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Coleman JA, Doste R, Beltrami M, Argirò A, Coppini R, Olivotto I, Raman B, Bueno-Orovio A. Effects of ranolazine on the arrhythmic substrate in hypertrophic cardiomyopathy. Front Pharmacol 2024; 15:1379236. [PMID: 38659580 PMCID: PMC11039821 DOI: 10.3389/fphar.2024.1379236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction: Hypertrophic cardiomyopathy (HCM) is a leading cause of lethal arrhythmias in the young. Although the arrhythmic substrate has been hypothesised to be amenable to late Na+ block with ranolazine, the specific mechanisms are not fully understood. Therefore, this study aimed to investigate the substrate mechanisms of safety and antiarrhythmic efficacy of ranolazine in HCM. Methods: Computational models of human tissue and ventricles were used to simulate the electrophysiological behaviour of diseased HCM myocardium for variable degrees of repolarisation impairment, validated against in vitro and clinical recordings. S1-S2 pacing protocols were used to quantify arrhythmic risk in scenarios of (i) untreated HCM-remodelled myocardium and (ii) myocardium treated with 3µM, 6µM and 10µM ranolazine, for variable repolarisation heterogeneity sizes and pacing rates. ECGs were derived from biventricular simulations to identify ECG biomarkers linked to antiarrhythmic effects. Results: 10µM ranolazine given to models manifesting ventricular tachycardia (VT) at baseline led to a 40% reduction in number of VT episodes on pooled analysis of >40,000 re-entry inducibility simulations. Antiarrhythmic efficacy and safety were dependent on the degree of repolarisation impairment, with optimal benefit in models with maximum JTc interval <370 ms. Ranolazine increased risk of VT only in models with severe-extreme repolarisation impairment. Conclusion: Ranolazine efficacy and safety may be critically dependent upon the degree of repolarisation impairment in HCM. For moderate repolarisation impairment, reductions in refractoriness heterogeneity by ranolazine may prevent conduction blocks and re-entry. With severe-extreme disease substrates, reductions of the refractory period can increase re-entry sustainability.
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Affiliation(s)
- James A. Coleman
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Ruben Doste
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alessia Argirò
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Raffaele Coppini
- Department of NeuroFarBa, University of Florence, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
- Meyer Children’s Hospital IRCCS, Florence, Italy
| | - Betty Raman
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
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Dini FL, Carluccio E, Ghio S, Pugliese NR, Galeotti G, Correale M, Beltrami M, Tocchetti CG, Mercurio V, Paolillo S, Palazzuoli A. Patient phenotype profiling using echocardiography and natriuretic peptides to personalise heart failure therapy. Heart Fail Rev 2024; 29:367-378. [PMID: 37728750 DOI: 10.1007/s10741-023-10340-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/21/2023]
Abstract
Heart failure (HF) is a progressive condition with a clinical picture resulting from reduced cardiac output (CO) and/or elevated left ventricular (LV) filling pressures (LVFP). The original Diamond-Forrester classification, based on haemodynamic data reflecting CO and pulmonary congestion, was introduced to grade severity, manage, and risk stratify advanced HF patients, providing evidence that survival progressively worsened for those classified as warm/dry, cold/dry, warm/wet, and cold/wet. Invasive haemodynamic evaluation in critically ill patients has been replaced by non-invasive haemodynamic phenotype profiling using echocardiography. Decreased CO is not infrequent among ambulatory HF patients with reduced ejection fraction, ranging from 23 to 45%. The Diamond-Forrester classification may be used in combination with the evaluation of natriuretic peptides (NPs) in ambulatory HF patients to pursue the goal of early identification of those at high risk of adverse events and personalise therapy to antagonise neurohormonal systems, reduce congestion, and preserve tissue/renal perfusion. The most benefit of the Guideline-directed medical treatment is to be expected in stable patients with the warm/dry profile, who more often respond with LV reverse remodelling, while more selective individualised treatments guided by echocardiography and NPs are necessary for patients with persisting congestion and/or tissue/renal hypoperfusion (cold/dry, warm/wet, and cold/wet phenotypes) to achieve stabilization and to avoid further neurohormonal activation, as a result of inappropriate use of vasodilating or negative chronotropic drugs, thus pursuing the therapeutic objectives. Therefore, tracking the haemodynamic status over time by clinical, imaging, and laboratory indicators helps implement therapy by individualising drug regimens and interventions according to patients' phenotypes even in an ambulatory setting.
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Affiliation(s)
- Frank L Dini
- Istituto Auxologico IRCCS, Centro Medico Sant'Agostino, Via Temperanza, 6, 20127, Milan, Italy.
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
| | - Erberto Carluccio
- Cardiology and Cardiovascular Pathophysiology, Santa Maria della Misericordia, University of Perugia, Perugia, Italy
| | - Stefano Ghio
- Cardiology Division, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | | | | | - Michele Correale
- Department of Cardiology, University Hospital Policlinico, Riuniti, Foggia, Italy
| | - Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, Azienda USL Toscana Centro, Florence, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences (DISMET), Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences (DISMET), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Section of Cardiology, Federico II University, Naples, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-thoracic and vascular Department, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
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Coleman JA, Doste R, Beltrami M, Coppini R, Olivotto I, Raman B, Bueno-Orovio A. Electrophysiological mechanisms underlying T wave pseudonormalisation on stress ECGs in hypertrophic cardiomyopathy. Comput Biol Med 2024; 169:107829. [PMID: 38096763 DOI: 10.1016/j.compbiomed.2023.107829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/09/2023] [Accepted: 12/04/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Pseudonormal T waves may be detected on stress electrocardiograms (ECGs) in hypertrophic cardiomyopathy (HCM). Either myocardial ischaemia or purely exercise-induced changes have been hypothesised to contribute to this phenomenon, but the precise electrophysiological mechanisms remain unknown. METHODS Computational models of human HCM ventricles (n = 20) with apical and asymmetric septal hypertrophy phenotypes with variable severities of repolarisation impairment were used to investigate the effects of acute myocardial ischaemia on ECGs with T wave inversions at baseline. Virtual 12-lead ECGs were derived from a total of 520 biventricular simulations, for cases with regionally ischaemic K+ accumulation in hypertrophied segments, global exercise-induced serum K+ increases, and/or increased pacing frequency, to analyse effects on ECG biomarkers including ST segments, T wave amplitudes, and QT intervals. RESULTS Regional ischaemic K+ accumulation had a greater impact on T wave pseudonormalisation than exercise-induced serum K+ increases, due to larger reductions in repolarisation gradients. Increases in serum K+ and pacing rate partially corrected T waves in some anatomical and electrophysiological phenotypes. T wave morphology was more sensitive than ST segment elevation to regional K+ increases, suggesting that T wave pseudonormalisation may sometimes be an early, or the only, ECG feature of myocardial ischaemia in HCM. CONCLUSIONS Ischaemia-induced T wave pseudonormalisation can occur on stress ECG testing in HCM before significant ST segment changes. Some anatomical and electrophysiological phenotypes may enable T wave pseudonormalisation due to exercise-induced increased serum K+ and pacing rate. Consideration of dynamic T wave abnormalities could improve the detection of myocardial ischaemia in HCM.
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Affiliation(s)
- James A Coleman
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Ruben Doste
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Raffaele Coppini
- Department of NeuroFarBa, University of Florence, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Meyer Children's Hospital IRCCS, Florence, Italy
| | - Betty Raman
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
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Uccello G, Bonacchi G, Rossi VA, Montrasio G, Beltrami M. Myocarditis and Chronic Inflammatory Cardiomyopathy, from Acute Inflammation to Chronic Inflammatory Damage: An Update on Pathophysiology and Diagnosis. J Clin Med 2023; 13:150. [PMID: 38202158 PMCID: PMC10780032 DOI: 10.3390/jcm13010150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Acute myocarditis covers a wide spectrum of clinical presentations, from uncomplicated myocarditis to severe forms complicated by hemodynamic instability and ventricular arrhythmias; however, all these forms are characterized by acute myocardial inflammation. The term "chronic inflammatory cardiomyopathy" describes a persistent/chronic inflammatory condition with a clinical phenotype of dilated and/or hypokinetic cardiomyopathy associated with symptoms of heart failure and increased risk for arrhythmias. A continuum can be identified between these two conditions. The importance of early diagnosis has grown markedly in the contemporary era with various diagnostic tools available. While cardiac magnetic resonance (CMR) is valid for diagnosis and follow-up, endomyocardial biopsy (EMB) should be considered as a first-line diagnostic modality in all unexplained acute cardiomyopathies complicated by hemodynamic instability and ventricular arrhythmias, considering the local expertise. Genetic counseling should be recommended in those cases where a genotype-phenotype association is suspected, as this has significant implications for patients' and their family members' prognoses. Recognition of the pathophysiological pathway and clinical "red flags" and an early diagnosis may help us understand mechanisms of progression, tailor long-term preventive and therapeutic strategies for this complex disease, and ultimately improve clinical outcomes.
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Affiliation(s)
- Giuseppe Uccello
- Division of Cardiology, Alessandro Manzoni Hospital—ASST Lecco, 23900 Lecco, Italy;
| | - Giacomo Bonacchi
- Division of Cardiology, Tor Vergata University Hospital, 00133 Rome, Italy;
| | | | - Giulia Montrasio
- Inherited Cardiovascular Diseases Unit, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BS, UK;
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy
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Halasz G, Capelli B, Nardecchia A, Cattaneo M, Cassina T, Biasini V, Barbieri D, Villa M, Beltrami M, Perone F, Villani M, Badini M, Gervasi F, Piepoli M, Via G. Cost-effectiveness and diagnostic accuracy of focused cardiac ultrasound in the pre-participation screening of athletes: the SPORT-FoCUS study. Eur J Prev Cardiol 2023; 30:1748-1757. [PMID: 37668353 DOI: 10.1093/eurjpc/zwad287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/02/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
AIMS The role of pre-participation screening (PPS) modalities in preventing sudden cardiac death (SCD) in athletes is debated due to a high false-positive rate. Focused cardiac ultrasound (FoCUS) has shown higher sensitivity and specificity, but its cost-effectiveness remains uncertain. This study aimed to determine the diagnostic performance and cost-effectiveness of FoCUS use in PPS. METHODS AND RESULTS A total of 2111 athletes (77.4% male, mean age 24.9 ± 15.2years) underwent standardized family and medical history collection, physical examination, resting electrocardiography (ECG), FoCUS (10 min/5 views protocol), comprehensive echocardiography and exercise stress test. We prospectively evaluated three PPS incremental models: Model A, standardized medical history and physical examination Model B, Model A plus resting and stress ECG and Model C, Model B plus FoCUS (10 min/5 views protocol). We determined their incremental diagnostic accuracy and cost-effectiveness ratio. A total of 30 athletes were diagnosed with a cardiac condition associated with SCD: 3 were identified by Model A, 14 by Model B, and 13 athletes by Model C. The introduction of FoCUS markedly increased the sensitivity of PPS, compared with Model A and Model B (sensitivity 94% vs. 19% vs. 58% specificity 93% vs. 93% vs. 92%). The total screening costs were as follows: Model A 35.64 euros, Model B 87.68 euros, and Model C 120.89 euros. Considering the sole conditions at risk of SCD, the incremental cost-effectiveness ratio was 135.62 euros for Model B and 114.31 for Model C. CONCLUSIONS The implementation of FoCUS into the PPS allows to identify a significantly greater number of athletes at risk of SCD and markedly lowers the false negative rate. Furthermore, the incorporation of FoCUS into the screening process has shown to be cost-effective.
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Affiliation(s)
- Geza Halasz
- Cardiology Department, Azienda Ospedaliera SanCamillo Forlanini, Circonvallazione Gianicolense, 87, Rome 00152, Italy
| | - Bruno Capelli
- Sport and Exercise Medicine, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Alessia Nardecchia
- Italian Ministry of Education and Research, I.I.S Ceccano, Via Gaeta 105, Ceccano 03023, Italy
| | - Mattia Cattaneo
- Cardiologia, Centro Medico, Lugano, Switzerland
- Cardiology Department, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Tiziano Cassina
- Cardiac Anesthesia and Intensive Care, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Vincenzo Biasini
- Sport Medicine and Exercise Medicine, Centro di Medicina dello Sport I° Livello, L'Aquila 67100, Italy
| | - Davide Barbieri
- Department of Neuroscience and Rehabilitation, University of Ferrara, Corso Ercole I d'Este 32, Ferrara, Italy
| | - Michele Villa
- Cardiac Anesthesia and Intensive Care, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, Florence 50142, Italy
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic 'Villa delle Magnolie', Castel Morrone, Caserta 81020, Italy
| | - Matteo Villani
- Intensive Care Unit, G. Da Saliceto Hospital, Via Taverna Giuseppe, 49, 29121 Piacenza, Italy
| | - Matteo Badini
- Cardiology Department, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Federico Gervasi
- Postgraduate School of Medical Statistics and Biometry, University of Milan, Via Festa del Perdono 7, Milan 20122, Italy
| | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, Via Morandi 30, San Donato Milanese, Milan 20097, Italy
- Department of Biomedical Science for Health, University of Milan, Via Festa del Perdono 7, Milan 20122, Italy
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland
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Beltrami M, Fedele E, Fumagalli C, Mazzarotto F, Girolami F, Ferrantini C, Coppini R, Tofani L, Bertaccini B, Poggesi C, Olivotto I. Long-Term Prevalence of Systolic Dysfunction in MYBPC3 Versus MYH7-Related Hypertrophic Cardiomyopathy. Circ Genom Precis Med 2023; 16:363-371. [PMID: 37409452 DOI: 10.1161/circgen.122.003832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 05/30/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND The 2 sarcomere genes most commonly associated with hypertrophic cardiomyopathy (HCM), MYBPC3 (myosin-binding protein C3) and MYH7 (β-myosin heavy chain), are indistinguishable at presentation, and genotype-phenotype correlations have been elusive. Based on molecular and pathophysiological differences, however, it is plausible to hypothesize a different behavior in myocardial performance, impacting lifetime changes in left ventricular (LV) function. METHODS We reviewed the initial and final echocardiograms of 402 consecutive HCM patients with pathogenic or likely pathogenic MYBPC3 (n=251) or MYH7 (n=151) mutations, followed over 9±8 years. RESULTS At presentation, MYBPC3 patients were less frequently obstructive (15% versus 26%; P=0.005) and had lower LV ejection fraction compared with MYH7 (66±8% versus 68±8%, respectively; P=0.03). Both HCM patients harboring MYBPC3 and MYH7 mutations exhibited a small but significant decline in LV systolic function during follow-up; however, new onset of severe LV systolic dysfunction (LV ejection fraction, <50%) was greater among MYBPC3 patients (15% versus 5% among MYH7; P=0.013). Prevalence of grade II/III diastolic dysfunction at final evaluation was comparable between MYBPC3 and MYH7 patients (P=0.509). In a Cox multivariable analysis, MYBPC3-positive status (hazard ratio, 2.53 [95% CI, 1.09-5.82]; P=0.029), age (hazard ratio, 1.03 [95% CI, 1.00-1.06]; P=0.027), and atrial fibrillation (hazard ratio, 2.39 [95% CI, 1.14-5.05]; P=0.020) were independent predictors of severe systolic dysfunction. No statistically significant differences occurred with regard to incidence of atrial fibrillation, heart failure, appropriate implanted cardioverter defibrillator shock, or cardiovascular death. CONCLUSIONS MYBPC3-related HCM showed increased long-term prevalence of systolic dysfunction compared with MYH7, in spite of similar outcome. Such observations suggest different pathophysiology of clinical progression in the 2 subsets and may prove relevant for understanding of genotype-phenotype correlations in HCM.
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Affiliation(s)
- Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy (M.B., C.F.)
| | - Elisa Fedele
- Department of Cardiology, Policlinico Casilino, Rome, Italy (E.F.)
| | - Carlo Fumagalli
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy (M.B., C.F.)
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy (C.F.)
| | - Francesco Mazzarotto
- Department of Molecular and Translational Medicine, University of Brescia, Italy (F.M.)
| | | | - Cecilia Ferrantini
- Department of Experimental and Clinical Medicine (C.F., C.P., I.O.), University of Florence, Italy
| | - Raffaele Coppini
- Division of Pharmacology, Department of Neuroscience, Psychology, Drug Sciences and Child Health (NeuroFarBa) (R.C.), University of Florence, Italy
| | - Lorenzo Tofani
- Department of Statistics, Computer Science, Applications (L.T., B.B.), University of Florence, Italy
| | - Bruno Bertaccini
- Department of Statistics, Computer Science, Applications (L.T., B.B.), University of Florence, Italy
| | - Corrado Poggesi
- Department of Experimental and Clinical Medicine (C.F., C.P., I.O.), University of Florence, Italy
| | - Iacopo Olivotto
- Meyer Children's Hospital, IRCSS, Florence, Italy (F.G., I.O.)
- Department of Experimental and Clinical Medicine (C.F., C.P., I.O.), University of Florence, Italy
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Moscatelli S, Leo I, Bianco F, Borrelli N, Beltrami M, Garofalo M, Milano EG, Bisaccia G, Iellamo F, Bassareo PP, Pradhan A, Cimini A, Perrone MA. The Role of Multimodality Imaging in Pediatric Cardiomyopathies. J Clin Med 2023; 12:4866. [PMID: 37510983 PMCID: PMC10381492 DOI: 10.3390/jcm12144866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Cardiomyopathies are a heterogeneous group of myocardial diseases representing the first cause of heart transplantation in children. Diagnosing and classifying the different phenotypes can be challenging, particularly in this age group, where cardiomyopathies are often overlooked until the onset of severe symptoms. Cardiovascular imaging is crucial in the diagnostic pathway, from screening to classification and follow-up assessment. Several imaging modalities have been proven to be helpful in this field, with echocardiography undoubtedly representing the first imaging approach due to its low cost, lack of radiation, and wide availability. However, particularly in this clinical context, echocardiography may not be able to differentiate from cardiomyopathies with similar phenotypes and is often complemented with cardiovascular magnetic resonance. The latter allows a radiation-free differentiation between different phenotypes with unique myocardial tissue characterization, thus identifying the presence and extent of myocardial fibrosis. Nuclear imaging and computed tomography have a complementary role, although they are less used in daily clinical practice due to the concern related to the use of radiation in pediatric patients. However, these modalities may have some advantages in evaluating children with cardiomyopathies. This paper aims to review the strengths and limitations of each imaging modality in evaluating pediatric patients with suspected or known cardiomyopathies.
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Affiliation(s)
- Sara Moscatelli
- Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
- Paediatric Cardiology Department, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London SW3 5NP, UK
| | - Isabella Leo
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
- Cardiology Department, CMR Unit, Royal Brompton and Harefield Hospitals, Guys' and St. Thomas' NHS Trust, London SW3 5NP, UK
| | - Francesco Bianco
- Cardiovascular Sciences Department-AOU "Ospedali Riuniti", 60126 Ancona, Italy
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | | | - Manuel Garofalo
- Department of Clinical and Experimental Medicine, Careggi University Hospital, 50134 Florence, Italy
| | - Elena Giulia Milano
- Centre for Cardiovascular Imaging, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Giandomenico Bisaccia
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Ferdinando Iellamo
- Division of Cardiology and Cardio Lab, Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Pier Paolo Bassareo
- School of Medicine, University College of Dublin, Mater Misericordiae University Hospital and Children's Health Ireland Crumlin, D07 R2WY Dublin, Ireland
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow 226003, India
| | - Andrea Cimini
- Nuclear Medicine Unit, St. Salvatore Hospital, 67100 L'Aquila, Italy
| | - Marco Alfonso Perrone
- Division of Cardiology and Cardio Lab, Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children's Hospital IRCCS, 00165 Rome, Italy
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8
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Fumagalli C, Bonanni F, Beltrami M, Ruggieri R, Zocchi C, Tassetti L, Maurizi N, Berteotti M, Zampieri M, Argirò A, Lovero F, Tomberli A, di Bari M, Marchionni N, Pieragnoli P, Ricciardi G, Checchi L, Cappelli F, Fumagalli S, Olivotto I. Incidence of stroke in patients with hypertrophic cardiomyopathy in stable sinus rhythm during long-term monitoring. Int J Cardiol 2023; 381:70-75. [PMID: 37061097 DOI: 10.1016/j.ijcard.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/29/2023] [Accepted: 04/04/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of stroke, but the incidence and factors associated with cardioembolic events in HCM patients without atrial fibrillation (AF) remain unresolved. We determined the incidence of stroke in patients in sinus rhythm (SR) monitored with a cardiac implantable electronic device (CIED). METHODS All consecutive patients diagnosed with HCM and referred to CIED implantation with >16 years at diagnosis and ≥ 1 year follow-up post CIED implantation were retrospectively reviewed. Severe LA dilatation was defined as ≥48 mm. Patients were stratified by rhythm as: Pre-existing AF (AF present prior to CIED); De novo AF (AF present after CIED implantation); SR: no episodes of AF. RESULTS Of 1651 patients, 185 (11.2%) implanted with a CIED were included (57% men, age: 54 ± 17 years). Baseline, pre-existing AF was present in 73 (39%) patients. Ischemic stroke was reported in 19 (10.3%, 1.78%/year) patients and was similar across the three groups (2.3%/year vs 1.1%/year vs 0.6%/year in patients in SR vs pre-existing AF vs de novo AF, respectively, p = 0.235). In SR patients, a LAD≥48 mm posed the greatest risk of stroke (Hazard Ratio: 10.03,95% Confidence-Interval 2.79-16.01). At Cox multivariable analysis, after adjustment for oral anticoagulation, LA was independently associated with stroke while rhythm was not. CONCLUSIONS in HCM patients with CIED long-term monitoring and no prior history of AF, stroke rates were similar in those with de novo AF or stable SR. Severe LA dilatation was a powerful risk factor, irrespective of AF.
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Affiliation(s)
- Carlo Fumagalli
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Francesca Bonanni
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Matteo Beltrami
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Roberta Ruggieri
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Chiara Zocchi
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Luigi Tassetti
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Niccolò Maurizi
- University Hospital of Lausanne, Cardiology Department, Lausanne, Switzerland
| | - Martina Berteotti
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Mattia Zampieri
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alessia Argirò
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Fabrizio Lovero
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alessia Tomberli
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Mauro di Bari
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paolo Pieragnoli
- Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Giuseppe Ricciardi
- Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Luca Checchi
- Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloid Center, Careggi University Hospital, Florence, Italy; Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Cardiothoracic and Vascular Department and Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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9
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Beltrami M, Galluzzo A, Brocci RT, Paoletti Perini A, Pieragnoli P, Garofalo M, Halasz G, Milli M, Barilli M, Palazzuoli A. The role of fibrosis, inflammation, and congestion biomarkers for outcome prediction in candidates to cardiac resynchronization therapy: is "response" the right answer? Front Cardiovasc Med 2023; 10:1180960. [PMID: 37378403 PMCID: PMC10291081 DOI: 10.3389/fcvm.2023.1180960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
Background Cardiac resynchronization therapy (CRT) is an established treatment in selected patients suffering from heart failure with reduced ejection fraction (HFrEF). It has been proposed that myocardial fibrosis and inflammation could influence CRT "response" and outcome. Our study investigated the long-term prognostic significance of cardiac biomarkers in HFrEF patients with an indication for CRT. Methods Consecutive patients referred for CRT implantation were retrospectively evaluated. The soluble suppression of tumorigenicity 2 (sST2), galectin-3 (Gal-3), N-terminal portion of the B-type natriuretic peptide (NT-proBNP), and estimated glomerular filtration rate (eGFR) were measured at baseline and after 1 year of follow-up. Multivariate analyses were performed to evaluate their correlation with the primary composite outcome of cardiovascular mortality and heart failure hospitalizations at a mean follow-up of 9 ± 2 years. Results Among the 86 patients enrolled, 44% experienced the primary outcome. In this group, the mean baseline values of NT-proBNP, Gal-3, and sST2 were significantly higher compared with the patients without cardiovascular events. At the multivariate analyses, baseline Gal-3 [cut-off: 16.6 ng/ml, AUC: 0.91, p < 0.001, HR 8.33 (1.88-33.33), p = 0.005] and sST2 [cut-off: 35.6 ng/ml AUC: 0.91, p < 0.001, HR 333 (250-1,000), p = 0.003] significantly correlated with the composite outcome in the prediction models with high likelihood. Among the parameters evaluated at 1-year follow-up, sST2, eGFR, and the variation from baseline to 1-year of Gal-3 levels showed a strong association with the primary outcome [HR 1.15 (1.08-1.22), p < 0.001; HR: 0.84 (0.74-0.91), p = 0.04; HR: 1.26 (1.10-1.43), p ≤ 0.001, respectively]. Conversely, the echocardiographic definition of CRT response did not correlate with any outcome. Conclusion In HFrEF patients with CRT, sST2, Gal-3, and renal function were associated with the combined endpoint of cardiovascular death and HF hospitalizations at long-term follow-up, while the echocardiographic CRT response did not seem to influence the outcome of the patients.
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Affiliation(s)
- Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, Azienda USL Toscana Centro, Florence, Italy
| | | | | | - Alessandro Paoletti Perini
- Department of Internal Medicine, Cardiology and Electrophysiology Unit, Azienda USL Toscana Centro, Florence, Italy
| | - Paolo Pieragnoli
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, Florence, Italy
| | - Manuel Garofalo
- Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Geza Halasz
- Department of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Massimo Milli
- Cardiology Unit, San Giovanni di Dio Hospital, Azienda USL Toscana Centro, Florence, Italy
| | - Maria Barilli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Le Scotte Hospital, Siena, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, Siena, Italy
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Rossi VA, Gruebler M, Monzo L, Galluzzo A, Beltrami M. The Different Pathways of Epicardial Adipose Tissue across the Heart Failure Phenotypes: From Pathophysiology to Therapeutic Target. Int J Mol Sci 2023; 24:6838. [PMID: 37047810 PMCID: PMC10095298 DOI: 10.3390/ijms24076838] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/28/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
Epicardial adipose tissue (EAT) is an endocrine and paracrine organ constituted by a layer of adipose tissue directly located between the myocardium and visceral pericardium. Under physiological conditions, EAT exerts protective effects of brown-like fat characteristics, metabolizing excess fatty acids, and secreting anti-inflammatory and anti-fibrotic cytokines. In certain pathological conditions, EAT acquires a proatherogenic transcriptional profile resulting in increased synthesis of biologically active adipocytokines with proinflammatory properties, promoting oxidative stress, and finally causing endothelial damage. The role of EAT in heart failure (HF) has been mainly limited to HF with preserved ejection fraction (HFpEF) and related to the HFpEF obese phenotype. In HFpEF, EAT seems to acquire a proinflammatory profile and higher EAT values have been related to worse outcomes. Less data are available about the role of EAT in HF with reduced ejection fraction (HFrEF). Conversely, in HFrEF, EAT seems to play a nutritive role and lower values may correspond to the expression of a catabolic, adverse phenotype. As of now, there is evidence that the beneficial systemic cardiovascular effects of sodium-glucose cotransporter-2 receptors-inhibitors (SGLT2-i) might be partially mediated by inducing favorable modifications on EAT. As such, EAT may represent a promising target organ for the development of new drugs to improve cardiovascular prognosis. Thus, an approach based on detailed phenotyping of cardiac structural alterations and distinctive biomolecular pathways may change the current scenario, leading towards a precision medicine model with specific therapeutic targets considering different individual profiles. The aim of this review is to summarize the current knowledge about the biomolecular pathway of EAT in HF across the whole spectrum of ejection fraction, and to describe the potential of EAT as a therapeutic target in HF.
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Affiliation(s)
- Valentina A. Rossi
- University Heart Center, Department of Cardiology, University Hospital of Zurich, 8091 Zurich, Switzerland
| | - Martin Gruebler
- Regional Hospital Neustadt, 2700 Wiener Neustadt, Austria
- Faculty of Medicine, Medical University of Graz, 8036 Graz, Austria
- Faculty of Medicine, Sigmund Freud University Vienna, 1020 Vienna, Austria
| | - Luca Monzo
- Centre d’Investigations Cliniques Plurithématique 1433 and Inserm U1116, Université de Lorraine, CHRU Nancy, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), 54035 Nancy, France
| | | | - Matteo Beltrami
- Azienda USL Toscana Centro, Cardiology Unit, San Giovanni di Dio Hospital, 50143 Florence, Italy;
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Palazzuoli A, Beltrami M, McCullough PA. Acute COVID-19 Management in Heart Failure Patients: A Specific Setting Requiring Detailed Inpatient and Outpatient Hospital Care. Biomedicines 2023; 11:biomedicines11030790. [PMID: 36979769 PMCID: PMC10045184 DOI: 10.3390/biomedicines11030790] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/24/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
The relationship existing between heart failure (HF) and COVID-19 remains questioned and poorly elucidated. Many reports suggest that HF events are reduced during pandemics, although other studies have demonstrated higher mortality and sudden death in patients affected by HF. Several vascular, thrombotic, and respiratory features may deteriorate stable HF patients; therefore, the infection may directly cause direct myocardial damage, leading to cardiac function deterioration. Another concern is related to the possibility that antiviral, anti-inflammatory, and corticosteroid agents commonly employed during acute COVID-19 infection may have potentially deleterious effects on the cardiovascular (CV) system. For these reasons, HF patients deserve specific management with a tailored approach in order to avoid arrhythmic complications and fluid retention events. In this review, we describe the complex interplay between COVID-19 and HF, the evolving trend of infection with related CV events, and the specific management strategy to adopt in this setting.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital University of Siena Italy, 53100 Siena, Italy
| | - Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, Azienda USL Toscana Centro, 50134 Florence, Italy
- Correspondence: ; Tel.: +39-339-5418158
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12
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Palazzuoli A, Tramonte F, Beltrami M. Laboratory and Metabolomic Fingerprint in Heart Failure with Preserved Ejection Fraction: From Clinical Classification to Biomarker Signature. Biomolecules 2023; 13:biom13010173. [PMID: 36671558 PMCID: PMC9855377 DOI: 10.3390/biom13010173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/29/2022] [Accepted: 01/10/2023] [Indexed: 01/17/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) remains a poorly characterized syndrome with many unknown aspects related to different patient profiles, various associated risk factors and a wide range of aetiologies. It comprises several pathophysiological pathways, such as endothelial dysfunction, myocardial fibrosis, extracellular matrix deposition and intense inflammatory system activation. Until now, HFpEF has only been described with regard to clinical features and its most commonly associated risk factors, disregarding all biological mechanisms responsible for cardiovascular deteriorations. Recently, innovations in laboratory and metabolomic findings have shown that HFpEF appears to be strictly related to specific cells and molecular mechanisms' dysregulation. Indeed, some biomarkers are efficient in early identification of these processes, adding new insights into diagnosis and risk stratification. Moreover, recent advances in intermediate metabolites provide relevant information on intrinsic cellular and energetic substrate alterations. Therefore, a systematic combination of clinical imaging and laboratory findings may lead to a 'precision medicine' approach providing prognostic and therapeutic advantages. The current review reports traditional and emerging biomarkers in HFpEF and it purposes a new diagnostic approach based on integrative information achieved from risk factor burden, hemodynamic dysfunction and biomarkers' signature partnership.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, 53100 Siena, Italy
- Correspondence: ; Tel.: +39-577585363 or +39-577585461; Fax: +39-577233480
| | - Francesco Tramonte
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, 53100 Siena, Italy
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13
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Georgiopoulos G, Figliozzi S, Pateras K, Nicoli F, Bampatsias D, Beltrami M, Finocchiaro G, Chiribiri A, Masci PG, Olivotto I. Comparison of Demographic, Clinical, Biochemical, and Imaging Findings in Hypertrophic Cardiomyopathy Prognosis: A Network Meta-Analysis. JACC Heart Fail 2023; 11:30-41. [PMID: 36599547 DOI: 10.1016/j.jchf.2022.08.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite hypertrophic cardiomyopathy (HCM) being the most common inherited heart disease and conferring increased risk for heart failure (HF) and sudden cardiac death (SCD), risk assessment in HCM patients is still largely unresolved. OBJECTIVES This study aims to synthesize and compare the prognostic impact of demographic, clinical, biochemical, and imaging findings in patients with HCM. METHODS The authors searched PubMed, Embase, and Cochrane Library for studies published from 1955 to November 2020, and the endpoints were: 1) all-cause death; 2) an arrhythmic endpoint including SCD, sustained ventricular tachycardia, ventricular fibrillation, or aborted SCD; and 3) a composite endpoint including (1) or (2) plus hospitalization for HF or cardiac transplantation. The authors performed a pairwise meta-analysis obtaining the pooled estimate separately for the association between baseline variables and study endpoints. A random-effects network meta-analysis was subsequently used to comparatively assess the prognostic value of outcome associates. RESULTS A total of 112 studies with 58,732 HCM patients were included. Among others, increased brain natriuretic peptide/N-terminal pro-B-type natriuretic peptide, late gadolinium enhancement (LGE), positive genotype, impaired global longitudinal strain, and presence of apical aneurysm conferred increased risk for the composite endpoint. At network meta-analysis, LGE showed the highest prognostic value for all endpoints and was superior to all other associates except New York Heart Association functional class >class II. A multiparametric imaging-based model was superior in predicting the composite endpoint compared to a prespecified model based on conventional risk factors. CONCLUSIONS This network meta-analysis supports the development of multiparametric risk prediction algorithms, including advanced imaging markers additively to conventional risk factors, for refined risk stratification in HCM. (Long-term prognosis of hypertrophic cardiomyopathy according to genetic, clinical, biochemical and imaging findings: a systemic review and meta-analysis; CRD42020185219).
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Affiliation(s)
- Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom; Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Greece.
| | | | - Konstantinos Pateras
- Department of Biostatistics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Dimitrios Bampatsias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Greece
| | - Matteo Beltrami
- Department of Experimental and Clinical Medicine, University of Florence, Meyer Children's Hospital and Careggi University Hospital, Florence, Italy
| | - Gherardo Finocchiaro
- School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom
| | - Pier Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom
| | - Iacopo Olivotto
- Department of Experimental and Clinical Medicine, University of Florence, Meyer Children's Hospital and Careggi University Hospital, Florence, Italy.
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14
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Beltrami M, Olivotto I, Figliozzi S, Pateras K, Niccoli F, Bampatsias D, Finocchiaro G, Chiribiri A, Masci PG, Georgiopoulos G. 983 COMPARISON OF DEMOGRAPHIC, CLINICAL, BIOCHEMICAL AND IMAGING AND IMAGING FINDINGS IN HYPERTROPHIC CARDIOMYOPATHY PROGNOSIS: A NETWORK META-ANALYSES. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartjsupp/suac121.587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Despite hypertrophic cardiomyopathy (HCM) being the most common inherited heart disease and conferring increased risk for heart failure (HF) and sudden cardiac death (SCD), risk assessment in HCM patients is still largely unresolved.
Objective
To synthesize and compare the prognostic impact of demographic, clinical, biochemical, and imaging findings in patients with HCM.
Methods
We searched PubMed, Embase, and Cochrane Library for studies published from inception to November 2020, and the endpoints were: i) all-cause death; ii) an arrhythmic endpoint including SCD, sustained ventricular tachycardia, ventricular fibrillation, or aborted SCD; iii) a composite endpoint including i) or ii) plus hospitalization for HF or cardiac transplantation. We performed a pairwise meta-analysis obtaining the pooled estimate separately for the association between baseline variables and study endpoints. A random-effects network meta-analysis (NMA) was subsequently used to comparatively assess the prognostic value of outcome predictors.
Results
One-hundred-eleven studies with 56,792 HCM patients were included. Among others, increased BNP/NT-proBNP, late-gadolinium-enhancement (LGE), positive genotype, impaired global longitudinal strain and presence of apical aneurysm conferred increased risk for the composite endpoint. At NMA, LGE showed the highest prognostic value for all endpoints and was superior to all other predictors except NYHA class≥II. A multiparametric imaging-based model was superior in predicting the composite endpoint compared to a pre-specified model based on conventional risk factors.
Conclusions
This network meta-analysis supports the development of multiparametric risk prediction algorithms, including advanced imaging markers additively to conventional risk factors, for refined risk stratification in HCM.
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Affiliation(s)
- Matteo Beltrami
- San Giovanni Di Dio Hospital, Florence, Cardiomyopathy Unit, University Of Florence
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15
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Pisani E, Bartolini S, Sani F, Signorini U, Milli M, Beltrami M. 889 ATRIOVENTRICULAR BLOCK, AN UNUSUAL CLINICAL PRESENTATION OF CALCIFIED BICUSPID AORTIC VALVE. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartjsupp/suac121.741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Bicuspid aortic valve (BAV) is the most frequent congenital valve disease in adults. It is often associated with other congenital cardiac defects. Sometimes it is associated with aortic dilatation. BAV is an heterogeneous disease with varying valve morphology (asymmetrical cusp size and rafe), annulus geometry and size, asymmetrical calcification of the aortic valve and left ventricular outflow tract.
Case Report
A 32 year-old male patient was diagnosed with bicuspid aortic valve after several cardiologic visits for eligibility to competitive sport. Since April 2021 he developed a progressive exertional dyspnea for strenuous efforts. In February 2022, he was referred to our department after a Holter ECG showed a bradyarrhythmia with complete atrioventricular block. The echocardiography evaluation demonstrated a preserved ejection fraction and a bicuspid aortic valve with a mild-moderate regurgitation. The coronary computed tomography showed a thick and calcified bicuspid aortic valve with a coarse calcification of the anterior cuspid that involve the pars membranacea of the interventricular septum. The ergometric exercise demonstrated chronotropy incompetence. The tomography confirmed the mildy aortic root dilatation. Therefore, an MRI was performed and reported a small laminar LGE on the infero-lateral wall of the left ventricle, of unclear significance. He underwent Dual-Chamber permanent pacemaker implantation. A conservative approach was preferred over valvular replacement, considering the mild aortic root dilatation on a background of mild-to- moderate aortic insufficiency.
Conclusion
Our case is unusual given the bicuspid aortic valve concomitant with atrioventricular block, which was connected with the location of the calcification. Thus, the aim of our case report is, to describe a complication to this condition which, although rare, represents a different clinical presentation of the pathology itself in a young adult.
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16
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Fumagalli C, Bonanni F, Beltrami M, Ruggiero R, Zocchi C, Tassetti L, Maurizi N, Zampieri M, Lovero F, Di Bari M, Marchionni N, Pieragnoli P, Cappelli F, Fumagalli S, Olivotto I. Incidence of stroke in patients with hypertrophic cardiomyopathy in stable sinus rhythm during long-term monitoring. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of atrial fibrillation (AF) and stroke, especially at an advanced disease stage. To date, however, the incidence and factors associated with cardioembolic events in HCM patients without AF remain unresolved.
Purpose
To determine the incidence of stroke in HCM patients in whom cardiac rhythm was monitored with a cardiac implantable electronic device (CIED). The association of stroke with left atrial (LA) enlargement was also examined.
Methods
Retrospective cohort study in an outpatient clinic in a tertiary HCM Referral Center.
All consecutive patients diagnosed with HCM and referred for CIED implantation with >16 years at diagnosis and >1 year follow-up post CIED implantation were reviewed. Severe LA dilatation was defined as a LA dimension (LAD) of >48mm at echocardiogram. Based on CIED monitoring, patients were classified as: Pre-existing AF (diagnosed with AF prior to CIED); De novo AF (diagnosed with AF after CIED implantation); Sinus Rhythm (SR): no episodes of AF. Incidence of stroke after CIED implantation was the primary outcome.
Results
A total of 185 patients (57% men, age: 54±17 years) were implanted with a CIED and were included. Pre-existing AF was present in 72 (36%) patients and de novo AF in 24 (13%); whereas 89 (48%) remained in SR. After 5 [2–9] years, stroke was reported in 19 (10.3%) patients: 7 occurred in patients with pre-existing AF (1.1%/year), 3 in patients with de novo AF (2.2%/year), and 9 in patients with SR (2.3%/year). No difference was captured by CHA2DS2-VASc score among rhythm categories. Patients with AF had larger LAD at baseline. Among patients in SR, those with a LAD>48mm had the greatest risk of stroke (4.8%/year vs 0.5%/year, p<0.01; Hazard Ratio [HR]: 8.56, 95% C.I. 2.03–36.15). At Cox multivariable regression analysis, LA (HR: 1.104, 95%C.I. 1.039–1.173, p=0.001) and AF (HR: 0.310, 95% C.I. 0.102–0.939, p=0.038) were associated with incident stroke.
Conclusions
In HCM patients with CIED long-term monitoring and no prior history of AF, stroke rates were similar in those with de novo AF or stable sinus rhythm. CHA2DS2-VASc considerably underestimated risk, whereas severe LA dilatation was a powerful predictor of risk, irrespective of AF.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- C Fumagalli
- Careggi University Hospital (AOUC), Cardiomyopathies Unit , Florence , Italy
| | - F Bonanni
- Careggi University Hospital (AOUC), Cardiomyopathies Unit , Florence , Italy
| | - M Beltrami
- Careggi University Hospital (AOUC), Cardiomyopathies Unit , Florence , Italy
| | - R Ruggiero
- Careggi University Hospital (AOUC), Cardiomyopathies Unit , Florence , Italy
| | - C Zocchi
- Careggi University Hospital (AOUC), Cardiomyopathies Unit , Florence , Italy
| | - L Tassetti
- Careggi University Hospital (AOUC), Cardiomyopathies Unit , Florence , Italy
| | - N Maurizi
- University Hospital of Lausanne, Cardiology Department , Lausanne , Switzerland
| | - M Zampieri
- Careggi University Hospital (AOUC), Cardiomyopathies Unit , Florence , Italy
| | - F Lovero
- Careggi University Hospital (AOUC), Cardiomyopathies Unit , Florence , Italy
| | - M Di Bari
- Careggi University Hospital , Florence , Italy
| | | | | | - F Cappelli
- Careggi University Hospital (AOUC), Cardiomyopathies Unit , Florence , Italy
| | - S Fumagalli
- Careggi University Hospital , Florence , Italy
| | - I Olivotto
- Careggi University Hospital (AOUC), Cardiomyopathies Unit , Florence , Italy
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Beltrami M, Dei LL, Milli M. The Role of the Left Atrium: From Multimodality Imaging to Clinical Practice: A Review. Life (Basel) 2022; 12:life12081191. [PMID: 36013370 PMCID: PMC9410416 DOI: 10.3390/life12081191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022]
Abstract
In recent years, new interest is growing in the left atrium (LA). LA functional analysis and measurement have an essential role in cardiac function evaluation. Left atrial size and function are key elements during the noninvasive analysis of diastolic function in several heart diseases. The LA represents a “neuroendocrine organ” with high sensitivity to the nervous, endocrine, and immune systems. New insights highlight the importance of left atrial structural, contractile, and/or electrophysiological changes, introducing the concept of “atrial cardiomyopathy”, which is closely linked to underlying heart disease, arrhythmias, and conditions such as aging. The diagnostic algorithm for atrial cardiomyopathy should follow a stepwise approach, combining risk factors, clinical characteristics, and imaging. Constant advances in imaging techniques offer superb opportunities for a comprehensive evaluation of LA function, underlying specific mechanisms, and patterns of progression. In this literature review, we aim to suggest a practical, stepwise algorithm with integrative multimodality imaging and a clinical approach for LA geometry and functional analysis. This integrates diastolic flow analysis with LA remodelling by the application of traditional and new diagnostic imaging techniques in several clinical settings such as heart failure (HF), atrial fibrillation (AF), coronary artery disease (CAD), and mitral regurgitation (MR).
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Affiliation(s)
- Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, 50142 Florence, Italy
- Correspondence: ; Tel.: +39-339-541-8158
| | - Lorenzo-Lupo Dei
- Cardiology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Massimo Milli
- Cardiology Unit, San Giovanni di Dio Hospital, 50142 Florence, Italy
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Re F, Halasz G, Moroni F, Beltrami M, Baratta P, Avella A, Zachara E, Olivotto I. Exercise-induced pulmonary hypertension in hypertrophic cardiomyopathy: a combined cardiopulmonary exercise test—echocardiographic study. Int J Cardiovasc Imaging 2022; 38:2345-2352. [DOI: 10.1007/s10554-022-02671-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/02/2022] [Indexed: 11/05/2022]
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Coppini R, Beltrami M, Doste R, Bueno-Orovio A, Ferrantini C, Vitale G, Pioner JM, Santini L, Argirò A, Berteotti M, Mori F, Marchionni N, Stefàno P, Cerbai E, Poggesi C, Olivotto I. Paradoxical prolongation of QT interval during exercise in patients with hypertrophic cardiomyopathy: cellular mechanisms and implications for diastolic function. European Heart Journal Open 2022; 2:oeac034. [PMID: 35919344 PMCID: PMC9242073 DOI: 10.1093/ehjopen/oeac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/14/2022] [Indexed: 11/21/2022]
Abstract
Aims Ventricular cardiomyocytes from hypertrophic cardiomyopathy (HCM) patient hearts show prolonged action potential duration (APD), impaired intracellular Ca2+ homeostasis and abnormal electrical response to beta -adrenergic stimulation. We sought to determine whether this behaviour is associated with abnormal changes of repolarization during exercise and worsening of diastolic function, ultimately explaining the intolerance to exercise experienced by some patients without obstruction. Methods and results Non-obstructive HCM patients (178) and control subjects (81) underwent standard exercise testing, including exercise echocardiography. Ventricular myocytes were isolated from myocardial samples of 23 HCM and eight non-failing non-hypertrophic surgical patients. The APD shortening in response to high frequencies was maintained in HCM myocytes, while β-adrenergic stimulation unexpectedly prolonged APDs, ultimately leading to a lesser shortening of APDs in response to exercise. In HCM vs. control subjects, we observed a lesser shortening of QT interval at peak exercise (QTc: +27 ± 52 ms in HCM, −4 ± 50 ms in controls, P < 0.0001). In patients showing a marked QTc prolongation (>30 ms), the excessive shortening of the electrical diastolic period was linked with a limited increase of heart-rate and deterioration of diastolic function at peak effort. Conclusions Abnormal balance of Ca2+- and K+-currents in HCM cardiomyocytes determines insufficient APD and Ca2+-transient shortening with exercise. In HCM patients, exercise-induced QTc prolongation was associated with impaired diastolic reserve, contributing to the reduced exercise tolerance. Our results support the idea that severe electrical cardiomyocyte abnormalities underlie exercise intolerance in a subgroup of HCM patients without obstruction.
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Affiliation(s)
- Raffaele Coppini
- Department NeuroFarBa, University of Florence , Viale G. Pieraccini 6, 50139 Florence, Italy
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital , Largo Brambilla 3, 50134 Firenze, Italy
| | - Ruben Doste
- Department of Computer Science, University of Oxford, Wolfson Building, Parks Rd , Oxford OX1 3QD, UK
| | - Alfonso Bueno-Orovio
- Department of Computer Science, University of Oxford, Wolfson Building, Parks Rd , Oxford OX1 3QD, UK
| | - Cecilia Ferrantini
- Department of Experimental and Clinical Medicine, University of Florence , Largo Brambilla 3, 50134 Firenze, Italy
| | - Giulia Vitale
- Department of Experimental and Clinical Medicine, University of Florence , Largo Brambilla 3, 50134 Firenze, Italy
| | - Josè Manuel Pioner
- Department of Experimental and Clinical Medicine, University of Florence , Largo Brambilla 3, 50134 Firenze, Italy
| | - Lorenzo Santini
- Department NeuroFarBa, University of Florence , Viale G. Pieraccini 6, 50139 Florence, Italy
| | - Alessia Argirò
- Cardiomyopathy Unit, Careggi University Hospital , Largo Brambilla 3, 50134 Firenze, Italy
| | - Martina Berteotti
- Cardiomyopathy Unit, Careggi University Hospital , Largo Brambilla 3, 50134 Firenze, Italy
| | - Fabio Mori
- Cardiothoracovascular Department, Careggi University Hospital , Largo Brambilla 3, 50134 Firenze, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence , Largo Brambilla 3, 50134 Firenze, Italy
- Cardiothoracovascular Department, Careggi University Hospital , Largo Brambilla 3, 50134 Firenze, Italy
| | - Pierluigi Stefàno
- Department of Experimental and Clinical Medicine, University of Florence , Largo Brambilla 3, 50134 Firenze, Italy
- Cardiothoracovascular Department, Careggi University Hospital , Largo Brambilla 3, 50134 Firenze, Italy
| | - Elisabetta Cerbai
- Department NeuroFarBa, University of Florence , Viale G. Pieraccini 6, 50139 Florence, Italy
| | - Corrado Poggesi
- Department of Experimental and Clinical Medicine, University of Florence , Largo Brambilla 3, 50134 Firenze, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital , Largo Brambilla 3, 50134 Firenze, Italy
- Department of Experimental and Clinical Medicine, University of Florence , Largo Brambilla 3, 50134 Firenze, Italy
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Beltrami M, Milli M, Dei LL, Palazzuoli A. The Treatment of Heart Failure in Patients with Chronic Kidney Disease: Doubts and New Developments from the Last ESC Guidelines. J Clin Med 2022; 11:jcm11082243. [PMID: 35456336 PMCID: PMC9025648 DOI: 10.3390/jcm11082243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/13/2022] [Accepted: 04/15/2022] [Indexed: 02/01/2023] Open
Abstract
Patients with heart failure (HF) and associated chronic kidney disease (CKD) are a population less represented in clinical trials; additionally, subjects with more severe estimated glomerular filtration rate reduction are often excluded from large studies. In this setting, most of the data come from post hoc analyses and retrospective studies. Accordingly, in patients with advanced CKD, there are no specific studies evaluating the long-term effects of the traditional drugs commonly administered in HF. Current concerns may affect the practical approach to the traditional treatment, and in this setting, physicians are often reluctant to administer and titrate some agents acting on the renin angiotensin aldosterone system and the sympathetic activity. Therefore, the extensive application in different HF subtypes with wide associated conditions and different renal dysfunction etiologies remains a subject of debate. The role of novel drugs, such as angiotensin receptor blocker neprilysin inhibitors and sodium glucose linked transporters 2 inhibitors seems to offer a new perspective in patients with CKD. Due to its protective vascular and hormonal actions, the use of these agents may be safely extended to patients with renal dysfunction in the long term. In this review, we discussed the largest trials reporting data on subjects with HF and associated CKD, while suggesting a practical stepwise algorithm to avoid renal and cardiac complications.
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Affiliation(s)
- Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, Via Torregalli 3, 50142 Florence, Italy;
- Correspondence: ; Tel.: +39-3395418158
| | - Massimo Milli
- Cardiology Unit, San Giovanni di Dio Hospital, Via Torregalli 3, 50142 Florence, Italy;
| | - Lorenzo Lupo Dei
- Cardiology, Department of Life, Health and Enviromental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, 53100 Siena, Italy;
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Re F, Halasz G, Moroni F, Beltrami M, Baratta P, Avella A, Zachara E, Olivotto I. 587 Exercise induced pulmonary hypertension in hypertrophic cardiomyopathy: a combined cardiopulmonary exercise test-echocardiographic study. Eur Heart J Suppl 2021. [DOI: 10.1093/eurheartj/suab142.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Aims
Pulmonary arterial hypertension (PAH) has been described in patients with hypertrophic cardiomyopathy (HCM) and it was associated with a worse prognosis. Nevertheless in most HCM patients, despite normal pulmonary pressures at rest, congestive symptoms are elicited by exercise. In the present study, combining cardiopulmonary exercise test (CPET) with echocardiography, we aimed to evaluate the presence of exercise-induced pulmonary hypertension (EiPAH) its role in functional limitation and its prognostic significance in a cohort of patients with obstructive and non-obstructive HCM.
Methods and results
182 HCM patients (35% females, mean age 47.5 ± 15.9) undergoing CPET. During CPET, LVOT velocities and trans-tricuspid gradient were measured. Thirty-seven patients (20%) developed sPAP > 40 mmHg at peak exercise (EiPAH). EiPAH was associated with an lower exercise performance, larger left atrial volumes, higher left ventricular gradient and higher VE/VCO2 slope .At multivariable model baseline sPAP (P < 0.0001) and baseline left ventricular obstruction (LVOT) (P = 0.028) were significantly associated with EiPAH .Kaplan-Meier curve analysis showed EiPAH was a significant predictor of HCM –related morbidity (hazards ratio: 6.21, 95% CI: 1.47–26.19; P = 0.05; 4.21, 95% CI: 1.94–9.12; P < 0.001) for the primary and the secondary endpoint respectively.
Conclusions
EiPAH was present in about one fifth of HCM patients without evidence of elevated pulmonary pressures at rest, and was associated with adverse clinical outcome. Diagnosing EiPAH by exercise echo/CPET may help physicians to detect early stage of PAH requiring a closer clinical monitoring and individualized treatment strategies.
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Affiliation(s)
- Federica Re
- Cardiology Department, San Camillo-Forlanini Hospital, Rome, Italy
| | - Geza Halasz
- Cardiac Unit, da Saliceto Hospital, Parma, Italy
| | | | - Matteo Beltrami
- Cardiology Department, San Giovanni di Dio Hospital, Florence, Italy
| | - Pasquale Baratta
- Cardiology Department, San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Avella
- Cardiology Department, San Camillo-Forlanini Hospital, Rome, Italy
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Fumagalli C, Zocchi C, Bonanni F, Tassetti L, Beltrami M, De Filippo V, Marchi A, Zampieri M, Argirò A, Tomberl A, Cappelli F, Olivotto I. 772 Incidence of stroke in patients with hypertrophic cardiomyopathy implanted with a cardiac implantable electronic device. Eur Heart J Suppl 2021. [DOI: 10.1093/eurheartj/suab142.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
Incidence of stroke in patients with an advanced stage hypertrophic cardiomyopathy (HCM) is associated with adverse outcome, impaired quality of life and loss of productivity. Still today, however, the real burden of stroke in both patients with and without atrial fibrillation (AF) is unresolved. To assess the prevalence and incidence of AF and stroke in patients with an advanced stage HCM implanted with cardiac implantable electronic devices (CIEDs) at our institution, a long-standing high flow referral centre for cardiomyopathies.
Methods and results
Clinical and instrumental data of HCM patients implanted with CIEDs [either pacemakers (PM) or implantable cardioverter defibrillator (ICD)] from 1998 to 2019 were retrospectively reviewed. Inclusion criteria were site-designated diagnosis of HCM, age at diagnosis >18 years, Follow-up >1 year. HCM phenocopies (e.g. Fabry disease) were carefully excluded. Patients were divided into three categories according to presence of AF (‘AF prior to CIED implantation’ vs. ‘AF after CIED implantation’ vs. ‘sinus rhythm’). Outcome was measured against incidence of thromboembolic events [stroke or transient ischaemic attack (TIA)] at Follow-up. Patients were also stratified by left atrial diameter (LAD) in two groups (<47 vs. > 48mm). Of 1861 patients followed at our Unit, a total of 185 (9.9%) patients implanted with a CIED were included (57% men, mean age at implantation 54 ± 17 years). At baseline, AF was present in 72 (36%) patients. Mean CHA2DS2VASc was 1.7 + 1.3 with no differences among patients with or without AF. Patients with AF at baseline had a more pronounced LAD dilation (51 ± 7 vs. 44 ± 8, P < 0.001) and a lower ejection fraction (55 ± 11 vs. 64 ± 12, P < 0.001). After 5.0 ± 3.8 years from CIED implantation, de novo AF was detected in 24 (21%) individuals, resulting in an annual incidence rate of 4.1%/year. Overall, 89 (48%) of patients remained is sinus rhythm. Stroke/TIAs were reported in 19 (10.3%) patients: seven (37%, 1.1%/year) occurred in patients with prior history of AF, three (16%, 2.2%/year) in patients with de novo AF, and nine (63%, 2.3%/year) in patients with no history of arrhythmias documented at CIED interrogation. Among patients in sinus rhythm, those with a LAD > 48 mm had the greatest risk of stroke (4.8%/year vs. 0.5%/year, P < 0.01, for LAD > 48 vs. LAD < 47, respectively). At multivariable analysis, after adjustment for CHA2DS2VASc, AF, and obstructive physiology, only LAD was associated with a higher risk for stroke (HR: 1.09, 95% CI: 1.03–1.11, P < 0.001).
Conclusions
In a large cohort of consecutive high risk HCM patients referred to CIED implantation, the incidence of stroke was high, with 1-in-10 patients experiencing at least one event. Among patients in sinus rhythm, those with a marked left atrial dilatation were at highest risk of ischaemic stroke, suggesting the existence of an unmet need to stratify risk of stroke even in patients with no detected arrhythmias.
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Beltrami M, Bartolini S, Milli M, Palazzuoli A. The relevance of specific heart failure outpatient programs in the COVID era: an appropriate model for every disease. Rev Cardiovasc Med 2021; 22:677-690. [PMID: 34565069 DOI: 10.31083/j.rcm2203077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/19/2021] [Accepted: 07/28/2021] [Indexed: 11/06/2022] Open
Abstract
Heart Failure (HF) is characterized by an elevated readmission rate, with almost 50% of events occurring after the first episode over the first 6 months of the post-discharge period. In this context, the vulnerable phase represents the period when patients elapse from a sub-acute to a more stabilized chronic phase. The lack of an accurate approach for each HF subtype is probably the main cause of the inconclusive data in reducing the trend of recurrent hospitalizations. Most care programs are based on the main diagnosis and the HF stages, but a model focused on the specific HF etiology is lacking. The HF clinic route based on the HF etiology and the underlying diseases responsible for HF could become an interesting approach, compared with the traditional programs, mainly based on non-specific HF subtypes and New York Heart Association class, rather than on detailed etiologic and epidemiological data. This type of care may reduce the 30-day readmission rates for HF, increase the use of evidence-based therapies, prevent the exacerbation of each comorbidity, improve patient compliance, and decrease the use of resources. For all these reasons, we propose a dedicated outpatient HF program with a daily practice scenario that could improve the early identification of symptom progression and the quality-of-life evaluation, facilitate the access to diagnostic and laboratory tools and improve the utilization of financial resources, together with optimal medical titration and management.
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Affiliation(s)
- Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, 50142 Florence, Italy
| | - Simone Bartolini
- Cardiology Unit, San Giovanni di Dio Hospital, 50142 Florence, Italy
| | - Massimo Milli
- Cardiology Unit, San Giovanni di Dio Hospital, 50142 Florence, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Internal Medicine, Le Scotte Hospital, University of Siena, 53100 Siena, Italy
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Citriniti G, Soriano A, Bertolini E, Sandri G, Bertani A, Tinazzi I, Martinis F, Girolimetto N, Salvarani C, Beltrami M, Macchioni P. POS0265 CLINICAL AND ULTRASONOGRAPHIC ENTHESITIS IN INFLAMMATORY BOWEL DISEASE WITH AND WITHOUT PSORIASIS. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.4162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Previous studies have reported an association between psoriasis (PsO) and inflammatory bowel disease (IBD). Coexistence of IBD and PsO has been associated with significant higher prevalence of enthesitis and dactylitis1.Objectives:To compare the prevalence of clinical and ultrasonographic peripheral enthesis abnormalities in a consecutive series of patients with IBD and psoriasis (PsO) as compared to a group of IBD patients without psoriasis (IBD).Methods:One-hundred seventy-four IBD consecutive patients [36 PsO and 138 IBD, M/F 91/83, mean age 42.6±14.7 years, mean disease duration 110 ±12.3 months] entered the study. A complete clinical examination, including rheumatological history, 66/68 peripheral joint count, MASES and LEI scores, BASDAI, and dactylitis count, was performed at study entry. Laboratory test (ESR, CRP, Hb, fecal calprotectin) were collected. Axial or peripheral SpA diagnosis was made using ASAS criteria 2.US examination was executed by a rheumatologist blind to clinical data, using an Esaote MyLabClass, 18-6MHz linear multifrequence transducer both in B-mode and PD-mode. The following sites were examined bilaterally: lateral epicondyle of the humerus, distal quadriceps femoris insertion into the patella, inferior pole of the patella, tibial distal insertion of the patellar tendon, calcaneal insertion of the Achilles tendon, and plantar aponeurosis insertion. Knee and ankle joints were evaluated for synovial hypertrophy, PD signal and fluid effusion. Enthesitis was defined according to OMERACT 3 and scored as 0-36 for GUESS and 0-136 for MASEI.Results:PsO patients had later IBD onset (mean age 39±14.7 vs 33 ± 13.2 in IBD group, p=0.02). There weren’t observed any significant differences in IBD duration and Crohn/UC prevalence.No significant difference between the two groups in rheumatological history and clinical examination was detected, except for familiar history of psoriasis (PsO 44% vs IBD 16%, p <0.001). Prevalence of SpA was 33,3% in PsO group and 37% in IBD group (p = 0.687).146 patients (83.4%) showed structural damage at ≥ 1 enthesis, 44 patients (25%) had at least 1 active enthesitis, with no significant difference between the two groups. PsO group showcased a significantly increased prevalence of patients having ≥ 1 thickened enthesis (86.1% vs 63.9%, p=0.009) and of PD signal at knee examination (11.1% vs 2.2%, p= 0.034). Higher values of GUESS score were observed in PsO (8.1±5.1 vs 5.8±3.9, p=0.017). Enthesis hypoechogenicity was more prevalent in IBD group (27.5% vs 11.1%, p=0.049).Enthesis thickness was significantly increased in PsO, in every examined site. Enthesophyte length was significantly increased in PsO group at quadriceps tendon, patellar distal insertion and Achilles tendon.Conclusion:No differences in clinical manifestation and rheumatological history between IBD and PsO patients were observed. Subclinical (US) abnormalities were significantly increased in IBD patients with associated PsO, as compared to patients affected by IBD.References:[1]Cantini, F. et al. J. Rheumatol.44, 1341–1346 (2017).[2]Rudwaleit, M. et al. Ann. Rheum. Dis.68, 777–783 (2009).[3]Balint, P. V. et al. Ann. Rheum. Dis.77, 1730–1735 (2018).Acknowledgements:Abbvie provided funding for medical writingDisclosure of Interests:Giorgia Citriniti: None declared, Alessandra Soriano: None declared, Elena Bertolini: None declared, Gilda Sandri: None declared, Angela Bertani: None declared, Ilaria Tinazzi: None declared, Federica Martinis: None declared, Nicolò Girolimetto: None declared, Carlo Salvarani: None declared, Marina Beltrami Grant/research support from: Abbvie provided funding for medical writing, Pierluigi Macchioni: None declared
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Palazzuoli A, Beltrami M. Are HFpEF and HFmrEF So Different? The Need to Understand Distinct Phenotypes. Front Cardiovasc Med 2021; 8:676658. [PMID: 34095263 PMCID: PMC8175976 DOI: 10.3389/fcvm.2021.676658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/12/2021] [Indexed: 12/20/2022] Open
Abstract
Traditionally, patients with heart failure (HF) are divided according to ejection fraction (EF) threshold more or <50%. In 2016, the ESC guidelines introduced a new subgroup of HF patients including those subjects with EF ranging between 40 and 49% called heart failure with midrange EF (HFmrEF). This group is poorly represented in clinical trials, and it includes both patients with previous HFrEF having a good response to therapy and subjects with initial preserved EF appearance in which systolic function has been impaired. The categorization according to EF has recently been questioned because this variable is not really a representative of the myocardial contractile function and it could vary in relation to different hemodynamic conditions. Therefore, EF could significantly change over a short-term period and its measurement depends on the scan time course. Finally, although EF is widely recognized and measured worldwide, it has significant interobserver variability even in the most accredited echo laboratories. These assumptions imply that the same patient evaluated in different periods or by different physicians could be classified as HFmrEF or HFpEF. Thus, the two HF subtypes probably subtend different responses to the underlying pathophysiological mechanisms. Similarly, the adaptation to hemodynamic stimuli and to metabolic alterations could be different for different HF stages and periods. In this review, we analyze similarities and dissimilarities and we hypothesize that clinical and morphological characteristics of the two syndromes are not so discordant.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital University of Siena, Siena, Italy
| | - Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, Florence, Italy
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Zampieri M, Emmi G, Beltrami M, Fumagalli C, Urban ML, Dei LL, Marchi A, Berteotti M, Tomberli A, Baldini K, Bettiol A, Pradella S, Silvestri E, Marchionni N, Vaglio A, Olivotto I, Prisco D. Cardiac involvement in eosinophilic granulomatosis with polyangiitis (formerly Churg-Strauss syndrome): Prospective evaluation at a tertiary referral centre. Eur J Intern Med 2021; 85:68-79. [PMID: 33358337 DOI: 10.1016/j.ejim.2020.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/24/2020] [Accepted: 12/08/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic vasculitis. Cardiac specific involvement (CSI) is caused by coronary artery vasculitis, but also by myocardial eosinophilic infiltration. To date, the prevalence of CSI associated with EGPA is unresolved. Aim of this study was to systematically assess the prevalence and clinical impact of CSI in a consecutive outpatient EGPA population. METHODS Between October 2018 and July 2019, we prospectively enrolled 52 consecutive EGPA patients. All underwent comprehensive evaluation including a standardized questionnaire, physical examination, 12-lead-ECG, echocardiography. Cardiac magnetic resonance and 24 h-Holter were performed as deemed clinically appropriate. Cardiac abnormalities were defined as CSI based on the likelihood of their relation to EGPA vasculitis, after exclusion of alternative diagnoses. RESULTS 52 enrolled patients, mean age 59±1 years. Thirteen of the 52 patients (25%) were classified as CSI+. CSI was characterized by myocarditis in four patients, non-scar-related regional wall motions abnormalities (RWMA) in three, apical thrombosis in two (one also had RWMA), pericarditis in three and non-atherosclerotic coronary disease (Prinzmetal angina and coronaritis) in 2. Five (38%) of the 13 CSI+ patients, presented an apical aneurysm. Peak eosinophil count at diagnosis was higher in CSI+: 8000 /μl vs CSI-: 3000 /μl, p = 0.017. Overall, 2 patients had severe LV dysfunction, 5 required urgent hospitalization and 8 required long-term cardioactive therapy. CONCLUSIONS CSI was present in one-quarter of patients, often associated with high peak eosinophils. Myocarditis, RWMA and apical aneurysms were the most common manifestations. Although rarely severe and life-threatening, CSI often required long-term cardioactive treatment.
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Affiliation(s)
- Mattia Zampieri
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Carlo Fumagalli
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lorenzo-Lupo Dei
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alberto Marchi
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | | | - Alessia Tomberli
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Katia Baldini
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvia Pradella
- Radiology Unit, Careggi University Hospital, Florence, Italy
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Cardiothoracovascular Medicine, Careggi University Hospital, Florence, Italy
| | - Augusto Vaglio
- Deptartment of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Firenze, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Beltrami M, Fumagalli C, Milli M. Frailty, sarcopenia and cachexia in heart failure patients: Different clinical entities of the same painting. World J Cardiol 2021; 13:1-10. [PMID: 33552398 PMCID: PMC7821009 DOI: 10.4330/wjc.v13.i1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/25/2020] [Accepted: 12/28/2020] [Indexed: 02/06/2023] Open
Abstract
Heart Failure (HF) in elderly patients is a systemic syndrome where advanced age, comorbidities with organ system deterioration, frailty and impaired cognition significantly impact outcome. Cardiac cachexia, sarcopenia and frailty despite overlap in definitions are different clinical entities that frequently coexist in HF patients. However, these co-factors often remain unaddressed, resulting in poor quality-of-life, prolonged physical disability and exercise intolerance and finally with higher rehospitalization rates and mortality. Strategy aim to increase muscle mass and muscle strength and delay the occurrence of frailty state appear essential in this regard. Common HF drugs therapy (b-blockers, angiotensin-converting enzyme inhibitors) and prescription of physical exercise program remain the cornerstone of therapeutic approach in HF patients with new promising data regarding nutritional supplementation. However, the treatment of all these conditions still remain debated and only a profound knowledge of the specific mechanisms and patterns of disease progression will allow to use the appropriate therapy in a given clinical setting. For all these reasons we briefly review current knowledge on frailty, sarcopenia and cachexia in HF patients with the attempt to define clinically significant degrees of multiorgan dysfunction, specific "red alert" thresholds in clinical practice and therapeutic approach.
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Affiliation(s)
- Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, Florence 50142, Italy
| | - Carlo Fumagalli
- Cardiomyopathy Unit, Careggi University Hospital, Florence 50139, Italy
| | - Massimo Milli
- Cardiology Unit, San Giovanni di Dio Hospital, Florence 50142, Italy
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Argirò A, Sciagrà R, Marchi A, Beltrami M, Spinelli E, Salvadori E, Bianchi A, Mascalchi M, Poggesi A, Olivotto I, Pescini F. Coronary microvascular function is impaired in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. Eur J Neurol 2020; 28:3809-3813. [PMID: 33314522 DOI: 10.1111/ene.14678] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a rare inherited disease caused by NOTCH3 gene mutations. Although the main clinical features reflect brain injury, CADASIL is a systemic microangiopathy, and cardiac involvement has been observed but not systematically assessed. We aimed to study the prevalence and severity of coronary microvascular dysfunction (CMD) in CADASIL patients. METHODS Seventeen patients with genetically confirmed CADASIL, aged <60 years (mean age 40 ± 9 years), with ≤1 cardiovascular risk factor underwent neurological and neuropsychological evaluation, 3T brain magnetic resonance imaging (MRI), 12-lead electrocardiography (ECG), standard echocardiography, and measurement of myocardial blood flow at rest (resting MBF) and of maximal myocardial blood flow following Regadenoson infusion (Reg-MBF) by 13 NH3 positron emission tomography (PET). Coronary flow reserve (CFR) was defined as Reg-MBF/resting MBF. PET results were compared to those of 15 healthy controls who were age and sex matched. RESULTS Twelve patients (71%) presented migraine, none (53%) had psychiatric disturbances, and one (6%) had a previous stroke. None had cognitive impairment or ECG or echocardiography abnormalities. Both Reg-MBF and CFR were blunted in CADASIL patients compared with controls (Reg-MBF 2.46 ± 0.54 vs. 3.09 ± 0.44 ml/g/min, respectively; p < 0.01; CFR 2.74 ± 0.36 vs. 3.28 ± 0.66, respectively, p < 0.01). No correlations were found between Reg-MBF values and neuropsychological performance or cerebral lesion burden on MRI. CONCLUSIONS CADASIL patients exhibit blunted CFR due to CMD, which can be severe and is independent of the severity of brain lesion load and cognitive performances. CADASIL is a systemic microcirculation disease, and active surveillance of cardiac symptoms should be considered in these patients.
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Affiliation(s)
- Alessia Argirò
- Referral Center for Myocardial Diseases, University of Florence, AOU Careggi, Florence, Italy
| | - Roberto Sciagrà
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Alberto Marchi
- Referral Center for Myocardial Diseases, University of Florence, AOU Careggi, Florence, Italy
| | - Matteo Beltrami
- Referral Center for Myocardial Diseases, University of Florence, AOU Careggi, Florence, Italy
| | - Enrico Spinelli
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | | | - Andrea Bianchi
- Neuroradiology Unit, Department of Services, AOU Careggi, Florence, Italy
| | - Mario Mascalchi
- Neuroradiology Research Program at Meyer Children Hospital, University of Florence, Florence, Italy.,Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Anna Poggesi
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.,Stroke Unit, Emergency Department, AOU Careggi, Florence, Italy.,NEUROFARBA Department, University of Florence, Florence, Italy
| | - Iacopo Olivotto
- Referral Center for Myocardial Diseases, University of Florence, AOU Careggi, Florence, Italy
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Walsh R, Mazzarotto F, Hawley M, Beltrami M, Beekman L, Boschi B, Girolami F, Roberts A, Cerbai E, Cook S, Ware J, Funke B, Olivotto I, Bezzina C, Barton P. The genetic architecture of left ventricular non-compaction reveals both substantial overlap with other cardiomyopathies and a distinct aetiology in a subset of cases. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Left ventricular non-compaction (LVNC) is a condition characterised by trabeculations in the myocardial wall and is the subject of considerable conjecture as to whether it represents a distinct pathology or a secondary phenotype associated with other cardiac diseases, particularly cardiomyopathies.
Purpose
To investigate the genetic architecture of LVNC by identifying genes and variant classes robustly associated with disease and comparing these to other genetically characterised cardiomyopathies.
Methods
We performed rare variant association analysis using six different LVNC cohorts comprising 840 cases together with 125,748 gnomAD population controls and compared results to similar analyses with dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM) cases.
Results
We observed substantial overlap in genes and variant classes enriched in LVNC and DCM/HCM, indicating that in many cases LVNC belongs to a spectrum of more established cardiomyopathies, with non-compaction representing a phenotypic variation in patients with DCM- or HCM-causing variants. In contrast, five variant classes were uniquely enriched in LVNC cases, of which truncating variants in MYH7, ACTN2 and PRDM16 may represent a distinct LVNC aetiology. MYH7 truncating variants are generally considered as non-pathogenic but were detected in 2% of LVNC cases compared to 0.1% of controls, including a cluster of variants around a single splice region. Additionally, structural variants (exon deletions) in RYR2 and missense variants in the transmembrane region of HCN4 were enriched in LVNC cases, confirming prior reports regarding the association of these variant classes with combined LVNC and arrhythmia phenotypes.
Conclusions
We demonstrated that genetic association analysis can clarify the relationship between LVNC and established cardiomyopathies, highlighted substantial overlap with DCM/HCM but also identified variant classes associated with distinct LVNC and with joint LVNC/arrhythmia phenotypes. These results underline the complex genetic landscape of LVNC and inform how genetic testing in LVNC cases should be pursued and interpreted.
Cardiomyopathy rare variant frequencies
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- R Walsh
- Amsterdam University Medical Center, Department of Clinical and Experimental Cardiology, Amsterdam, Netherlands (The)
| | - F Mazzarotto
- University of Florence, Department of Experimental and Clinical Medicine, Florence, Italy
| | - M Hawley
- Laboratory for Molecular Medicine, Cambridge, United States of America
| | - M Beltrami
- Careggi University Hospital, Cardiomyopathy Unit, Florence, Italy
| | - L Beekman
- Amsterdam University Medical Center, Department of Clinical and Experimental Cardiology, Amsterdam, Netherlands (The)
| | - B Boschi
- Careggi University Hospital, Genetic Unit, Florence, Italy
| | - F Girolami
- Meyer University Hospital, Department of Paediatric Cardiology, Florence, Italy
| | - A Roberts
- Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - E Cerbai
- University of Florence, Department of Neurosciences, Psychology, Drug Research and Child Health, Florence, Italy
| | - S Cook
- National Heart Centre Singapore, Singapore, Singapore
| | - J Ware
- Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - B Funke
- Massachusetts General Hospital - Harvard Medical School, Department of Pathology, Boston, United States of America
| | - I Olivotto
- Careggi University Hospital, Cardiomyopathy Unit, Florence, Italy
| | - C Bezzina
- Amsterdam University Medical Center, Department of Clinical and Experimental Cardiology, Amsterdam, Netherlands (The)
| | - P Barton
- Imperial College London, National Heart and Lung Institute, London, United Kingdom
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Fumagalli C, Ruggieri R, De Filippo V, Cappelli F, Beltrami M, Bertini A, Carrassa G, Marchi A, Tomberli A, Baldini K, Olivotto I. Prevalence of device-detected atrial fibrillation and stroke in patients with hypertrophic cardiomyopathy. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Atrial fibrillation (AF) is highly prevalent in patients with hypertrophic cardiomyopathy (HCM) and is associated with adverse outcome, impaired quality of life, loss of productivity, and the risk for embolic stroke. However, still today, the real burden of AF is unresolved due to the unknown frequency of silent asymptomatic episodes.
Purpose
To assess the prevalence of device-detected AF and stroke in patients with HCM implanted with cardiac implantable electronic devices (CIEDs) at our institution, a long-standing high flow referral center for cardiomyopathies.
Methods
Clinical and instrumental data of HCM patients implanted with CIEDs (either pacemakers [PM] or implantable cardioverter defibrillator [ICD]) from 1998 to 2019 were retrospectively reviewed. Inclusion criteria were site-designated diagnosis of HCM, age at diagnosis >18 years, >1 follow up visit, follow up >1 year. HCM phenocopies (e.g. Fabry disease) were carefully excluded.
Patients were divided into three categories according to presence of AF (“AF prior to CIED implantation” vs “AF after CIED implantation” vs “no arrhythmia detected”). Outcome was measured against prevalence of thromboembolic events (stroke or transient ischemic attack [TIA]) at follow up. All-cause and cardiovascular (CV) mortality were also assessed.
Results
A total of 255 patients received a CIED (57% men, mean age at implantation 54±17 years). Men were younger at implantation (52±17 vs 56±18 years, p=0.022). At baseline, AF was present in 90 (35.3%) patients.
During 5.0±4.1 years, de novo AF was detected in 30 (11.8%) individuals, resulting in an annual incidence rate of 6.1%/year. Overall, 135 (52.9%) of patients remained is sinus rhythm.
Stroke/TIAs were reported in 30 (11.8%) patients: 16 (53.3%) occurred in patients with prior history of AF, 3 (10%) in patients with de novo AF (with men being at higher risk, OR 3.73, 95% CI 1.88–6.09, p=0.041), and 11 (36.7%) in patients with no history of arrhythmias.
Long term, 45 (17.6%) patients died (CV mortality N=38, 14.9%). At multivariable analysis, history of stroke was directly related to all-cause mortality irrespective of AF in men (OR 4.15, 95% CI 1.35–12.77, p=0.018) but not in women (OR 0.891, 95% CI 0.17–4.64, p=0.801).
Conclusions
In a large cohort of consecutive high risk HCM patients referred to CIED implantation, the incidence of de-novo AF was high. Thromboembolic events were associated to worse outcome only in men, likely due to competing heart failure related causes in women. Strategies promoting early identification of AF and anticoagulation may play an important role in management and prevention of disease-related complications.
Prevalence of AF and Stroke
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- C Fumagalli
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - R Ruggieri
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - V De Filippo
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - F Cappelli
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - M Beltrami
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - A Bertini
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - G Carrassa
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - A Marchi
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - A Tomberli
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - K Baldini
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - I Olivotto
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
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Argiro A, Sciagra R, Marchi A, Beltrami M, Spinelli E, Bianchi A, Mascalchi M, Olivotto I, Salvadori E, Pescini F. Coronary microvascular function is impaired in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL; OMIM 125310) is a rare inherited disease, caused by NOTCH3 gene mutations. Main clinical manifestations of CADASIL include recurrent subcortical ischemic events, migraine, cognitive impairment and psychiatric disturbances. CADASIL is a systemic microangiopathy and cardiac involvement has been observed in a series of Dutch patients, presenting higher frequency of myocardial infarction compared to non-mutated relatives and general population. In particular, electron microscopic examination of myocardial tissue of a study participant demonstrated CADASIL characteristics.
We sought to investigate the relationship between CADASIL and microvascular dysfunction (MVD).
Seventeen patients with genetically-confirmed CADASIL, aged <60 years, with ≤1 cardiovascular risk factor (current smoke, diabetes, hypertension, dyslipidemia), recent (<3 months) neurological evaluation with neuropsychological tests and 3 Tesla brain magnetic resonance imaging (MRI) underwent 12-lead ECG, echocardiography, and measurement of maximal myocardial blood flow following Regadenoson infusion (Reg-MBF) by 13NH3positron emission tomography (PET), to investigate the presence of coronary microvascular dysfunction (CMD). Coronary flow reserve (CFR) was defined as Reg-MBF/resting MBF. PET results were compared to those of 15 healthy controls matched for age and sex recruited among a historical cohort of healthy patients. The study was approved by the institutional review board and all the subjects gave informed consent.
Mean age was 40±9 years (range 28–57 years); 6 patients (35%) were male. One was a current smoker and 3 ex-smokers; 1 patient was on aspirin, 1 on acetazolamide and 2 on escitalopram, none was taking statins. 12 patients (71%) presented with migraine, 9 (53%) had psychiatric disturbances and 1 (6%) had a previous stroke. Brain MRI showed mild-moderate and severe leukoencephalopathy in 11 (65%) and 5 (29%) patients respectively, lacunes were present in 14 patients and microbleeds in 1; one patient had normal findings. Both Reg-MBF and CFR were blunted in CADASIL patients compared with controls (Reg-MBF 2.46±0.54 versus 3.09±0.44 ml/gr/min respectively, p<0.001; CFR 2.74±0.36 vs. 3.28±0.66, respectively, p<0.01). In 3 male patients (17%), CFR reduction was severe (<2). Segmental Reg-MBF analysis of left ventricular flow showed diffuse hypoperfusion, excluding preferential regional involvement. No correlations were found between Reg-MBF values and neuropsychological performance or cerebral lesion burden, suggesting that neurological and cardiac involvement might be independent in CADASIL.
These data represent the first documentation of coronary microvascular involvement in a group of young and mildly symptomatic CADASIL patients, confirming the systemic nature of the disease. This proof of concept study expands our understanding of genetically-driven CMD.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- A Argiro
- Careggi University Hospital (AOUC), Florence, Italy
| | - R Sciagra
- Careggi University Hospital (AOUC), Florence, Italy
| | - A Marchi
- Careggi University Hospital (AOUC), Florence, Italy
| | - M Beltrami
- Careggi University Hospital (AOUC), Florence, Italy
| | - E Spinelli
- Careggi University Hospital (AOUC), Florence, Italy
| | - A Bianchi
- Careggi University Hospital (AOUC), Florence, Italy
| | - M Mascalchi
- Careggi University Hospital (AOUC), Florence, Italy
| | - I Olivotto
- Careggi University Hospital (AOUC), Florence, Italy
| | - E Salvadori
- Careggi University Hospital (AOUC), Florence, Italy
| | - F Pescini
- Careggi University Hospital (AOUC), Florence, Italy
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Ciabatti M, Fumagalli C, Beltrami M, Vignini E, Martinese L, Tomberli A, Zampieri M, Bertini A, Carrassa G, Marchi A, Berteotti M, Cappelli F, Bolognese L, Pieroni M, Olivotto I. Prevalence, causes and predictors of cardiovascular hospitalization in patients with hypertrophic cardiomyopathy. Int J Cardiol 2020; 318:94-100. [DOI: 10.1016/j.ijcard.2020.07.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/24/2020] [Accepted: 07/23/2020] [Indexed: 12/16/2022]
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Zampieri M, Beltrami M, Fumagalli C, Dei L, Urban L, Emmi G, Marchi A, Carrassa G, Chiriatti C, Tomberli A, Baldini K, Olivotto I. Eosinophilic granulomatosis with polyangiitis, a new recurrent feature in an extremely rare disease. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Eosinophilic granulomatosis with polyangiitis (EGPA) is an extremely rare necrotizing vasculitis affecting small- and medium-sized vessels. EGPA may affect the heart leading to myocardial inflammation and necrosis. Although, only a few cardiological based studies have been conducted.
Purpose
This study aimed to investigate the prevalence and clinical impact of cardiac-specific involvement (CSI+) and to give an update on EGPA cardiological manifestations.
Methods
This is a single-centre study. Cardiological evaluation included ECG, blood test, echocardiography, global longitudinal strain (GLS), cardiac magnetic resonance (CMR).
Results
We prospectively enrolled 52 consecutive EGPA patients, between October 2018 and October 2019, mean age 59±3 years, 30 (57%) female. We identified 13 (25%) CSI+ patients: 6 myocarditis, 2 pericarditis, 1 coronaritis, 1 Prinzmetal angina, 2 LV apical thrombosis, 1 unexplained wall motions abnormalities (WMA) in the absence of coronary artery disease.
Twelve-leads ECG revealed abnormalities in 11 (85%) CSI+ vs 9 (23%) CSI−, p=0.0001; ECG abnormalities identified CSI+ with 85% sensitivity, 77% specificity, 94% negative predictive value.
Median troponin level in CSI+ 9 ng/L (IQR 6–11) vs CSI− 11 ng/L (IQR 6–25), p=0.2548; NT-pro-BNP value in CSI+ 210 pg/L (IQR 175–484) vs CSI− 159 ng/L (IQR 66–299), p=0.0576.
Echocardiographic left ventricular end diastolic volume in CSI+ 62±4 ml/m2 vs CSI− 52±1 ml/m2, p=0.0116; LV ejection fraction in CSI+ 57%±2 vs CSI− 66%±1, p=0.0002. In CSI+ patients GLS was −15±1 vs CSI− GLS −21±0.4, p<0.0001. Echocardiography identified WMA in 8 (61%) CSI+ vs 1 (3%) CSI−. In 7 (54%) CSI+ patients, apical segments showed WMA and among them 5 demonstrated the presence of apical aneurysm.
Twelve patients underwent CMR, it showed non ischaemic late gadolinium enhancement in 7 patients; in 5 patients we identified akinetic or dyskinetic segments without associated LGE. Two patients showed LV apical thrombus.
Conclusions
EGPA showed a high prevalence of CSI. We repeatedly found a tropism for apical involvement in WMA that often manifested themselves as apical aneurysm. These may be a new clinical feature, previously not described, in such a rare condition.
Cardiac involvement EGPA
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- M Zampieri
- Careggi University Hospital (AOUC), Florence, Italy
| | - M Beltrami
- Careggi University Hospital (AOUC), Florence, Italy
| | - C Fumagalli
- Careggi University Hospital (AOUC), Florence, Italy
| | - L Dei
- Careggi University Hospital (AOUC), Florence, Italy
| | - L Urban
- Careggi University Hospital (AOUC), Florence, Italy
| | - G Emmi
- Careggi University Hospital (AOUC), Florence, Italy
| | - A Marchi
- Careggi University Hospital (AOUC), Florence, Italy
| | - G Carrassa
- Careggi University Hospital (AOUC), Florence, Italy
| | - C Chiriatti
- Careggi University Hospital (AOUC), Florence, Italy
| | - A Tomberli
- Careggi University Hospital (AOUC), Florence, Italy
| | - K Baldini
- Careggi University Hospital (AOUC), Florence, Italy
| | - I Olivotto
- Careggi University Hospital (AOUC), Florence, Italy
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Marquis A, Zhuang J, Marra G, Zhao X, Calleris G, Kan Y, Beltrami M, Huang H, Oderda M, Zhang Q, Faletti R, Wang W, Molinaro L, Bergamasco L, Guo H, Gontero P. Outcomes and predictors of pain in transperineal free-hand mpMRI fusion-targeted biopsies under local anesthesia: A multicenter study of 1,008 patients. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)35389-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Marra G, Zhuang J, Beltrami M, Marquis A, Zhao X, Calleris G, Kan Y, Oderda G, Huang H, Faletti R, Zhang Q, Molinaro L, Wang W, Bergamasco L, Guo H, Gontero P. Outcomes and predictors of pain in men undergoing transperineal free-hand mpMRI fusion-targeted biopsies under local anesthesia: A multicenter prospective study of 1008 patients. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)34169-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Calleris G, Marra G, Zhuang J, Beltrami M, Zhao X, Marquis A, Kan Y, Oderda M, Greco A, Zitella A, Bisconti A, Huang H, Faletti R, Zhang Q, Molinaro L, Falcone M, Cappuccelli S, Wang W, Barale M, Giordano A, Agnello M, Guo H, Gontero P. Transperineal free-hand mpMRI targeted prostate biopsies under local anesthesia: A preliminary analysis of learning curves. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)34179-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Marra G, Zhuang J, Beltrami M, Calleris G, Zhao X, Marquis A, Kan Y, Oderda M, Huang H, Faletti R, Zhang Q, Molinaro L, Tappero S, D’Agate D, Wang W, Bergamasco L, Guo H, Gontero P. Do we need addition of systematic cores when performing transperineal mpMRI targeted biopsy under local anesthesia? Results of a multicenter prospective study of 1,014 cases. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)32666-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Marra G, Zhuang J, Beltrami M, Marquis A, Zhao X, Calleris G, Kan Y, Oderda M, Huang H, Faletti R, Zhang Q, Molinaro L, Wang W, Bergamasco L, Guo H, Gontero P. Pain in men undergoing transperineal free-hand mpMRI fusion-targeted biopsies under local anesthesia: Outcomes and predictors from a multicenter study of 1008 patients. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)34176-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Marra G, Zhuang J, Beltrami M, Calleris G, Zhao X, Marquis A, Kan Y, Oderda M, Huang H, Faletti R, Zhang Q, Molinaro L, Wang W, Bergamasco L, Tappero S, D’Agate D, Guo H, Gontero P. Transperineal free-hand mpMRI fusion targeted biopsies under local anesthesia for prostate cancer diagnosis: A multicenter prospective study of 1,014 cases. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)34177-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Fumagalli C, Fedele E, Beltrami M, Maurizi N, Passantino S, Targetti M, Arretini A, Baldini K, Tomberli A, Mazzarotto F, Coppini R, Ferrantini C, Cecchi F, Poggesi C, Olivotto I. P1243Comparison of long-term clinical course and outcome of MYBPC3 - versus MYH7 - related hypertrophic cardiomyopathy. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
The presence of sarcomere mutations is a powerful predictor of heart failure-related outcomes in Hypertrophic Cardiomyopathy (HCM). However, whether the prevalence of left ventricular (LV) dysfunction differs in patients with mutations in the two most prevalent HCM-associated genes (i.e. MYBPC3 and MYH7) is unclear.
Purpose
To ascertain lifetime trends in prevalence of LV dysfunction in HCM associated with pathogenic or likely-pathogenic MYBPC3 versus MYH7 mutations.
Methods
Clinical and instrumental records of 402 HCM patients with MYBPC3 (N=251) or MYH7 (N=151) mutations were retrospectively reviewed. Presence of systolic dysfunction (ejection fraction [EF] <50%) and diastolic dysfunction (Grade II and III) were assessed for each patient. In vitro analysis of septal myectomy samples was performed to further compare electro-mechanic properties of MYBC3 and MYH7 patients.
Results
Patients were diagnosed at a mean age of 39±17 years and 63% were men. At first evaluation MYBPC3-HCM patients were less frequently obstructive (15% vs 26% in MYH7; p=0.005) and had lower LVEF (61±11% vs 64±9%; p=0.01). Prevalence of diastolic dysfunction increased with age and was lowest in MYBPC3 patients <40 years at diagnosis (19.5% vs 35.4% in MYH7, p=0.043). At a mean follow-up (FU) of 13±11 years, patients developed comparable left atrium enlargement (MYBPC3 52±29 ml/m2 vs 41±18 at baseline, p<0.001; MYH7 54±25ml/m2 vs 45±22, p=0.003). Prevalence of diastolic dysfunction was also similar. MYBPC3 patients had lower LVEF at final evaluation (61±11% vs 64±9% in MYH7, p=0.01) with greater prevalence of overt systolic dysfunction (EF<50%, MYBPC3 vs MYH7: 15% vs 5%, OR: 2.3 95% CI: 1.2–5.8, p=0.013).
No significant differences were observed in terms of NYHA class change, atrial fibrillation, stroke, heart failure, appropriate ICD intervention or cardiovascular death. However, prevalence of NSVT was higher for MYBPC3 (39% vs 14% in MYH7, p<0.0001). At Cox multivariable analysis independent predictors of systolic dysfunction at follow-up were MYBPC3 positive status (HR 2.53 95% CI: 1.09–5.82, p=0.029) and age at initial evaluation (HR 1.03 95% CI 1.00–1.06, p=0.027).
In vitro cross-sectional evaluation of myocardial samples taken during septal myectomy at different ages showed a decline in contraction-relaxation properties after age 40 in MYPBC3 carriers, but preserved function in MYH7 patients (Figure).
Kinetic of myosin cross-bridges
Conclusions
In HCM patients, mutations in the MYBPC3 gene and early diagnosis are associated with slowly progressing systolic impairment leading to overt dysfunction in 15% compared to 5% in MYH7-HCM. However, outcome was similar in the two subsets. These differences in lifetime myocardial performance between the two most common HCM-associated genes suggest diverse pathways of disease progression, potentially amenable to requiring different molecular approaches.
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Affiliation(s)
- C Fumagalli
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - E Fedele
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - M Beltrami
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - N Maurizi
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - S Passantino
- Meyer Children's Hospital, Cardiology Department, Florence, Italy
| | - M Targetti
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - A Arretini
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - K Baldini
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - A Tomberli
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - F Mazzarotto
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
| | - R Coppini
- University of Florence, Florence, Italy
| | | | - F Cecchi
- IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
| | - C Poggesi
- University of Florence, Florence, Italy
| | - I Olivotto
- Careggi University Hospital (AOUC), Cardiomyopathies Unit, Florence, Italy
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Beltrami M, Fumagalli C. Heart failure with preserved ejection fraction in elderly. From pathophysiology to treatment: an unresolved problem. Monaldi Arch Chest Dis 2019; 89. [DOI: 10.4081/monaldi.2019.1026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 05/20/2019] [Indexed: 11/23/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) has a significant impact on healthcare resources and while its occurrence in the elderly is increasing, its prognosis has not improved. Despite the prevalence of HFpEF, the understanding of its pathophysiology is still incomplete, and optimal treatment remains largely undefined. The net clinical benefit of medical treatment with ACE inhibitors, ARBs, MRAs and beta-blockers has led to the incorporation of these drugs into HF clinical practice guidelines. However, little or no progress has been done for patients with HFpEF and there are no convincing and validated therapies able to reduce mortality or morbidity. HFpEF is a heterogeneous clinical syndrome embracing varieties of phenotypes and could benefit from a phenotype-specific approach. In the era of precision medicine, targeted approaches have proved effective in various disciplinary medical settings and for this reason this modern approach should be encouraged also in cardiology. In elderly patients, multi-level strategies and interventions aimed at improving adherence to guidelines and tailoring therapy, could be the key to improving outcome, and to reducing costs related to HF-related re-admissions. In the present review we briefly discuss current information available regarding pathophysiology, outcome, treatment and safety of the most common drugs used in this “geriatric syndrome”.
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Beltrami M, Palazzuoli A, Padeletti L, Cerbai E, Coiro S, Emdin M, Marcucci R, Morrone D, Cameli M, Savino K, Pedrinelli R, Ambrosio G. The importance of integrated left atrial evaluation: From hypertension to heart failure with preserved ejection fraction. Int J Clin Pract 2018; 72. [PMID: 29283475 DOI: 10.1111/ijcp.13050] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/29/2017] [Indexed: 12/28/2022] Open
Abstract
AIM Functional analysis and measurement of left atrium are an integral part of cardiac evaluation, and they represent a key element during non-invasive analysis of diastolic function in patients with hypertension (HT) and/or heart failure with preserved ejection fraction (HFpEF). However, diastolic dysfunction remains quite elusive regarding classification, and atrial size and function are two key factors for left ventricular (LV) filling evaluation. Chronic left atrial (LA) remodelling is the final step of chronic intra-cavitary pressure overload, and it accompanies increased neurohormonal, proarrhythmic and prothrombotic activities. In this systematic review, we aim to purpose a multi-modality approach for LA geometry and function analysis, which integrates diastolic flow with LA characteristics and remodelling through application of both traditional and new diagnostic tools. METHODS The most important studies published in the literature on LA size, function and diastolic dysfunction in patients with HFpEF, HT and/or atrial fibrillation (AF) are considered and discussed. RESULTS In HFpEF and HT, pulsed and tissue Doppler assessments are useful tools to estimate LV filling pressure, atrio-ventricular coupling and LV relaxation but they need to be enriched with LA evaluation in terms of morphology and function. An integrated evaluation should be also applied to patients with a high arrhythmic risk, in whom eccentric LA remodelling and higher LA stiffness are associated with a greater AF risk. CONCLUSION Evaluation of LA size, volume, function and structure are mandatory in the management of patients with HT, HFpEF and AF. A multi-modality approach could provide additional information, identifying subjects with more severe LA remodelling. Left atrium assessment deserves an accurate study inside the cardiac imaging approach and optimised measurement with established cut-offs need to be better recognised through multicenter studies.
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Affiliation(s)
- Matteo Beltrami
- Cardio-Thoracic and Vascular Department, University of Florence, Florence, Italy
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Alberto Palazzuoli
- Department of Internal Medicine, Cardiovascular Diseases Unit, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | | | - Elisabetta Cerbai
- Department of NeuroFarBa, C.I.M.M.B.A., University of Florence, Florence, Italy
| | - Stefano Coiro
- Division of Cardiology, University of Perugia School of Medicine, Perugia, Italy
| | - Michele Emdin
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Center for Atherothrombotic diseases, University of Florence, Florence, Italy
| | - Doralisa Morrone
- Surgery, medicine, molecular and critical area Department, Cardiovascular disease Section 2, Pisa, Italy
| | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Ketty Savino
- Division of Cardiology, University of Perugia School of Medicine, Perugia, Italy
| | - Roberto Pedrinelli
- Department of Surgery, Medical, Molecular, and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine, Perugia, Italy
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Beltrami M, Ruocco G, Ibrahim A, Lucani B, Franci B, Nuti R, Palazzuoli A. Different trajectories and significance of B-type natriuretic peptide, congestion and acute kidney injury in patients with heart failure. Intern Emerg Med 2017; 12:593-603. [PMID: 28181125 DOI: 10.1007/s11739-017-1620-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 01/25/2017] [Indexed: 01/29/2023]
Abstract
The exact relationship existing among congestion status, brain natriuretic peptide (BNP) changes and acute kidney injury (AKI) has not been elucidated in patients with acute heart failure (AHF). The aims of this study are: to investigate the relation and prognostic role of BNP, AKI and clinical congestion after discharge; to define the exact BNP cut off value or a BNP in-hospital reduction to identify patients with higher risk during vulnerable post-discharge phase. We consecutively enrolled 157 patients with a diagnosis of AHF. BNP and creatinine were measured in all patients, and degree of failure was assessed. AKI was defined as a creatinine increase ≥0.3 mg/dL or eGFR reduction ≥20% during hospitalization. All patients were followed for 1 and 3 months. Of 146 included patients, 110 patients (75%) displayed effective decongestion, 116 (79%) showed a BNP decrease ≥30%, and 28 (19%) developed in-hospital AKI. BNP in-hospital decrease ≥30% was found more often in patients who showed good decongestion in comparison to patients in persistent failure (63 vs 22%; p < 0.001). The ROC curve analyses at 3 months show that both BNP reduction of 30% between admission and discharge and decongestion at discharge identifies patients with a reduced incidence of cardiovascular events (AUC = 0.79, confidence interval 0.68-0.90, sensibility 90%, sensitivity 50% p < 0.001). Kaplan-Meier survival plots show a better outcome in patients with a BNP decrease ≥30% and good decongestion at discharge (p = 0.03). BNP reduction in AHF is associated with decongestion. BNP reduction associated with decongestion at discharge is a favorable prognostic indicator at 90-day survival irrespective of the AKI occurrence.
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Affiliation(s)
- Matteo Beltrami
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Gaetano Ruocco
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Aladino Ibrahim
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Barbara Lucani
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Beatrice Franci
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Ranuccio Nuti
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy.
- Department of Internal Medicine and Metabolic Diseases, Cardiology, Le Scotte Hospital, Viale Bracci, 53100, Siena, Italy.
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Sassone B, Bertini M, Beltrami M, Malagù M, Pasanisi G, Kuwornu HA, Avigni N, Fucà G, Pacchioni F, Minarelli M, Bacchi Reggiani ML, Padeletti L. Relation of QRS Duration to Response to Cardiac Resynchronization Therapy in Patients With Left Bundle Branch Block. Am J Cardiol 2017; 119:1803-1808. [PMID: 28391991 DOI: 10.1016/j.amjcard.2017.02.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/17/2017] [Accepted: 02/17/2017] [Indexed: 11/16/2022]
Abstract
Left ventricular (LV) dyssynchrony (LVdys) is a necessary condition for successful cardiac resynchronization therapy (CRT). Despite left bundle branch block (LBBB) representing a reliable surrogate of LVdys, not all LBBB patients will respond to CRT. Our aim was to investigate the relation between QRS duration and LVdys in patients with LBBB who underwent CRT. We retrospectively studied 165 patients with LBBB who underwent CRT implantation according to the current guidelines. A 6-month reduction of LV end-systolic volume ≥15% identified responders to CRT. Baseline LVdys was defined as the delay between peak systolic velocities of the interventricular septum and lateral wall assessed by color-coded tissue Doppler imaging. Baseline characteristics of responders (61%) and nonresponders (39%) were comparable except for larger QRS complex (172 ± 24 vs 160 ± 16 ms, p <0.001) and lower degree of LVdys (46 ± 42 vs 72 ± 31 ms, p <0.001) in nonresponders. Receiver-operating characteristic curve analysis demonstrated that an optimal cut-off value of 3 for the ratio of QRS duration and LVdys (QRS/LVdys) yielded a sensitivity of 66% and specificity of 80% to predict nonresponsiveness to CRT; QRS/LVdys >3 remained an independent predictor at multivariate analysis. In patients with nonischemic origin of cardiomyopathy, the linear regression analysis documented a significant inverse relation between QRS duration and LVdys, as dyssynchrony progressively decreased as QRS widening increased (p = 0.006). This was not evident in patients with ischemic origin. In conclusion, in LBBB patients with nonischemic origin and marked QRS widening, the absence of LVdys may account for a lower response to CRT compared with patients with intermediate QRS widening.
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Affiliation(s)
- Biagio Sassone
- Department of Cardiology, SS.ma Annunziata Hospital, Azienda Unità Sanitaria Locale Ferrara, Cento, Ferrara, Italy; Department of Cardiology, Delta Hospital, Azienda Unità Sanitaria Locale Ferrara, Lagosanto, Ferrara, Italy.
| | - Matteo Bertini
- Department of Cardiology, S. Anna Hospital, University of Ferrara, Cona, Ferrara, Italy
| | - Matteo Beltrami
- Careggi Hospital, Institute of Internal Medicine and Cardiology, University of Florence, Florence, Italy
| | - Michele Malagù
- Department of Cardiology, S. Anna Hospital, University of Ferrara, Cona, Ferrara, Italy
| | - Giovanni Pasanisi
- Department of Cardiology, Delta Hospital, Azienda Unità Sanitaria Locale Ferrara, Lagosanto, Ferrara, Italy
| | - Helene Afi Kuwornu
- Department of Cardiology, Delta Hospital, Azienda Unità Sanitaria Locale Ferrara, Lagosanto, Ferrara, Italy
| | - Nicola Avigni
- Department of Cardiology, Delta Hospital, Azienda Unità Sanitaria Locale Ferrara, Lagosanto, Ferrara, Italy
| | - Giuseppe Fucà
- Department of Cardiology, SS.ma Annunziata Hospital, Azienda Unità Sanitaria Locale Ferrara, Cento, Ferrara, Italy
| | - Federico Pacchioni
- Department of Cardiology, SS.ma Annunziata Hospital, Azienda Unità Sanitaria Locale Ferrara, Cento, Ferrara, Italy
| | - Monica Minarelli
- Department of Cardiology, SS.ma Annunziata Hospital, Azienda Unità Sanitaria Locale Ferrara, Cento, Ferrara, Italy
| | | | - Luigi Padeletti
- Careggi Hospital, Institute of Internal Medicine and Cardiology, University of Florence, Florence, Italy; IRCCS Multimedica, Milan, Italy
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Fumagalli S, Pieragnoli P, Ricciardi G, Mascia G, Mascia F, Michelotti F, Mascioli G, Beltrami M, Padeletti M, Nesti M, Marchionni N, Padeletti L. Cardiac resynchronization therapy improves functional status and cognition. Int J Cardiol 2016; 219:212-7. [DOI: 10.1016/j.ijcard.2016.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/07/2016] [Indexed: 01/08/2023]
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Menti C, Beltrami M, Possan AL, Martins ST, Henriques JAP, Santos AD, Missell FP, Roesch-Ely M. Biocompatibility and degradation of gold-covered magneto-elastic biosensors exposed to cell culture. Colloids Surf B Biointerfaces 2016; 143:111-117. [PMID: 26998872 DOI: 10.1016/j.colsurfb.2016.03.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/17/2016] [Accepted: 03/10/2016] [Indexed: 11/29/2022]
Abstract
Magneto-elastic materials (ME) have important advantages when applied as biosensors due to the possibility of wireless monitoring. Commercial Metglas 2826MB3™ (FeNiMoB) is widely used, however sensor stabilization is an important factor for biosensor performance. This study compared the effects of biocompatibility and degradation of the Metglas 2826MB3™ alloy, covered or not with a gold layer, when in contact with cell culture medium. Strips of amorphous Metglas 2826MB3™ were cut and coated with thin layers of Cr and Au, as verified by Rutherford Backscattering Spectroscopy (RBS). Using Inductively Coupled Plasma-Optical Emission Spectrometry (ICP-OES), the presence of metals in the culture medium was quantitatively determined for up to seven days after alloy exposure. Biocompatibility of fibroblast Chinese Hamster Ovary (CHO) cultures was tested and cytotoxicity parameters were investigated by indirect means of reduction of MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) at 1, 2 and 7 days. Cell death was further evaluated through in situ analysis using Acridine Orange/Ethidium Bromide (AO/EB) staining and images were processed with ImageJ software. Ions from Metglas(®) 2826MB3™ induced a degradation process in living organisms. The cytotoxicity assay showed a decrease in the percentage of live cells compared to control for the ME strip not coated with gold. AO/EB in situ staining revealed that most of the cells grown on top of the gold-covered sensor presented a normal morphology (85.46%). Covering ME sensors with a gold coating improved their effectiveness by generating protection of the transducer by reducing the release of ions and promoting a significant cell survival.
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Affiliation(s)
- C Menti
- Laboratório de Genômica, Proteômica e Reparo de DNA, Instituto de Biotecnologia, Universidade de Caxias do Sul, Brazil
| | - M Beltrami
- Laboratório de Caracterização Magnética, CCET, Universidade de Caxias do Sul, Brazil
| | - A L Possan
- Laboratório de Caracterização Magnética, CCET, Universidade de Caxias do Sul, Brazil
| | - S T Martins
- Laboratório de Genômica, Proteômica e Reparo de DNA, Instituto de Biotecnologia, Universidade de Caxias do Sul, Brazil
| | - J A P Henriques
- Laboratório de Genômica, Proteômica e Reparo de DNA, Instituto de Biotecnologia, Universidade de Caxias do Sul, Brazil
| | - A D Santos
- Instituto de Física, Universidade de São Paulo, São Paulo, SP, Brazil
| | - F P Missell
- Laboratório de Caracterização Magnética, CCET, Universidade de Caxias do Sul, Brazil
| | - M Roesch-Ely
- Laboratório de Genômica, Proteômica e Reparo de DNA, Instituto de Biotecnologia, Universidade de Caxias do Sul, Brazil.
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Beltrami M, Ruocco G, Dastidar AG, Franci B, Lucani B, Aloia E, Nuti R, Palazzuoli A. Additional value of Galectin-3 to BNP in acute heart failure patients with preserved ejection fraction. Clin Chim Acta 2016; 457:99-105. [DOI: 10.1016/j.cca.2016.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/23/2016] [Accepted: 04/06/2016] [Indexed: 12/11/2022]
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Bertolini E, Macchioni P, Beltrami M, Bassi F, Marani B, Salvarani C, Catanoso M. FRI0411 A Cross Sectional Study of The Clinical and Ultrasound Entheseal Involvement in Patients with IBD. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.4203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Palazzuoli A, Beltrami M, Ruocco G, Franci B, Campagna MS, Nuti R. Diagnostic utility of contemporary echo and BNP assessment in patients with acute heart failure during early hospitalization. Eur J Intern Med 2016; 30:43-48. [PMID: 26718066 DOI: 10.1016/j.ejim.2015.11.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 10/20/2015] [Accepted: 11/30/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND The use of B-type natriuretic peptide (BNP) and echocardiography in acute heart failure (AHF) diagnosis is poorly employed in the Emergency Department. The aim of the present study is to evaluate relation among BNP levels systolic and diastolic dysfunction during early phases of AHF hospitalization. METHODS We performed contemporary echocardiographic and BNP assessment in 310 patients with AHF within 12h since hospital admission. We studied the correlation among BNP and degree of diastolic dysfunction evaluated by pulsed Doppler transmitral flow and Tissue Doppler flow. Finally we investigated the relation among BNP and the right systolic longitudinal ventricular function (TAPSE) and the systolic pulmonary arterial pressure (PAPs). RESULTS BNP levels were 1417±1126, 1081±955, 894±901pg/mL, for patients with EF≤25%, EF 25-40% and EF 40-50% (p=0.005), respectively. "BNP levels linearly correlate with the degree of diastolic dysfunction: 582±406pg/mL in altered relaxation pattern, 712±557pg/mL in pseudonormal pattern and 1694±805 in restrictive filling pattern (p<0.001 for all patterns)." BNP levels were significantly increased in patients with right systolic ventricular dysfunction (TAPSE<18mm; p=0.006) and in patients with PAPs≥40mmHg (p=0.001). ROC curve and logistic regression analysis highlighted the power of BNP to detect severe systolic dysfunction, right ventricular (RV) overload and dysfunction and diastolic dysfunction patterns. CONCLUSIONS BNP levels correlate linearly with LV systolic dysfunction as well as with impaired degree of diastolic dysfunction. Significant PAP increase is a further factor influencing BNP elevation in patients with AHF during early hospitalization phase.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiology Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital Siena, University of Siena, Italy.
| | - Matteo Beltrami
- Cardiology Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital Siena, University of Siena, Italy
| | - Gaetano Ruocco
- Cardiology Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital Siena, University of Siena, Italy
| | - Beatrice Franci
- Cardiology Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital Siena, University of Siena, Italy
| | - Maria Stella Campagna
- Cardiology Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital Siena, University of Siena, Italy
| | - Ranuccio Nuti
- Cardiology Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital Siena, University of Siena, Italy
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Beltrami M, Palazzuoli A, Ruocco G, Aspromonte N. The predictive value of plasma biomarkers in discharged heart failure patients: the role of plasma BNP. Minerva Cardioangiol 2016; 64:147-156. [PMID: 26474369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
To date, heart failure (HF) prognosis is still difficult: symptoms and signs are often non-specific, and poor sensitive indicators for HF severity. Brain natriuretic peptide (BNP) is now included in the current guidelines for HF diagnosis, management and risk assessment because of its high specificity and sensibility. BNP became a first-line exam in HF patients' evaluation at hospital admission together with clinical and chest X-ray. In discharged patients, the prognostic role of BNP is associated with decongestion and its significant reduction compared to admission level appears one of the best outcome predictors. In fact BNP measurement could identify patients with increased risk of adverse events and left ventricular remodeling. Although a single BNP value assay and the absolute value during hospitalization is related to the prognosis, especially at discharge. On the other hand, hormone levels could be influenced by several factors (i.e., renal dysfunction, anemia, age, liver insufficiency, Body Mass Index) independently from systemic and pulmonary congestion. Therefore, a new approach which considers a multimodality strategy including BNP assay among the traditional clinical examination and imaging studies should be routinely encouraged to better define cardiac dysfunction's etiology and severity, as well as to recognize patients at risk of adverse outcome.
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Affiliation(s)
- Matteo Beltrami
- Cardiology Unit, Department of Internal and Surgical Medicine, Le Scotte Hospital, University of Siena, Italy -
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