femoral approach was almost exclusive (97.4%). Coronary angiography revealed a predominance of anterior interventricular affection (84.2%). Type B lesions were the most frequent (68.4%). The single-truncal valve affection was predominant (76.3%). Direct stenting accounted for 63.2% of procedures. Twenty-one bare stents (55.3%) and 17 active stents (44.7%) were implanted. The results were excellent (94.7%). One case of acute stent thrombosis was noted. Echocardiography of dobutamine stress during follow-up was positive in 04 patients (12.5%). The control coronary angiography performed in two patients revealed an ISR. The predictive factors for restenosis were dominated by a deterioration in the segmental kinetics (p=0.009), in the diastolic function (p=0.002), the systolic function (p=0.003), a high post angioplasty troponin (p=0.004), the presence of calcifications (p=0.004) and a high SYNTAX score (p=0.021). Conclusion: According to these results, Angioplasty is an effective therapy for coronary disease. However, a correct intake of double platelet antiaggregants and clinical and non-invasive screening are required for follow-up to avoid stent thrombosis or restenosis.

Thrombolysis with tissue plasminogen activator (tPA) has been plagued by inadequate efficacy and a high risk of intracranial hemorrhage (ICH), which led to its replacement by procedures like percutaneous coronary intervention (PCI) whenever possible. Since this requires hospitalization, it is time-consuming, and compromising salvage of brain tissue and myocardium. Thrombolysis is the only first-line treatment that can provide sufficiently timely treatment for optimal recovery of organ function. However, for this potential to be realized, its efficacy and safety must be significantly improved over the current method. By adopting the sequential, synergistic fibrinolytic paradigm of the endogenous system, already verified by a clinical trial, this becomes possible. The endogenous system’s function is evidenced by the fibrinolytic product D-dimer that is invariably present in blood, and which increases >20-fold in the presence of thromboembolism. This system uses tPA to initiate lysis, which is then completed by the other fibrin-specific activator prourokinase (proUK). Since tPA and proUK in combination are synergistic in fibrinolysis, it helps explain their efficacy at their low endogenous concentrations.

Background: Patients with myocardial infarction (MI) often experience anxiety, depression and poor quality of life (QoL) compared with a normative population. Mood disturbances and QoL have been extensively investigated, but only a few studies have examined the long-term effects of MI on these complex phenomena. Aims: To examine the levels and associated predictors of anxiety, depression, and QoL in patients 2 years after MI. Methods: This was a single center, observational study of patients with MI (n=377, 22% women, median age 66 years). Two years after MI (2012-2014), the patients were asked to answer the Hospital Anxiety and Depression Scale (HADS) and EuroQol 5-dimension (EQ-5D-3L) questionnaires. Results: Most patients experienced neither anxiety (87%, 95% confidence interval [CI]: 83-90%) nor depression (94%, 95% CI: 92-97%) 2 years post-MI. Elderly patients experienced more depression than younger patients (p=0.003) and women had higher anxiety levels than men (p=0.009). Most patients had “no problems” with any of the EQ-5D-3L dimensions (72-98%), but 48% (95% CI: 43%-53%) self-reported at least “some problems” with pain/discomfort. In a multiple logistic regression model (EQ-5D-3L) higher age (p<0.001) and female sex (p<0.001) were associated with more pain/discomfort. Female sex (p=0.047) and prior MI (p=0.038) were associated with anxiety/depression. History of heart failure was associated with worse mobility (p=0.005) and problems with usual activities (p=0.006). The median total health status of the patients (EQ-VAS) was 78 (95% CI: 75-80)

The problem of synchronization of oscillations of various physical nature is discussed. From the standpoint of the theory of synchronism, a model of the heart is considered as a system of four connected between self-oscillating links: two atria and two ventricles. The synchronous and asynchronous operating modes are considered at sinusoidal and relaxation oscillations. A computer program has been compiled that simulates the fluctuations in the heart using four differential equations. Four examples of calculation according to the program are given for asynchronous and synchronous operation modes. The possibility of evaluating the ablation procedure from the perspective of a computer model is discussed.

Critical congenital heart defects (CCHDs) are preferably diagnosed prenatally or soon after birth. Late diagnosis has been related to poorer prognosis. The aim of this study is to assess when CCHDs are diagnosed in Iceland and whether late diagnosis is a problem. All live born children in Iceland and foetuses diagnosed with CCHDs during the years 2000-2014 were included. CCHD was defined as a defect requiring intervention or causing death in the first year of life, or leading to abortion. The total number of pre- and postnatal diagnosis of CCHDs was 188. Prenatal diagnosis was made in 69 of 188 (36.7%). Of 69 diagnosed prenatally 33 were terminated due to CCHD. Of the 155 live born children with CCHD, 36 (23.2%) had a prenatal diagnosis and 100 (64.5%) were diagnosed shortly after birth, before discharge from birth facility. 19 children (12.3%) were diagnosed late, that is after discharge from birth facility. Coarctation of the aorta was the most common CCHD diagnosed late (6/19). Prenatal screening and newborn examination give good results in diagnosis of CCHDs in Iceland. Late diagnosis are relatively few, but both the number of prenatally diagnosed CCHDs and CCHDs diagnosed shortly after birth can be further improved.

Chronic heart failure has been extensively characterized as a disorder arising from a complex interaction between impaired ventricular performance and neurohormonal activation. Since beta adrenoceptor blocking agents are currently considered an integral component of therapy for the management of patients with severe chronic heart failure; several well designed clinical trials have been conducted to determine the morbidity and mortality benefits of these agents these studies, however did not yield the same results in terms of morbidity and mortality benefits. Currently only Bisoprolol, Carvedilol and sustained release metoprolol succinate have clinically proven and convincing morbidity and mortality benefits the current list of approved medicines of the National Health Insurance Scheme (NHIS) of the republic of Ghana does not provide coverage for these lifesaving therapeutic agents. The objective of this review was to collate the relevant scientific evidence that will convince the authorities at the National Health Insurance Authority (NHIA) of the Republic of Ghana to include at least one of the evidence based beta adrenoceptor blocking agents in the list of approved medicines. A thorough search on the internet was conducted using Google scholar to obtain only the clinically relevant studies associated with the benefits of beta adrenoceptor blocking agents in patients with chronic heart failure published in the English language. The phrases beta adrenoceptor blocking agents and chronic heart failure were used as search engines. The search engine yielded several studies that met the predefined inclusion criteria. However, only the Cardiac Insufficiency BIsoprolol Studies (CIBIS-I and CIBIS-II), Carvedilol Prospective Randomized Cumulative Survival Study (COPERNICUS) and Metoprolol CR/XL Randomized Intervention Trial (MERIF-HF) because of the clinical relevance of their findings Beta adrenoceptor blocking agents such as atenolol and propranolol have been used in the management of patients with chronic heart failure. However, their efficacy and optimal dose in reducing mortality have not been scientifically established not all beta adrenoceptor blocking agents scientifically studied provide the same degree of clinically meaningful and convincing morbidity and mortality benefits in patients with chronic heart failure.

Background: Hypertrophic cardiomyopathy (HCM) patients have a predisposition for malignant VT/VF and consequently, sudden cardiac death (SCD). In single center studies, late gadolinium enhancement (LGE) defined fibrosis has been linked to VT/VF. However, despite innumerable investigations, SCD has not been definitely attributable to LGE. Explanations for these are believed to be related to insufficient statistical power. Methods: We performed an electronic search of MEDLINE, PubMed: and CMR abstracts for original data published or presented between Jan 2001 to Mar 2011. Key search terms: HCM, LV fibrosis, SCD and LGE. Studies were screened for eligibility based on inclusion criteria: referral for CMR exam with LGE for HCM; and follow-up for incidence of VT/VF and SCD. Categorical variables were evaluated between patient groups via Chi-square test. Results: A total of 64 studies were initially identified. Of these, 4 (6.3%) were identified and included (n = 1063 patients). Three prospective and one retrospective study were included. LGE was detected in 59.6% of patients. As expected, the presence of myocardial fibrosis was associated with VT/VF (x2 = 6.5, p < 0.05; OR 9.0, (95% CI 1.2 to 68.7). Moreover, myocardial fibrosis strongly predicted SCD (x2 = 6.6, p < 0.05; OR 3.3 (95% CI 1.2 to 9.7). Conclusion: Despite single center CMR studies, LGE has consistently predicted VT/VF while prediction of SCD has remained paradoxically unlinked. Although the lack of studies meeting our criteria limited our ability to perform a comprehensive meta-analysis, we have been able to demonstrate for the first time that LGE-defined fibrosis is a predictor of SCD in patients with HCM0.

A key platform underpinning the traditional understanding of the cardiovascular system, with respect to the behavior of large arterial vessels, is Otto Frank’s Windkessel Hypothesis [1]. This hypothesis posits simply that the smooth muscle walls of large arteries do not undergo rhythmic contractions in synchrony with the heartbeat but, rather, behave as passive elastic tubes undergoing distension from pulsatile pressure waves. The Windkessel Hypothesis is elegant, well described for over a century, ingrained in the understanding of cardiovascular medicine and physiology, and simply wrong. Several groups have now shown that the arterial smooth muscle wall undergoes rhythmic activation in synchrony with the heartbeat in a variety of tissues, including human brachial artery; canine coronary, femoral, and carotid arteries; rabbit aorta; feline pulmonary artery and rodent aorta [2-8]. The phasing of these events is such that the upstroke of the contraction slightly precedes the upstroke of the pulse wave, suggesting nomenclature for the events as pulse synchronized contractions, or PSCs [3,6-8]. PSCs have been found to be of neurogenic origin, sensitive to the neural blocker tetrodotoxin [3,8]. Although the specific neural pathways regulating PSCs have not been elucidated, the alpha-adrenergic system is at least partially involved, as evidenced by reduction or blockade of PSCs by the alpha-adrenergic blocker phentolamine [8]. Further, PSCs have not been observed following vessel excision in in vitro studies, as an intact nervous system is not present. The pacemaker for the PSC resides in the right atrium, as suggested by two lines of evidence. First, pacing of the right atrial region to faster than spontaneous frequencies leads to a one-to-one correspondence of PSC frequency with the stimulation rate [3]. Additionally, excision of the right, but not the left, atrial appendage results in elimination of PSCs [3]. As the pacemaker region for PSCs and the heartbeat both lie in the right atrium, this may potentially allow for coordination between the heartbeat and pulse wave with PSCs [3,5,8]. Extensive evaluations also have been performed showing the PSC was not an artifact produced either by cardiac contractility or from the vessel distension from the pulse wave [3,5,6].

A 56-year-old man was admitted to our hospital because of sudden onset of right-sided thoracic pain. The ECG showed inferior ST segment elevations. He has been treated with aspirin, clopidogrel, unfractionated heparin and tenecteplase, and his symptoms resolved after 30 minutes. About half an hour later, the patient developed again left-sided thoracic pain and the signs of an anterior myocardial ST-segment elevation infarction. 90 minutes after receiving the initial medications, the performed coronary angiography revealed a long dissection of a large ramus circumflexus. Furthermore, the left anterior descending coronary artery was occluded at about the mid-level. The left ventriculography showed a reduced ventricular function and a Stanford type A aortic dissection. Immediate patient transfer for emergency surgical intervention was arranged. However, ventricular fibrillation occurred during transport and he required endotracheal intubation and prolonged cardiopulmonary resuscitation. Unfortunately, he died during further transport. In a patient with massive thoracic pain of initially uncommon localization in combination with fluctuation of ST-segment elevations, aortic dissection should be seriously taken into the differential diagnosis as well as into therapeutic management decisions (in particular antiplatelet and thrombolytic therapy).

The involvement of the angiotensin II type 1 receptor in the Frank-Starling Law of the Heart, where the various activations are very limited, allows simple analysis of the kinase systems involved and thence extrapolation of the mechanism to that of angiotensin control of activation of cardiac and skeletal muscle contraction. The involvement of phosphorylation of the myosin light chain in the control of contraction is accepted but not fully understood. The involvement of troponin-I phosphorylation is also indicated but of unknown mechanism. There is no known signal for activation of myosin light chain kinase or Protein Kinase C-βII other than Ca2+/calmodulin but the former is constitutively active and thus has to be under control of a regulated inhibitor, the latter kinase may also be the same. Ca2+/calmodulin is not activated in Frank-Starling, i.e. there are no diastolic or systolic [Ca2+] changes. I suggest here that the regulated inhibition is by myosin light chain phosphatase and/or β-arrestin. Angiotensin activation, not involving G proteins. is by translocation of the β-arrestin from the sarcoplasm to the plasma membrane thus reducing its kinase inhibition action in the sarcoplasm. This reduced inhibition has been wrongly attributed to a mythical downstream agonist property of β-arrestin.