C23 HOW TO IMPROVE ADHERENCE TO ESC HF GUIDELINES THE PONTE (PDTA FOR INTEGRATED FOLLOW–UP TERRITORY HOSPITAL OF THE PATIENT WITH CARDIAC HEART FAILURE) PROJECT

Background

A careful and integrated follow up after hospitalization for heart failure (HF) may represent a feasible strategy to optimize the adherence to ESC guidelines and reduce the occurrence of adverse events (mortality, re–hospitalizations).

Methods

A strict integration between hospital and local health district proximity office cardiologist through an integrated clinical data sharing software has been implemented in Apulia region, Italy, in order to optimize the management of the HF patient after an hospitalization: the PONTE (PDTA FOR INTEGRATED FOLLOW–UP TERRITORY HOSPITAL OF THE PATIENT WITH CARDIAC HEART FAILURE) (bridge) project. As until December 2021, 1200 patients with HF have been enrolled in the project, both with reduced (HFrEF) and preserved ejection fraction (HFpEF). Adherence to ESC HF guidelines in HFrEF patients before vs after December 2020 was compared.

Results

In the HFrEF population (56%) the mean age was 63 years, 38% were hypertensive, 15% diabetic, 40% had ischemic heart disease, 42% were previously treated with coronary angioplasty, 56% had an ICD/CRT, 22% had atrial fibrillation. Mean NYHA class was 2.2, mean LVEF 30%, mean NT–proBNP values 4027 pg/mL, mean serum creatinine 1 mg/dL, 91% were taking beta–blockers (BB), 86% mineral corticoid receptor antagonists (MRA), 98% ACE–inhibitors/angiotensin–receptor–antagonists/neprilysin and angiotensin receptor antagonists (ACE/ARB/ARNI), and 13% ARNI. Compared to patients enrolled before 2020, ARNI prescription increased in 2021 (60% vs 13%, p < 0.001); in 30% ARNI were prescribed in hospital before discharge. Furthermore, in 10% of the population (most diabetics), sodium glucose cotransporter type 2 inhibitors (SGLT2i) have been prescribed as indicated by the latest ESC 2021 guidelines.

Conclusions

The implementation the PONTE project shows an improved adherence to ESC HF guidelines.

Exposure to cAMP and beta-adrenergic stimulation recruits Ca(V)3 T-type channels in rat chromaffin cells through Epac cAMP-receptor proteins

T-type channels are expressed weakly or not at all in adult rat chromaffin cells (RCCs) and there is contrasting evidence as to whether they play a functional role in catecholamine secretion. Here we show that 3-5 days after application of pCPT-cAMP, most RCCs grown in serum-free medium expressed a high density of low-voltage-activated T-type channels without altering the expression and characteristics of high-voltage-activated channels. The density of cAMP-recruited T-type channels increased with time and displayed the typical biophysical and pharmacological properties of low-voltage-activated Ca(2+) channels: (1) steep voltage-dependent activation from -50 mV in 10 mm Ca(2+), (2) slow deactivation but fast and complete inactivation, (3) full inactivation following short conditioning prepulses to -30 mV, (4) effective block of Ca(2+) influx with 50 microM Ni(2+), (5) comparable permeability to Ca(2+) and Ba(2+), and (6) insensitivity to common Ca(2+) channel antagonists. The action of exogenous pCPT-cAMP (200 microM) was prevented by the protein synthesis inhibitor anisomycin and mimicked in most cells by exposure to forskolin and 1-methyl-3-isobutylxanthine (IBMX) or isoprenaline. The protein kinase A (PKA) inhibitor H89 (0.3 microM) and the competitive antagonist of cAMP binding to PKA, Rp-cAMPS, had weak or no effect on the action of pCPT-cAMP. In line with this, the selective Epac agonist 8CPT-2Me-cAMP nicely mimicked the action of pCPT-cAMP and isoprenaline, suggesting the existence of a dominant Epac-dependent recruitment of T-type channels in RCCs that may originate from the activation of beta-adrenoceptors. Stimulation of beta-adrenoceptors occurs autocrinally in RCCs and thus, the neosynthesis of low-voltage-activated channels may represent a new form of 'chromaffin cell plasticity', which contributes, by lowering the threshold of action potential firing, to increasing cell excitability and secretory activity during sustained sympathetic stimulation and/or increased catecholamine circulation.

Analysis of microvascular integrity, contractile reserve, and myocardial viability after acute myocardial infarction by dobutamine echocardiography and myocardial contrast echocardiography

The purpose of this study was to evaluate, in postinfarction dysfunctioning myocardium, the relative potential of myocardial contrast and low-dose dobutamine echocardiography in detecting myocardial viability, and the relation between microvascular integrity, contractile reserve, and functional recovery at follow-up. Twenty-four patients with recent myocardial infarction were studied before hospital discharge with low-dose dobutamine and myocardial contrast echocardiography. In the dysfunctioning infarct area, wall motion score index was calculated at baseline, during low-dose dobutamine, and at 3-month follow-up. Revascularization of the infarct-related artery was performed if clinically indicated. Eighteen patients (group A) had myocardial enhancement of the dysfunctioning infarct area at myocardial contrast echocardiography of >50%, whereas the remaining patients (group B) had an increase of < or = 50%. Wall motion score index was similar at baseline in groups A and B (2.6 +/- 0.4 and 2.8 +/- 0.2; p = NS), but it improved during low-dose dobutamine and at follow-up only in group A (1.9 +/- 0.9 and 1.9 +/- 0.7, respectively; p <0.001 vs baseline). In group B, wall motion score index was 2.7 +/- 0.4 with low-dose dobutamine and 2.8 +/- 0.2 at follow-up (p = NS vs rest). In identifying viable myocardial segments, myocardial contrast echo had 100% sensitivity and 46% specificity, whereas low-dose dobutamine echo had 71% sensitivity and 88% specificity. Thus, microvascular integrity after acute myocardial infarction is a fundamental prerequisite for ensuring myocardial contractile reserve and regional functional recovery. Myocardial contrast and low-dose dobutamine echocardiography have different, but complementary, diagnostic characteristics in detecting myocardial viability.

Coronary flow dynamics and reserve assessed by transesophageal echocardiography in obstructive hypertrophic cardiomyopathy

Myocardial ischemia is frequently associated with left ventricular outflow obstruction. To assess coronary flow impairment in obstructive hypertrophic cardiomyopathy (HC), 10 patients with echo-Doppler-detected obstructive HC and normal coronary arteries underwent transesophageal echo-Doppler examination of both coronary flow velocity (CFV) at rest, recorded in the proximal left anterior descending coronary artery, and coronary flow reserve (CFR) evaluated by means of dipyridamole infusion response. Ten normal patients were similarly studied and served as a control group. Two relevant alterations in coronary flow dynamics were detected in patients with HC: (1) a significantly increased diastolic/systolic CFV ratio, and (2) a significantly reduced dipyridamole/baseline CFV ratio. Compared with normal subjects, the CFV pattern showed a significantly greater diastolic and a significantly lower systolic component at rest (in some patients it was reversed). Diastolic/systolic CFV ratio was significantly higher in patients with HC at baseline (3.1 +/- 1 vs 1.6 +/- 0.5; p < 0.01) and increased further after dipyridamole infusion (4.9 +/- 2 vs 2.2 +/- 0.7; p < 0.01). In addition, CFR was impaired in patients with HC (1.8 +/- 0.3 vs 3.1 +/- 0.5; p < 0.01). Furthermore, a significant correlation between CFR and intraventricular pressure gradient was found. Thus, transesophageal echo-Doppler examination is a useful tool for evaluating CFV dynamics and CFR as demonstrated in patients with obstructive HC.

[Multiplane transesophageal echocardiography in the study of expansive mediastinal processes compressing the right heart: a report of clinical cases]

In order to assess the role of multiplane transesophageal echocardiography in detecting mediastinal masses and in evaluating the manifestations of cardiac compression due to tumoral growth, 3 cases of patients with right ventricular outflow obstruction are presented. In each of these patients transesophageal echocardiography provided an accurate evaluation of the hemodynamic consequences of the tumoral process.