Improvement in Left and Right Ventricular Function after Introduction of SGLT2 Inhibitors in Heart Failure Outpatients with Reduced Ejection Fraction

BACKGROUND

Type 2 sodium-glucose cotransporter inhibitors (SGLT2i) are among the main therapeutic options for patients with chronic heart failure with reduced ejection fraction (HFrEF). The aim of this study was to evaluate the effects of SGLT2i on the echocardiographic parameters of left (LV) and right (RV) ventricular function among outpatients with a long history of HFrEF, in optimized therapy.

METHODS

We evaluated consecutive patients affected by HFrEF in whom the SGLT2i therapy was prescribed. Following a baseline evaluation (T0), in which SGLT2i was prescribed, patients were re-evaluated at 3 (T3), 6 (T6), and 12 (T12) months.

RESULTS

We considered 60 patients for the analysis with a median history of HFrEF of more than seven years in optimal medical and electrical therapy. After SGLT2i therapy, LV ejection fraction and LV global longitudinal strain improved from baseline at T3, T6, and T12. Analogously, RV global and free wall longitudinal strain improved at T3 and T6.

CONCLUSIONS

Our study shows that the addition of SGLT2i to the optimized therapy for HFrEF was associated with a significant improvement in both LV and RV function, thus highlighting a possible mechanism responsible for the benefit obtained with this class of drugs.

Atrial paced rhythm and heart rate-dependent worsening of left atrial and ventricular function

BACKGROUND AND AIM OF THE STUDY

The response to the increase in heart rate (HR) could be characterized by failure in both left ventricular (LV) and left atrial (LA) functions. This study aimed to evaluate the relationship between the increase in paced HR and the changes in LV and LA functions, assessed by two-dimensional speckle tracking analysis.

METHODS

In a group of patients with an implantable cardioverter defibrillator (ICD) or pacemaker, the atrial paced rhythm was progressively increased from 60 to 70, from 70 to 80, and from 80 to 90 beats per minute (bpm). For each paced HR, using two-dimensional speckle tracking analysis, LA reservoir (LAr), LA conduit (LAc), LA contraction (LAct), and LV global longitudinal strain (LV-GLS) were evaluated every 10 bpm.

RESULTS

Of the 45 patients enrolled, a significant reduction in LAr was observed at higher HR. However, when the patients were dichotomized according to the HR-related response of LV-GLS, the worsening of LAr was observed in those with LV-GLS worsening and not in those without (maximum LAR absolute changes -2.7 ± 7.2% vs. +2.7 ± 7.2%, respectively, p .028). Moreover, the worsening of LA and LV strain measures was associated with an increase in the estimated filling pressures.

CONCLUSIONS

In patients with atrial paced rhythm, the increase in HR could be associated with worsening of LA and LV functions, as assessed by two-dimensional speckle tracking analyses. These results offer new data on HR-related atrioventricular function and could be useful for guiding the optimal HR responsiveness of the implanted devices.

Relationship between the strain measures of left atrial function and heart failure worsening

BACKGROUND

Two-dimensional speckle tracking evaluation (2D-STE) is a useful tool to evaluate the complexity of atrial function by the analysis of the different phases of atrial deformation and by the combination with Doppler measurements of diastolic function.

AIM OF THE STUDY

To evaluate the role of the left atrial (LA) strain parameters to predict worsening chronic heart failure (CHF).

METHODS

We enrolled outpatients affected by CHF referred to our heart failure unit. Each patient underwent a medical visit, an electrocardiogram (ECG), and an echocardiographic examination. LA function was assessed by 2D-STE. The three phases of LA strain, that is, the reservoir (LAr), the conduit (LAcd), and the contraction (LAct)-were evaluated. Moreover, the ratio between E and LAr (E/LAr) and those between LAr and septal (LAr/Ees), lateral (LAr/Eel), and septal-lateral (LAr/Eem) E/e' were measured. During follow-up, the events related to worsening of heart failure were evaluated.

RESULTS

Two hundred eleven patients were enrolled. During a mean follow-up of 14 ± 7 months, 37 patients showed at least one event related to heart failure worsening. At univariate Cox regression analysis, LAr, LAcd, LAct, E/LAr, LAr/Ees, LAr/Eel, and LAr/Eem were all associated with events related to heart failure worsening, but at multivariate regression analyses, only LAr (Hazard Ratio, HR: .95; 95% Confidence Interval, CI: .92-.99; p: .031), LAct (HR: 1.06; 95% CI: 1.01-1.12; p: .027), E/LAr (HR: 1.10; 95%CI: 1.0-1.16; p < .001), LAr/Ees (HR: .57; 95% CI: .37-.87; p: .010), and LAr/Eem (HR: .71; 95% CI: .53-.96; p: .026) remained significantly associated with the events. Finally, in a predictive model including the other relevant echocardiographic parameters LAr < 18%, LAct > -10.0%, LAr/Ees < 1.28, and E/LAr > 3.70 were associated with a statistically significant overall net reclassification improvement.

CONCLUSIONS

In CHF patients, the measure of the LA reservoir and contraction by 2D-STE is independently associated with heart failure worsening, but the accuracy in predicting the events is even greater when the reservoir is combined with the Doppler measures of diastolic function.

Introduction of SGLT2 Inhibitors and Variations in Other Disease-Modifying Drugs in Heart Failure Patients: A Single-Centre Real-World Experience

BACKGROUND

The sodium-glucose cotransporter-2 inhibitors (SGLT2i) have emerged as a crucial therapeutic option for patients with chronic heart failure with reduced ejection fraction (HFrEF). The aim of this study was to evaluate, in a real-world population from a single centre, the feasibility of introducing SGLT2i and their interaction with other recommended drug classes.

METHODS

Consecutive patients affected by chronic heart failure (CHF) were evaluated beginning in January 2022. At the baseline clinical visit, both the patient's current medication and the prescribed treatments were recorded. Over a 6- to 12-month follow-up, changes in concomitant therapy were analysed.

RESULTS

At baseline, among 350 patients evaluated, only 17 (5%) were already taking SGLT2i: 13 with HFrEF, five with mildly reduced (HFmrEF), preserved (HFpEF) or improved (HFimpEF) ejection fraction. After the baseline assessment, SGLT2i were prescribed to 224 (64%) of the patients, including 179 (84%) with HFrEF, 27 (42%) with HFmrEF/HFimpEF, and 18 (22%) with HFpEF/HFimpEF. After follow-up, SGLT2i therapy was well tolerated and was associated with a significant increase in sacubitril/valsartan prescriptions and a decrease in diuretic use. Finally, a significant improvement in functional status and left ventricular systolic function after SGLT2i therapy was observed.

CONCLUSIONS

In this single-centre, real-world study, SGLT2i were primarily prescribed to HFrEF patients who were already on other recommended drug classes for their treatment. Additionally, there was a noticeable enhancement in the prescribed therapy during a short-term follow-up. These findings further bolster the inclusion of this therapeutic approach in regular clinical practice.

The Evolving Phenotypes of Cardiovascular Disease during COVID-19 Pandemic

COVID-19 pandemic has negatively impacted the management of patients with acute and chronic cardiovascular disease: acute coronary syndrome patients were often not timely reperfused, heart failure patients not adequately followed up and titrated, atrial arrhythmias not efficaciously treated and became chronic. New phenotypes of cardiovascular patients were more and more frequent during COVID-19 pandemic and are expected to be even more frequent in the next future in the new world shaped by the pandemic. We therefore aimed to briefly summarize the main changes in the phenotype of cardiovascular patients in the COVID-19 era, focusing on new clinical challenges and possible therapeutic options.

Left Atrial Functional Remodeling in Patients with Chronic Heart Failure Treated with Sacubitril/Valsartan

(1) Background: Previous studies showed left ventricular (LV) and left atrial (LA) improvement and reverse remodeling after therapy with Sacubitril/Valsartan (S/V) in patients affected by heart failure with reduced ejection fraction (HFrEF). Therefore, we sought to investigate predictors of LA structural and functional reverse remodeling (LARR) in this setting of patients after therapy with S/V, focusing on left atrial strain parameters, such as peak atrial longitudinal strain (PALS). (2) Methods: Patients with HFrEF underwent clinical and echocardiographic evaluation at baseline and after six months of therapy with S/V. Measures of LA structure (LA volume index, LAVi) and function (LA emptying fraction (LAEF), PALS, LA conduit strain and peak atrial contraction strain (PACS) were also analyzed. Patients were divided in two groups, those with a LARR (relative reduction in LAVi > 15%, LARR+) and those without (LARR-). (3) Results: A total of 47 consecutive patients (66 ± 8 years, 85% male, mean LVEF 28 ± 6%) were enrolled in the study and followed up. A significant increase of LAEF (46 ± 13 vs. 37 ± 11%, p < 0.001) and a significant reduction of LAVi (42 ± 15 vs. 45 ± 15 mL/m², p = 0.008) were found after 6 months of S/V therapy; 47% of the population showed LA reverse remodeling. LA strain parameters, PALS (19 ± 8 vs. 15 ± 7 %, p < 0.001) and LA conduit (-9.7 ± 5.2% vs. -7.6 ± 4.1%, p = 0.007) significantly improved after 6 months of S/V therapy. At multivariable stepwise regression analysis, changes in LV End Diastolic Volume (LVEDV) and PALS were significantly proportional to changes in LAVi values. (4) Conclusions: Six months of treatment with S/V in patients with HFrEF was associated with an improvement in LA functional reverse remodeling in a real-world scenario. LARR was not significantly correlated to baseline echocardiographic variables, but was proportional to changes in LV volumes and LA strain parameters. Finally, after S/V therapy, a strict connection between LA and LV reverse remodeling and between LA anatomical and functional reverse remodeling seems to be outlined.

Impact of intra-aortic balloon counterpulsation on all-cause mortality among patients with Takotsubo syndrome complicated by cardiogenic shock: results from the German-Italian-Spanish (GEIST) registry

Aims

Takotsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction and can be complicated by cardiogenic shock (CS). However, few data are available on optimal care in TTS complicated by CS. Aim of this study was to evaluate short- and long-term impact of intra-aortic balloon pumping (IABP) on mortality in this setting.

Methods and results

In a multi-centre, international registry on TTS, 2248 consecutive patients were enrolled from 38 centres from Germany, Italy, and Spain. Of the 2248 patients, 212 (9.4%) experienced CS. Patients with CS had a higher prevalence of diabetes (27% vs. 19%), male sex (25% vs. 10%), and right ventricular involvement (10% vs. 5%) (P < 0.01 in all cases). Forty-three patients with CS (20% of 212) received IABP within 8 h (interquartile range 4-18) after admission. No differences in terms of age, gender, cardiovascular risk factors, and admission left ventricular ejection fraction were found among patients with and without IABP. There were no significant differences in terms of 30-day mortality (16% vs. 17%, P = 0.98), length of hospitalization (18.9 vs. 16.7 days, P = 0.51), and need of invasive ventilation (35% vs. 41%, P = 0.60) among two groups: 30-day survival was not significantly different even after propensity score adjustment (log-rank P = 0.73). At 42-month follow-up, overall mortality in patients with CS and TTS was 35%, not significantly different between patients receiving IABP and not (37% vs. 35%, P = 0.72).

Conclusions

In a large multi-centre observational registry, the use of IABP was not associated with lower mortality rates at short- and long-term follow-up in patients with TTS and CS.

38 PERIPHERAL ENDOTHELIAL FUNCTION AND CARDIOPULMONARY FUNCTION IN PATIENTS AFFECTED BY PULMONRY HYPERTENSION

Background

Pulmonary arterial hypertension (PAH) is a progressive and severe rare disease. It is a pulmonary vasculature obstructive disease that leads to right heart failure and death. Pulmonary circulation dysfunction endotelial is characterized by vasoconstriction and proliferation.

Aim of study

to search possible correlations between peripheral endothelian function and cardiopulmonary function in patients with suspect PAH.

Materials

Between February 2021 and May 2022, consecutive patients with suspect PAH underwent to assessment of peripheral endotelial function by FMD before of right heart catheterization and cardiopulmonary exercise testing.

Results

46 patients (22 male, 67,9 ± 10,4 years old) with pulmonary hypertension were enrolled in the study. The following correlations were found between stress-resting absolute difference and % difference radial diameter: ramp (r: 0,69; p: 0,003 and r: 0,54; p: 0,028, respectively), Watt_AT (r: 0,63; p: 0,01 and r: 0,54; p: 0,03, respectively) and WATT_peak (r: 0,64, p: 0,009).

Conclusions

peripheral endothelial function may be related to funtional capacity in patients affected by pulmonary hypertension.

39 ECHOCARDIOGRAPHIC FINDING BETWEEN PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION IN TREATMENT WITH ARNI AND SGLT2I

Background

Cardiac remodelling is an adverse phenomenon linked to heart failure progression. Cardiac remodelling could represent the real therapeutic goal in the treatment of patients with heart failure with reduced ejection fraction (HFrEF), being potentially reversed through different pharmacotherapies. Currently, there are well-established drugs such as angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and β-blockers with anti-remodelling effects; recently, angiotensin receptor neprilysin inhibitor effects on inhibiting cardiac remodelling were demonstrated. Benefits of gliflozins on left ventricular hypertrophy, dilation, and systolic and diastolic function were also described.

Aim of study

to evaluate possible echocardiographic differences between patients with HFrEF in treatment with ARNI or SGLT2I and patients with HFrEF in therapy with ARNI plus SGLT2i.

Materials

Between June 2021 and April 2022, consecutive patients with HFrEF underwent to conventional and advanced echocardography (TDI, 2DSTE). After 3 month, these patients underwent to echocardiographic follow-up.

Results

76 patients (68 male, 66,51±9,68 years old) with HFrEF were enrolled in the study. After 3 month of therapy, there was an inverse relation between number of HFrEF drugs (0, 1 or 2) and echocardiographic parameters [E/E’ (r: -0,28; p: 0,036) and E/A (r: -0,37; p: 0,012)].

Conclusions

About cardiac remodelling, there are not significant echocardiographic differeces but a better trend for the diastolic dysfunction in patients with HFrEF in treatment with ARNI plus SGLT2i vs HFrEF patients in therapy with ARNI or SGLT2i was showed.

797 ENDOTHELIAL FUNCTION AND RIGHT VENTRICLE DIMENSION AND FUNCTION IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background

Systemic sclerosis (SSc) is a connective tissue disease characterized by the fibrosis of skin and internal organs, frequent immunity abnormalities and alterations in microvasculature. Among SSc complications, Pulmonary Hypertension (PH) is a frequent and severe one.

Many echocardiographic parameters are used to assess pulmonary pressure and Right Ventricle (RV) dimension and function in these patients, from classical echocardiographic indexes to the most recent Speckle-Tracking Echocardiography (STE), while flow-mediated vasodilation (FMD) is the most common method to assess vascular reactivity.

Aim of the study

To evaluate any possible relations between endothelial function and RV dimension and function in patients with SSc.

Method

48 sclerodermic patients underwent to echocardiographic examination and FMD, searching for relations between RV dimension and function and endothelial function indexes. For the RV we considered: 1) the eccentricity index (EI), 2) the fractional area change (FAC), 3) the ratio TAPSE/PAPs, 4) the RV basal diameter, 5) the RV free-wall strain and 6) the tricuspid regurgitation velocity; for the endothelium we evaluated the absolute difference between the radial artery diameters before and after 5 minutes of ischemia. We used a t-Student test (t-test) for unpaired samples with similar variances to verify the hypothesis that patients with altered RV parameters show a lower value in the absolute difference between radial diameters.

Results

Only EI and endothelial function showed a significant relation. In fact, with a level of confidence of the 95% we can say that patients with an EI&gt;=1,1 report a minor increase in radial artery diameter than patients with EI&lt;1,1.

Conclusions

In patients affected by SSc, the endothelial function is related to eccentricity index. Multicenter studies are needed in order to confirm the results of our study

782 RATIONALE AND DESIGN OF EFI-CHF (ENDOTHELIAL FUNCTION IN PATIENTS WITH CHRONIC HEART FAILURE TREATED BY SGLT2I)STUDY

Background

Chronic heart failure (CHF) is characterized by endothelial dysfunction (ED). Sodium-glucose cotransporter type 2 inhibitors (SGLT-2i) represent a unique class of anti-hyperglycemic agents for type 2 diabetes mellitus (T2DM) that selectively inhibit renal glucose reabsorption, thereby increasing urinary excretion of glucose. Several studies have demonstrated the cardioprotective effects of SGLT-2i in patients with heart failure (HF), unrelated to its glucosuric effect. Nevertheless, it is unclear whether the benefits of SGLT-2i therapy also rely on the endothelial function in patients with CHF.

Aim of the study

To evaluate the effect of SGLT-2i on endothelial function through flow-mediated dilatation (FMD) in patients with CHF at baseline and after 3 months.

Design and Methods

EFI-CHF is a multi-center, prospective study that will evaluate the effect of SGLT-2i on endothelial function in patients with chronic stable heart failure across the left ventricular ejection fraction (LVEF) spectrum. Patients with NYHA class II/III symptoms, eGFR&gt; 25 mL/min/1.73 m2, age &gt;18 years will be enroll. Exclusion criteria are type 1 diabetes mellitus (T1DM), previous amputation surgery, recurrent urinary tract infections. For each patient medical history, clinical and biochemistry data will be collected. Starting treatment with SGLT2 inhibitors will be included. All patients will undergo FMD in an ambulatory setting, at time of enrolment and after 3 months of begin of study.

Results

The primary endpoint will be the improvement of endothelial function as assessed by FMD. An univariate and multivariate analysis will be performed to search for predictors of improvement of endothelian function.

Conclusions

The EFI-CHF will determine whether SGLT2i therapy improves endothelian function in patients with CHF starting SGLT2i therapy.

Near zero vascular complications using echo-guided puncture during catheter ablation of arrhythmias: A retrospective study and literature review

Background

Catheter ablation (CA) is routinely used for the treatment of arrhythmias. Vascular complications are the most common complications during these procedures. Previous data reported that ultrasound (US)-guided puncture is a useful method to avoid vascular complications. We reported our experience using US-guided puncture in patients undergoing CA for arrhythmias.

Methods

A total of 273 patients (mean age 57 ± 17 years; 58% male) were referred to our center for CA of arrhythmias from January 2016 to December 2019. All procedures were performed by expert operators, and US-guided vascular access was performed on all patients. Doppler sonography was performed the day after the procedure on all patients.

Results

Eighty-four patients (31%) underwent atrioventricular nodal reentrant tachycardia ablation, 49 patients (18%) atrioventricular reentrant tachycardia ablation, 14 patients (5%) atrial tachycardia ablation, 25 patients (9%) atrial flutter ablation, 63 patients (23%) atrial fibrillation ablation, and 38 patients (14%) ventricular tachycardia ablation. Vascular pseudo-aneurysms and arteriovenous fistula were defined as major complications; furthermore, venous thrombosis and inguinal hematomas were as defined minor complications. The percentage of major vascular complications was 0.3% (1 arteriovenous fistula) and the percentage of minor vascular complications was 0.3% (1 venous thrombosis).

Discussion

Ultrasound-guided vascular puncture in patients undergoing CA is useful to improve procedural success and reduce complications.

Incidence of cardiovascular events in patients with chronic myeloid leukaemia treated with tyrosine kinase inhibitors

BACKGROUND

The introduction of imatinib and tyrosine kinase inhibitors as therapeutic strategy for Philadelphia chromosome-positive chronic myeloid leukaemia (CML) has represented an important step forward for treatment of this disease. The aim of this study was therefore to evaluate the incidence of cardiovascular adverse events (CVEs) in patients affected by CML treated with TKI in an observational prospective study.

METHODS

All consecutive patients affected by CML and treated with TKI in our Institution were enrolled in the study from February 2005 to September 2018 with a clinical, laboratory and instrumental follow-up.

RESULTS

Sixty-one consecutive patients were enrolled, 29 with imatinib, 15 with nilotinib, 11 with dasatinib, 3 with bosutinib and 3 with ponatinib. Neither patients in therapy with bosutinib nor with nilotinib had CVE during follow-up. Incidence rates per person/year were 0 for bosutinib and nilotinib, 0.15 for dasatinib, 0.19 for imatinib and 1.69 for ponatinib (Log Rank p < 0.05); differences in terms of incidence of adverse outcomes remained significant also after multivariate correction.

CONCLUSIONS

In patients with CML treated with TKIs, therapy with ponatinib was associated with a higher risk of CVE than other TKIs. The lowest incidence of CVE was associated with bosutinib and nilotinib.

61 Right ventricular function in patient with heart failure with reduced ejection fraction and sacubitril/valsartan treatment

Aims

Observational studies have demonstrated that treatment with sacubitril/valsartan may improve left ventricular (LV) systolic and diastolic function in subjects with reduced LV ejection fraction (LVEF) in real-world studies. Subjects with heart failure and reduced EF (HFrEF), however, are also characterized by an impaired right ventricular (RV) function. We therefore aimed to evaluate whether also RV function may improve after S/V therapy and possible predictors of RV improvement could be identified at echocardiography and tissue Doppler imaging.

Methods

Fifty consecutive patients (67 ± 8 years, LVEF 28 ± 6%, male 86%) with chronic HFrEF and NYHA Classes II–III were followed up for 6 months after therapy with S/V. LV&RV function was assessed at baseline and after 6 months of therapy.

Results

After 6-month therapy with S/V a significant improvement was shown in the following echocardiography parameters assessing RV function: PAsP (31 ± 11 vs. 35 ± 10 mmHg, P &lt; 0.001), TAPSE (19 ± 3 vs. 18 ± 3 mm, P &lt; 0.001), RV FAC (38 ± 7 vs. 34 ± 6 mm, P &lt; 0.001), RV S’ (12 ± 2 vs. 10 ± 2 cm/sec, P &lt; 0.001), RV-FW-LS (−20 ± 5 vs. −18 ± 5%, P &lt; 0.001), RV-4Ch-LS (−16 ± 5 vs. −14 ± 5%, P &lt; 0.001). At multivariable analysis improvement in RV-FW-LS was associated to baseline levels of RV S’ (r 0.75, P &lt; 0.01) and RAV (r –0.32, P &lt; 0.05).

Conclusions

In a real-world scenario, 6-month therapy with S/V was associated with an improved RV function in HFrEF. RV function improvement may be predicted by assessing baseline RV S’ and right atrial volume values.

63 Peripheral endothelial function in patients affected by pulmonary hypertension. Relationship between endothelial function, haemodynamic parameters, and therapy response

Aims

Pulmonary hypertension (PH) is defined as a mean pulmonary arterial pressure (mPAP) of 25 mmHg or greater at rest, confirmed by right heart catheterization (RHC). The World Health Organization has classified PH into five clinical subgroups. Pulmonary arterial hypertension (PAH) (group 1) is characterized by loss and obstructive remodelling of the pulmonary vascular bed. These patients are characterized haemodynamically by the presence of precapillary PH, defined as an mPAP of 25 mm Hg or greater, pulmonary artery wedge pressure (PAWP) of 15 mm Hg or less, and pulmonary vascular resistance (PVR) of three Wood units (WU) or greater. Pulmonary hypertension due to left-sided heart disease (LHD) (PH-LHD) (group 2) occurs in HF. Patients with PH-LHD usually have isolated postcapillary PH (PAWP &gt;15 mm Hg and PVR &lt;3 WU), although some of them have combined postcapillary and precapillary PH (PAWP &gt;15 mm Hg and PVR ≥3 WU). PH due to chronic lung disease (CLD) (PH-CLD) and/or hypoxia (group 3) can occur in many lung diseases. These patients have precapillary PH. Chronic thromboembolic PH (CTEPH) (group 4) is characterized by obstruction of the pulmonary vasculature by organized thromboembolic material and vascular remodelling, resulting from prior pulmonary embolism. Patients with unclear and/or multifactorial mechanisms are listed as group 5. Specific pulmonary vasodilators are approved only in PAH patients. While research was predominantly focused on pulmonary vasculature, little is known about the peripheral endothelial damage in different vascular beds in PH patients. To evaluate the relationship between the peripheral endothelial function and the haemodynamic parameters, in order to provide a non-invasive method for the indirect evaluation of mean pulmonary pressure and vascular resistance, to predict if the PH is a precapillary or postcapillary, to select more accurately the patients who should undergo RHC. Moreover, we investigate if there is a possible correlation between endothelial dysfunction and response to specific PH therapies.

Methods and results

Patients with suspected PH, based on symptoms, medical history, and clinics will undergo physical examination, ECG, echocardiography, and RHC. In all patients, endothelial function was assessed by FMD. Medical history, heart rate, systolic blood pressure, body mass index, WHO functional class, and medications were recorded. All patients underwent blood analysis, erythrocyte sedimentation rate (ERS), high sensitivity C-reactive protein (CRP), and NT-proBNP levels were assayed. Increased peripheral endothelial dysfunction in patients with precapillary PH, with a linear correlation between endothelium dysfunction and increased PVR at the right catheterization. To differentiate pre and post capillary PH forms by cut-off values of the FMD. The degree of endothelial dysfunction could be a marker of therapy response. Sequential combination therapy in the pre-capillary PH forms could be the one with a worst endothelial response than up-front combination therapy.

25 Atrial remodelling in patients affected by chronic heart failure in therapy with sacubitril/valsartan

Aims

Left atrial (LA) enlargement has been demonstrated to be a predictor of adverse cardiovascular outcomes, such as atrial fibrillation (AF), heart failure (HF), and cardiovascular death. Previous studies showed left ventricle ejection fraction (LVEF) improvement and reverse remodelling can be achieved after therapy with sacubitril/valsartan in real-world settings. We sought to investigate the association between left atrial (LA) structural and functional remodelling in patients with chronic HF after therapy with sacubitril/valsartan.

Methods and results

Patients affected by chronic HF with LV dysfunction (LVEF &lt; 35%), NYHA functional class II–III were followed up between September 2019 and March 2020. All patients underwent clinical and echocardiography Follow-up at baseline and after 6 months of therapy with sacubitril/valsartan. Measures of LA structure [LA end-systolic volume (LAESV)] and function [left atrial emptying fraction (LAEF), peak atrial longitudinal strain (PALS), LA conduit strain and peak atrial contraction strain (PACS)] were calculated. A total of 47 patients (median age 66 ± 7.97, male gender 85%, mean LVEF 28.33 ± 5.61%) were enrolled. The left atrial strain parameters (PALS and LA conduit) resulted higher at 6 months follow-up respect to baseline values, (14.68 ± 7.16 vs. 18.67 ± 8.03, P &lt; 0.001, and −7.61 ± 4.07 vs. −9.71 ± 5.23, P = 0.007, respectively).

Conclusions

Treatment with sacubitril/valsartan in patients with HFrEF is associated with an improvement in LA functional remodelling in a real-world scenario.

24 Gliflozins and ventricular function in patients affected by chronic heart failure with diabetes mellitus

Aims

Diabetes is the most common comorbidity of HF patients. SGLT2 inhibitors has been shown to reduce hospitalization in patients with HF. The cardioprotective mechanisms of gliflozines have not been elucidated. The aim of our study was to evaluate the effect of SGLT2 inhibitors on right and left ventricular function in T2DM patients with HF.

Methods and results

One hundred and fifteen consecutive outpatients with CHF and T2DM were screened in the Daunia Heart Failure Registry. Seventy-eight of them were enrolled and followed up between May 2019 and September 2020. All patients underwent conventional, TDI and strain echocardiography in an ambulatory setting, at the beginning and after 3 months of therapy with SGLT2 inhibitors. Seventy-eight consecutive outpatients with CHF and T2DM (mean age 67.4 ± 8.4 years, male: 83%) were enrolled in the study. Thirty-eight of them started the treatment with SGLT2 inhibitors, while the remaining forty continued their original therapy. After 3 months of therapy, LVEF, LVEDD, and LVESD statistically improved (respectively, from 39.68 ± 7.78% to 45.08 ± 9.04%, P: 0.001 and 57.32 ± 9.76 mm to 54.16 ± 6.54 mm, P: 0.01 and from 47.51 ± 1.58 mm to 43.24 ± 8.12, P: 0.0008). Changes in left ventricular function and dimensions were not significant in patients who did not started a therapy with SGLT2 inhibitors. There was a statistically significant reduction of E/E′ (from 16.51 ± 22.55 to 9.73 ± 3.35, P: 0.0007) in patients with treatment with SGLT2i. Moreover, there was an improvement of right ventricular function, due to a statistically significant reduction of PAPs and increase of TAPSE (respectively, from 30.63 ± 8.80 to 24.00 ± 8.35, P: 0.008; from 19.16 ± 2.54 to 21.18 ± 2.84, P: 0.0003) and S′ (10.42 ± 2.09 to 12.91 ± 2.50, P: 0.000) 3 months after the administration of SGLT2 inhibitors therapy vs. the control group.

Conclusions

In a real-world scenario, our results showed that the treatment with SGLT-2 inhibitors in patients with CHF and diabetes is associated with an echocardiographic biventricular function improvement.

Remodelling is inversely proportional to left ventricular dimensions in a real-life population of patients with chronic heart failure after therapy with sacubitril/valsartan

BACKGROUND

Left ventricular (LV) remodelling is a major mechanism underlying disease progression in patients with heart failure (HF) with reduced ejection fraction (EF). Previous studies that LVEF improvement and reverse remodelling can be achieved after therapy with Sacubitril/Valsartan in real-world settings. Therefore, we sought to investigate possible predictors of LV remodelling, in particular echocardiographic parameters derived by Tissue Doppler Imaging.

METHODS

Patients with chronic HF, LV dysfunction (EF < 35%), NYHA class II-III were followed up between September 2016 and January 2019. All patients underwent clinical and echocardiography follow up at baseline and after 12 months of therapy with sacubitril/valsartan.

RESULTS

Fifty-four consecutive outpatients were enrolled in the study. At follow-up visit LVEF (38 ± 9 vs. 30 ± 5%, p < 0.0001), LVEDD (61 ± 8 vs. 62 ± 8 mm, p = 0.0085), LVESV (114 ± 57 vs. 130 ± 56 mm³, p = 0.0001), mitral regurgitation severity (1 ± 1 vs. 2 ± 1, p < 0.0001), and left atrial area (23 ± 6 vs. 24 ± 6 mm², p = 0.0121) changed compared to the baseline value. Changes in LVEF (follow up vs baseline) correlated with baseline levels of heart rate (r = 0.24, p = 0.048), LVEDD (r= -0.33, p = 0.004), LVEDV (r= -0.39, p = 0.001), LVESV (r = 0.37, p = 0.002), and changes in LVESV (r=-0.34, p = 0.006). Correlations remained significant even after correction at multivariate analysis including age and gender.

CONCLUSIONS

Treatment with sacubitril/valsartan in patients with systolic dysfunction is associated with an improvement in LVEF in a real world scenario. Smaller LV volumes are associated with better reverse LV remodelling.

New Targets in Heart Failure Drug Therapy

Despite recent advances in chronic heart failure management (either pharmacological or non-pharmacological), the prognosis of heart failure (HF) patients remains poor. This poor prognosis emphasizes the need for developing novel pathways for testing new HF drugs, beyond neurohumoral and hemodynamic modulation approaches. The development of new drugs for HF therapy must thus necessarily focus on novel approaches such as the direct effect on cardiomyocytes, coronary microcirculation, and myocardial interstitium. This review summarizes principal evidence on new possible pharmacological targets for the treatment of HF patients, mainly focusing on microcirculation, cardiomyocyte, and anti-inflammatory therapy.

Chronic thromboembolic pulmonary hypertension mimicking coronary artery disease

We report the case of 63-year-old man, complaining of dyspnea and with abnormal systolic motion of the interventricular septum at echocardiography, referred for coronary angiography and suspect coronary artery disease. In the presence of normal coronary angio, a specific work-up showed chronic thromboembolic pulmonary hypertension requiring pulmonary endarterectomy. The case highlights the need for a global cardiovascular and imaging approach in presence of poorly specific symptoms and signs of coronary artery disease.

Neutrophil/lymphocyte ratio predicts in-hospital complications in Takotsubo syndrome. Results from a prospective multi-center registry

Background

Several hematological indices including subtypes of leukocytes populations have been associated with cardiovascular outcome. Takotsubo syndrome (TTS) is a form of acute heart failure syndrome featured by several in‐hospital complications (IHCs).

Hypothesis

Hematological indices at admission may predict IHCs in TTS patients.

Methods

One hundred and sixty consecutive patients with TTS were enrolled in a multicenter prospective registry. Clinical data, admission hemogram, and IHCs were recorded.

Results

Incidence of IHCs was 37%, including pulmonary edema 9%, cardiogenic shock 9%, need of invasive ventilation 10%, death 8%, stroke 2.5%, and left ventricular thrombi 6%.

Patients with IHCs were older, more frequently male, with physical stressor‐induced TTS, lower left ventricular ejection fraction at admission. Neutrophil/lymphocyte ratio (NLr) (12 ± 12 vs 7 ± 8, P = .002) and white blood cells/mean platelet volume ratio (1.2 ± 0.5 vs 1.0 ± 0.5, P = .03) at admission were significantly higher in patients with IHCs.

NLr values were predictor of IHCs (Odds ratios [OR] 1.07, 95% CI 1.03‐1.11, P < .01). When stratified according to NLr into tertiles, the rate of IHCs was from first to third tertile was, respectively, 22%, 31%, and 58%. NLr values in the higher tertile were independent predictors of IHCs even at multivariate analysis (OR 3.7, 95% CI 1.5‐9.4, P < .01).

NLr values higher than 5 were able to predict IHCs with a sensitivity of 82% and specificity of 58%; negative predictive power was 84% (area under the ROC curve 0.73).

Conclusions

NLr is an independent predictor of IHCs in patients admitted with TTS. Admission hemogram may represent a potential tool for prediction of IHCs in TTS.

Chromogranin-A serum levels in patients with takotsubo syndrome and ST elevation acute myocardial infarction

BACKGROUND

Sympathergic hyperactivity is considered one of the main trigger precipitating takotsubo syndrome (TTS). Chromogranin-A (CgA), a prognostic biomarker of sympatho-adrenal activation, is markedly high in acute coronary syndrome (ACS) and heart failure (HF), but its role in TTS is unknown.

METHODS

CgA serum levels from patients with TTS and symptoms onset <24 hours were consecutively evaluated and compared with anterior ST-elevation myocardial infarction (STEMI) patients from November 2016 to December 2019. Short and long-term follow-up data were recorded.

RESULTS

Eleven women with TTS and 10 subjects with anterior STEMI were analyzed and compared; differences were not significant in terms of age, gender and cardiovascular risk factors. NT-pro-BNP levels were similar (9,887 ± 12,170 vs 8,969 ± 15,053 pg/ml, p = .88), while troponin-I levels were higher in patients with STEMI (4 ± 3.2 vs 13.3 ± 10 ng/dl, p = .03). CgA admission levels were significantly lower in TTS patients (2.2 ± 1.5 vs 7.3 ± 6.2 nMol/l, p = .017), even after multivariable correction for principal bias. CgA levels correlated with NTproBNP levels (p = .02) and were higher in subjects with in-hospital events (3.7 ± 1.1 vs 1.6 ± 1.2 nMol/l, p = .03), even after multivariable forward stepwise analysis (p < .01). CgA levels <3.25 nMol/l (AUC 0.754, 95% C.I. 0.54-0.968) were able to discriminate TTS from anterior STEMI (negative predictive power of 99%).

CONCLUSIONS

Systemic CgA levels in the acute phase of TTS are lower than in anterior STEMI, possibly indicating a greater myocardial catecholamine release rather than adrenal.

Assessment of the German and Italian Stress Cardiomyopathy Score for Risk Stratification for In-hospital Complications in Patients With Takotsubo Syndrome

Importance

Takotsubo syndrome (TTS) is an acute, reversible heart failure syndrome featured by significant rates of in-hospital complications. There is a lack of data for risk stratification during hospitalization.

Objective

To derive a simple clinical score for risk prediction of in-hospital complications among patients with TTS.

Design, Setting, and Participants

In this prognostic study, 1007 consecutive patients were enrolled in the German and Italian Stress Cardiomyopathy (GEIST) registry from July 1, 2007, through December 31, 2017, and identified as the derivation cohort; 946 patients were enrolled in the Spanish Registry for Takotsubo Cardiomyopathy (RETAKO) as the external score validation. An admission risk score was developed using a stepwise multivariable regression analysis from 2 registries. Data analysis was performed from March 1, 2018, through July 31, 2018.

Main Outcomes and Measures

In-hospital complications were defined as death, pulmonary edema, need for invasive ventilation, and cardiogenic shock. Four variables were identified as independent predictors of in-hospital complications and were used for the score: male sex, history of neurologic disorder, right ventricular involvement, and left ventricular ejection fraction (LVEF).

Results

Of the 1007 patients enrolled in the GEIST registry, 107 (10.6%) were male, with mean (SD) age of 69.8 (11.4) years. Overall rate of in-hospital complications was 23.3% (235 of 1007) (death, 4.0%; pulmonary edema, 5.8%; invasive ventilation, 6.4%; and cardiogenic shock, 9.1%). The GEIST prognosis score was derived by providing 20 points each for male sex and history of neurologic disorders and 30 points for right ventricular involvement and then subtracting the value in percent of LVEF (decimal values between 0.15 and 0.70). Score accuracy on area under the receiver operating characteristic curve analysis was 0.71, with a negative predictive power of 87% with scores less than 20. External validation in the RETAKO population (124 [13.1%] male; mean [SD] age, 69.5 [14.9] years) revealed an area under the curve of 0.73 (P = .46 vs GEIST derivation cohort). Stratification into 3 risk groups (<20, 20-40, and >40 points) classified 316 patients (40.9%) as having low risk; 342 (44.3%) as having intermediate risk, and 114 (14.8%) as having high risk of complications. The observed in-hospital complication rates were 12.7% for low-risk patients, 23.4% for intermediate-risk patients, and 58.8% for high-risk patients (P < .001 for trend). After 2.6 years of follow-up, patients with in-hospital complications had significantly higher rates of mortality than those without complications (40% vs 10%, P = .01).

Conclusions and Relevance

The GEIST prognostic score may be useful in early risk stratification for TTS. High-risk patients with TTS may require an intensive care unit stay, and low-risk patients with TTS could be discharged within a few days. In-hospital complications in patients with TTS may be associated with increased risk of long-term mortality.

Switch to direct anticoagulants and improved endothelial function in patients with chronic heart failure and atrial fibrillation

BACKGROUND

Chronic heart failure (CHF) is characterized by higher rates of atrial fibrillation (AF) and endothelial dysfunction (ED). First line anticoagulant therapy in AF is represented by direct oral anticoagulants (DOACs); several patients, however, are still treated with vitamin-K inhibitors. The use of DOACs is associated in previous studies with an improved vascular function. We therefore sought to evaluate possible changes in endothelial function assessed by flow-mediated dilation (FMD) in patients with CHF and AF shifting from warfarin to DOACs.

METHODS

Forty-three consecutive outpatients were enrolled in the study. FMD was assessed at baseline and after 4 months. Patients were compared according to AC therapy.

RESULTS

After the first measurement of FMD, 18 patients "switched" to DOACs because of poor compliance to warfarin therapy or time in therapeutic range, 19 patients continued to use DOACs, 6 warfarin. "Switched" patients to DOACs therapy showed an improved FMD (19.0 ± 6.6% vs 3.8 ± 1.3%, p < 0.0001); C-reactive protein (CRP) levels decreased in "switched" patients from 1.4 ± 0.5 to 1.0 ± 0.7 mg/dl (p < 0.05). FMD and CRP changes were not significant in patients who did not changed anticoagulant therapy. In switched patients, changes in CRP levels were proportional to FMD changes (r = -0.50, p < 0.05). Shifting from warfarin to DOACs was significantly correlated to improved FMD levels even at multivariable analysis (p < 0.05).

CONCLUSIONS

Switch from warfarin to DOACs in patents with CHF and AF was associated in an observational non randomized study with an improved endothelial function. Changes in FMD values were related to changes in CRP levels.

Meta-analysis study on direct oral anticoagulants vs warfarin therapy in atrial fibrillation and PCI: Dual or triple approach?

Background

Dual antiplatelet therapy and anticoagulants may be required in the case of coexistence of coronary artery disease and atrial fibrillation (AF) undergoing (PCI), with associated increased bleeding rates. The introduction of direct oral anticoagulants (DOACs), however, significantly reduced the incidence of bleeding complications in this clinical setting of patients. We therefore sought to assess whether the recent publication of the AUGUSTUS and ENTRUST-AF PCI studies significantly impacted current evidence on the use of DOACs in AF patients treated with PCI.

Methods

We performed a meta-analysis of randomized controlled studies enrolling patients with nonvalvular AF undergoing PCI. We assessed pooled estimates of risk ratios (RRs) and 95%CIs for any bleeding (AB), cardiovascular events (CVE), and death at follow-up: 12,542 patients have been included in the analysis. We particularly analyzed data comparing dual anti-thrombotic therapy (DOAC plus single anti-platelet therapy) with triple (DOAC plus dual anti-platelet therapy).

Results

When compared with patients receiving standard triple therapy with warfarin, patients receiving DOACs had a significantly lower risk of AB (RR 0.65; 95% CI, 0.61–0.70, p < 0.00001) and of MB (RR 0.63; 95% CI, 0.53–0.73, p < 0.00001). The risk of cardiovascular events and mortality were comparable between DOAC and VKA groups (RR 1.05, 95% CI 0.93–1.18, RR 1.14, 95% CI 0.94–1.37, respectively, p n.s.). Similar results were observed comparing triple therapy vs dual therapy.

Conclusions

DOACs are safer than and as effective as warfarin when used in patients with AF undergoing PCI; dual therapy with DOACs is comparable to triple therapy in terms of safety and efficacy.

[PEGASUS or COMPASS? A guide for a wise clinical choice.]

The recent publication of the PEGASUS and COMPASS studies could have a great influence on the clinical management of patients with stable ischemic heart disease. In the presence of possible eligibility for both approaches, a practical tool based on inclusion/exclusion criteria of the two studies could be useful for clinical decision of ideal treatment for suitable patients. We therefore report a simple nomogram helpful in identifying the treatment indicated on the base of patient's characteristics.

Advanced heart failure: non-pharmacological approach

Patients with advanced heart failure have poor prognosis despite traditional pharmacological therapies. The early identification of these subjects would allow them to be addressed on time in dedicated centers to select patients eligible for heart transplantation or ventricular assistance. In this article we will report the current management of these patients based on latest international guidelines, underlining some critical aspects, with reference to future perspectives.

Mitral annular calcification: Can CMR be useful in identifying caseous necrosis?

Mitral annular calcification (MAC) can resemble an intracardiac mass and it is defined as a chronic degeneration of the mitral annulus. Often reported is caseous mitral annulus calcification (CMAC), a periannular, extensive calcification resembling a tumor. We report the case of a 68-year-old woman who had been hospitalized for palpitations and dyspnea. The transthoracic and transesophageal echocardiography revealed a non-homogeneous, slightly mobile, round mass, attached to the ventricular side of posterior mitral leaflet, with central echo-lucent area and without acoustic shadowing. Therefore, a cardiac magnetic resonance (CMR) was performed; delayed enhancement sequences showed a non-enhanced central core surrounded by a hyperenhanced rim (fibrous cap). To confirm the diagnosis, a multidetector computed tomography (MDCT) was performed; the MDCT showed a hyperdense mass with a hypodense center and a calcified peripheral rim. The central content had heterogeneous fluid density without significant contrast enhancement. The MDCT findings were considered highly suggestive of CMAC. CMR may be useful for the identification and definition of pericardial and myocardial masses and CMAC.

Parachute mitral valve assessed by cardiac magnetic resonance

Parachute mitral valve (PMV) is a congenital cardiac malformation where typically all tendons chordae converge and insert into one major papillary muscle. We report the case of 27-year-old man affected by Hodgkin’s lymphoma-mixed cellularity subtype with polychemotherapy treatment and Barrett’s esophagus who came to our attention for routine echocardiographic exam and evaluation of left ventricular function. In the presence of normal left ventricular systolic function and mild-moderate mitral regurgitation, a careful examination of mitral apparatus showed a single papillary muscle suspected for PMV. In the presence of Barrett’s esophagus, the patient was further assessed cardiac magnetic resonance (CMR) that confirmed the diagnosis of PMV and excluded other associated congenital anomalies. Despite the rare incidence of PMV and a diagnosis generally based on transesophageal echocardiography, CMR could represent a useful tool, in selected cases, to confirm the diagnosis of PMV, identify other possible congenital anomalies, and assess ventricular and valvular function.

Sacubitril/valsartan improves right ventricular function in a real-life population of patients with chronic heart failure: The Daunia Heart Failure Registry

Background

Previous studies and case-series showed improvement in left ventricular (LV) function and reverse remodeling after sacubitril/valsartan therapy in real-world studies. We therefore aimed to evaluate whether also right ventricular (RV) function may improve after sacubitril/valsartan therapy.

Methods

Sixty consecutive patients with chronic heart failure and NYHA class II-III were followed up for 12 months after therapy with sacubitril/valsartan. Left and (RV) function was assessed at baseline and after 12 months of therapy.

Results

At 12-month control, therapy with sacubitril/valsartan was associated with a significant improvement in a series of echo parameters: LVEF (p < 0.05), LV end-systolic volume (p < 0.01), left atrium area (p < 0.05).Right ventricular echo parameters were also improved after sacubitril/valsartan therapy: PAsP (31.0 ± 12.8 vs 34.7 ± 12.5 mmHg, p < 0.05), TAPSE (17.8 ± 3.9 vs 16.5 ± 4.0 mm, p < 0.001); mean PAsP reduction was 3.7 ± 11.4 mmHg (-6.3 ± 37.7%), mean TAPSE increase 1.3 ± 2.5 mm (+9.5 ± 15.7%).Indexed (%) improvement in PAsP (r 0.33, p < 0.01) and TAPSE (r -0.42, p < 0.01) values were proportional to baseline levels. Improvement in PAsP and TAPSE were independent of left ventricular improvements except for PAsP and end-systolic volumes (r 0.44, p < 0.01).

Conclusions

In a real world scenario, sacubitril/valsartan was associated with an improved RV function.

Liver disease and heart failure

INTRODUCTION

Several systemic conditions, inflammatory disease, infections and alcoholism, may affect both the heart and the liver. Common conditions, such as the non-alcoholic fatty liver disease (NAFLD), may increase the risk of cardiac dysfunction. Patients with acute decompensated HF (ADHF) may develop acute ischemic hepatitis and, chronic HF patients may develop congestive hepatopathy (CH).

EVIDENCE ACQUISITION

Laboratory anomalies of hepatic function may predict the outcome of patients with advanced HF and the evaluation of both cardiac and hepatic function is very important in the management of these patients. In clinically apparent ischemic hepatitis more than 90% of patients have some right-sided HF. There are systemic disorders characterized by the accumulation of metals or by metabolism defects that may affect primarily the liver but also the heart leading to symptomatic hypertrophic cardiomyopathy (HCM).

EVIDENCE SYNTHESIS

Abnormal LFTs indicate the mechanism of liver injury: liver congestion or liver ischemia. In AHF, it's important an adequate evaluation of heart and liver function in order to choose the treatment in order to ensure stable hemodynamic as well as optimal liver function.

CONCLUSIONS

Measurements of LFTs should be recommended in the early phase of ADHF management. Physicians with interest in HF should be trained in the evaluation of LFTs. It's very important for cardiologists to know the systemic diseases affecting both heart and liver and the first imaging or laboratory findings useful for a diagnosis. it is very important for internists, nephrologists, cardiologists, primary physicians and any physicians with interest in treating HF to recognize such signs and symptoms belong to rare diseases and liver diseases that could be mistaken for HF.

Anomalous Right Coronary Artery Origin from Left Main Stem: Role of Cardio-Computed Tomography in the Diagnosis and Therapeutic Approach

Anomalous coronary arteries (ACAs) are rare but potentially life-threatening abnormalities of coronary circulation. Most of the variants are benign; however, some may lead to myocardial ischemia and/or sudden cardiac arrest. We report the case of a 75-year-old male complaining of exertion chest discomfort. Admission electrocardiogram on presentation showed sinus bradycardia with a slight elevation of ST-T in inferior leads. Troponin levels, however, were normal. Coronary angiography showed an anomalous right coronary artery (RCA) originating from the left main stem without significant stenosis. Cardio-CT confirmed the anomalous origin of the RCA from the left main stem and showed its anomalous course between the aorta and the pulmonary artery. The patient was deemed a candidate for surgery and transferred to a cardiac surgery center. Only the exact definition of the anatomic and clinical features of ACAs may allow the identification of the most appropriate and effective treatment. Multislice computed tomography may play a fundamental role in the diagnosis and treatment of ACAs.

Dual Coronary-Pulmonary Fistula Firstly Found at Routine Doppler Echocardiogram

Congenital coronary-pulmonary fistulas (CPFs) are defined as an abnormal direct communication between one or more coronary arteries, with a cardiac or thoracic structure bypassing the capillary network. We report the case of a 73-year-old male, with a history of hypertension, asymptomatic for angina and dyspnea, who was referred for routine clinical control. Echocardiogram unexpectedly showed the presence of diastolic flow from the pulmonary trunk in parasternal short-axis view. Pulsed-wave Doppler confirmed the presence of diastolic flow and displayed the typical coronary flow pattern. Coronary angiography hence showed the presence of dual CPFs originating from the second segment of the left anterior descending coronary and the right coronary arteries. Careful routine Doppler echocardiograph examination may raise the suspicion of CPF in case of otherwise unexplained symptoms and may represent a simple, easy, repeatable tool for the first suspected diagnosis and follow-up of CPFs.

Available oral lipid-lowering agents could bring most high-risk patients to target: an estimate based on the Dyslipidemia International Study II-Italy

AIMS

The analysis evaluated the contemporary percentage of patients with established coronary heart disease (CHD) reaching the European guidelines recommended LDL-cholesterol (LDL-C) levels of less than 70 mg/dl and the threshold required for proprotein convertase subtlisin/kexin type 9 reimbursement in Italy (100 mg/dl). It also assessed how these percentages would change in case of diffuse use of ezetimibe.

METHODS

The Dyslipidemia International Study II enrolled CHD patients aged at least 18 either on lipid-lowering therapy (LLT) for at least 3 months or not on LLT at the time of the lipid profile. Distribution of LLTs and LDL-C target attainment were assessed. Multivariate logistic regression evaluated predictors of LDL-C target attainment. A 24% LDL-C lowering was modeled in patients not taking ezetimibe to assess its potential effects.

RESULTS

Among 676 Italian CHD patients enrolled, LDL-C concentrations were lower among the 631 patients (93.3%) who were on LLT (82 versus 118 mg/dl; P < 0.001). The LDL-C target was attained by 35.4% of patients. Statin dose (median atorvastatin dose 40 mg/day) was the sole significant predictor of LDL-C target attainment. The simple addition of ezetimibe in the model reduced the percentage of patients more than 70 and 100 mg/dl from 64.6 to 37.9% and from 25.1 to 11.8%, respectively.

CONCLUSION

Despite treatment in more than 90%, only one-third of Italian stable CHD patients attained the recommended LDL-C target. Statin dose was the sole predictor of the target achievement. The addition of ezetimibe would almost double patients at target and halve the potential candidates for reimbursement of more expensive agents such as proprotein convertase subtlisin/kexin type 9 inhibitors.

Tricuspid Papillary Fibroelastoma at Multimodal Imaging

Papillary fibroelastoma is a rare benign cardiac tumor, second after cardiac myxoma as more frequent cardiac valvular tumor. The therapy is usually based on surgery according to size, mobility, symptoms, and risks of surgery. We report the case of a 67-year old female with transient ischemic attack. Echocardiography showed the presence of a round mobile formation localized on the atrial side of septal leaflets of tricuspid valve, first identified as an endocarditis vegetation. Cardiac magnetic resonance (cMRI) confirmed the presence of the mass and showed an isointense signal in T1-turbo spin echo sequences, hypointense in cine steady-state free precession and in first-pass sequences, and hyperintense in T2 and phase-sensitive inversion recovery with central hypointense core, with a suspected diagnosis of fibroelastoma. The patient underwent cardiac surgery and histology confirmed the presence of fibroelastic tissue with papillary extroflexions compatible with diagnosis of fibroelastoma. The use of cMRI may be useful in the evaluation of the exact position, dimensions, and nature of cardiac masses and fibroelastomas, diagnostic workup, and preliminary assessment before surgery.

Hospitalization cost reduction with sacubitril-valsartan implementation in a cohort of patients from the Daunia Heart Failure Registry

Introduction

Aim of this study was to assess the impact of the introduction of new class of drugs (ARNI: angiotensin receptor-neprilysin inhibitor) on hospital related costs in a real world cohort of patients with chronic heart failure (CHF).

Methods

Seventy-three consecutive patients with CHF and systolic dysfunction eligible for the treatment with ARNIs from the Daunia Heart Failure Registry were enrolled. Incidence of hospitalizations before and after treatment with ARNI, costs for drug and hospitalization for HF were recorded, indexed per year and compared.

Results

Indexed mean number of hospitalizations per year was 0.93 ± 1.70 before and 0.19 ± 0.70 after introduction of ARNI (p < 0.001, −80%), 2.26 ± 1.95 before and 0.38 ± 1.2 after ARNI in the subgroup of patients with at least one hospitalization for HF in the year before treatment with ARNI (p < 0.001, −83%).

Mean indexed cost for hospitalization was 2067 ± 3715 euros before and 1847 ± 1549 after ARNI (p n.s., −11%); in the subgroup with at least one hospitalization for HF 5175 ± 4345 before and 2311 ± 2308 after ARNI (p < 0.001, −55%). Cost reduction increased with the number of indexed hospitalization per year before ARNI from 11% to 66%.

Conclusion

In a real world scenario, treatment with ARNI is associated with lower indexed rates of hospitalizations and hospitalization related costs. Cost reduction increases with at least one indexed hospitalization for heart failure before treatment with ARNI.

Delayed ventricular pacing failure and correlations between pacing thresholds, left ventricular ejection fraction, and QTc values in a male with Takotsubo cardiomyopathy

BACKGROUND

Transient pacing failure caused by transient increased pacing threshold has been reported in patients with transient left ventricular apical dysfunction (Takotsubo cardiomyopathy [TC]). Normal pacing thresholds usually recover after normalization of systolic dysfunction.

HYPOTHESIS

Pacing failure correlates with clinics of TC.

METHODS

We report the case of a 76-year-old man with a dual chamber pacemaker, admitted for acute chest pain and dyspnea and final diagnosis of TC. One month after index admission, the patient came back complaining again of chest pain. Unexpectedly, admission electrocardiogram showed ventricular pacing failure and an increased pacing threshold. In the following weeks, pacing threshold gradually recovered with left ventricular ejection fraction and QTc values.

RESULTS

Ventricular pacing threshold correlated directly to QTc values and inversely to left ventricular ejection fraction over time (P < 0.05).

CONCLUSIONS

This is one of the first cases of delayed transient ventricular pacing failure in a male patient with transient left ventricular apical ballooning, in the presence of spared right ventricular function. Given the possibility of acute transient anomalies in myocardial impedance and pacing failure even in the subacute phase of TC several weeks after clinical onset of transient systolic dysfunction, pacing threshold should be carefully monitored in subjects with TC, both during the acute phase of the disease and in first months of follow-up after discharge. Ventricular pacing threshold correlated directly to QTc values and inversely to left ventricular ejection fraction over time.

Endothelin-receptor antagonists in the management of pulmonary arterial hypertension: where do we stand?

Pulmonary arterial hypertension, a disease largely neglected until a few decades ago, is presently the object of intense studies by several research teams. Despite considerable progress, pulmonary arterial hypertension remains a major clinical problem, because it is not always easy to diagnose, treat, and prevent. The disease was considered incurable until the late 1990s, when Epoprostenol was introduced as the first tool against this illness. More recently, therapy for pulmonary arterial hypertension gained momentum after publication of the SERAPHIN and AMBITION trials, which also highlighted the importance of upfront therapy. This review also focuses on recent substudies from these trials and progress in drugs targeting the endothelin pathway. Future perspectives with regard to endothelin-receptor antagonists are also discussed.

Exhaled Nitric Oxide and Exhaled Breath Temperature as Potential Biomarkers in Patients with Pulmonary Hypertension

BACKGROUND

Pulmonary hypertension (PH) is a progressive fatal disease thus, noninvasive prognostic tools are needed to follow these patients. The aim of our study was to evaluate fractional exhaled nitric oxide (FeNO) and exhaled breath temperature (EBT) values in patients with PH from different causes and to correlate them with respiratory functional data.

METHODS

Twenty-four PH patients underwent spirometry, carbon monoxide diffusion (DLCO) test, transthoracic echocardiography, right-heart catheterization, and FeNO and EBT measurements.

RESULTS

We studied 3 groups according to the type of PH: 10 patients with pulmonary arterial hypertension (PAH) (group A), 11 patients with PH due to chronic obstructive pulmonary disease (COPD) (group B), and 3 patients with PH associated with left heart disease (group C). Mean FeNO values tend to be higher in group B (15.0 ± 9.3ppb) compared with other groups (respectively, 9.9 ± 5.7 and 8.5 ± 5.2 ppb in groups A and C; p = 0.271) but no statistical significance has been reached. Mean values of alveolar NO concentration (CANO) were higher in groups A and B compared to group C (respectively, 16.9 ± 12.6; 13.9 ± 6.8; and 6.7 ± 2.0 ppb) (p = 0.045). EBT mean values were significantly lower in group C when compared with other groups (group C: 29.0 +- 1.3°C, groups A and B: 30.9 ± 1.3 and 31.2 ± 1.2°C, respectively: p = 0.041). EBT levels were inversely correlated to mean pulmonary artery pressure (PAPm) levels (Spearman coefficient -0.481; p = 0.017).

CONCLUSIONS

eNO, CANO, and EBT have been evaluated in three groups of PH patients. Interestingly EBT reduction was correlated with PAPm increase, whereas FeNO was higher in COPD patients and CANO in PAH and COPD groups. Further studies are needed to clarify EBT, FeNO, and CANO roles as biomarkers in the monitoring of patients with PH.

Additional value of inflammatory biomarkers and carotid artery disease in prediction of significant coronary artery disease as assessed by coronary computed tomography angiography

Aims

To evaluate the relationship between an incremental model including cardiovascular risk factors, carotid disease, and inflammatory biomarkers to predict the presence of obstructive coronary artery disease (CAD).

Methods and results

A total of 134 consecutive and asymptomatic intermediate-risk patients (mean age 61 ± 9 years, 52% men) were enrolled. Each subject underwent circulating levels assessment of interleukin (IL)-2r, IL-6, IL-8, IL-10, high-sensitivity C-reactive protein (hs-CRP) and carotid and coronary artery evaluation using carotid ultrasound and coronary computed tomography angiography (CCTA), respectively. Carotid disease was diagnosed in 71 (53%) patients. Obstructive and multi-vessel CAD were found in 50 (37%) and 18 (14%) patients, respectively. Patients in whom CCTA showed multi-vessel CAD had a higher rate of carotid disease (89 vs. 46%, P = 0.001) and increased values of all interleukins when compared with patients without multi-vessel obstructive CAD. The univariate and multivariate analysis showed that male gender, diabetes, carotid disease, and IL-6 were independently associated with obstructive CAD. At receiver operating characteristic curve analysis, the multivariate model (including male gender, carotid disease, IL-6 > 5.9 pg/mL, and diabetes) showed the highest area under the curve for prediction of obstructive CAD, multi-vessel CAD, and high-risk plaque defined as mixed and/or remodelled plaque when compared with all other models (P < 0.001).

Conclusion

Among asymptomatic intermediate-risk patients, the presence of increased IL6 levels in addition to traditional risk factors (male gender with diabetes) and carotid artery disease predicts higher rates of obstructive CAD and it could be of help to identify which subset of asymptomatic patients could be referred to CCTA for screening.