bluuebunny/crossref_metadata_2025 huggingface dataset:
YOUNG WOMAN WITH LEFT VENTRICULAR DYSFUNCTION AND MITRAL LAMBL EXCRESCENCE: WHAT TO DO WHEN ISCHEMIC STROKE IS RECURRENT?
Authors: Facchini E , Maffè S , Ticozzi S , Paffoni P , Prenna E , Ariotti S , Bergamasco L , Franchetti Pardo N , Paino A , Dellavesa P
Published: May 2024

Lambl excrescence describing rare cardiac growths that develop at the valvular coaptation sites of the heart which are seen as a thin, hypermobile and filiform strand on an echocardiogram. These filiform strands can be noted in association with embolic stroke. Also heart failure (HF) and stroke frequently coexist because of an overlap of shared risk factors and subsequent mechanisms and a higher risk of stroke is present also in HF patients in sinus rythm (SR). The clinical case concerns a 54–year–old woman. In March 2020 she was admitted for ischemic stroke by occlusion of middle cerebral artery subjected to thrombolysis and mechanical thromboctomy. Electrocardiogram showed SR and left branch block. Echocardiogram and echocardiogram transesophageal showed left ventricular (LV) dysfunction (EF 40%) withouth clear presence of emboligen sources. Thrombophilic screening and neurological checks were negative. Single antiaggregant therapy has been started. New hospitalization in October 2023 for recurrent ischemic stroke. Echocardiogram showed worsening of LV dysfunction (EF 20%). Transesophageal echocardiogram showed the presence of a filiform filament on the mitral leaflets on the atrial side (Fig 1) without the presence of intracavitary thrombi. Coronary TC angiography (Fig 2) was negative. Cardiac magnetic resonance (Fig 3) confirmed reduced ejection fraction and showed subepicardial late gadolinium enhancement in lateral wall. There are no clear evidence–based guidelines for the treatment of Lambl excrescences. When associated with stroke, an exhaustive stroke workup to identify the potential cause of stroke should always be undertaken. If the workup remains negative without any identifiable cause, then the patients can be treated with antiplatelet agents such as aspirin and clopidogrel or anticoagulation with warfarin. Also the indication to antithrombotic strategies in patients with HF, SR and stroke is controversial. There are no data to support a routine strategy of anticoagulation in patients with HF with LV dysfuncion in SR who do not have history of paroxysmal atrial fibrillation (ESC 2022 HF guidelines). So which therapy to start in young patient, with recurrent strokes, heart failure /severe LV dysfunction and mitral lambl excrescence? Oral anticoagulant? Double platelet antiaggregation? Oral anticoagulant and single platelet antiaggregation? Definitely the choice is not simple but we decided to start warfarin and continue follow–up.
CLINICAL BENEFITS OF ADVANCED ALGORITHMS IN HEART FAILURE MANAGEMENT IN PATIENTS UNDERGOING CARDIAC CONTRACTILITY MODULATION DEVICE IMPLANTATION
Authors: Floris R , Demontis M , Orru F , Marongiu M , Casula M , Sirigu F , Pippia V , Mule M , Delogu G
Published: May 2024

Introduction

A 71–year–old man, diagnosed with primary dilated cardiomyopathy and severe left ventricular dysfunction (LVDTD 60 mm, LVEF 20%), exhibited normal right ventricular function (RVDTD 36 mm, TAPSE 21 mm, RV S’ TDI 11 cm/s), and moderate mitral regurgitation. In early 2019, he was hospitalized for heart failure and underwent the implantation of a biventricular defibrillator for primary prevention, activating a multiparametric algorithm for heart failure management. At discharge, maximal pharmacological therapy was confirmed. Since September 2022, the heart failure synthetic index exceeded the critical threshold, reaching a value of 17, triggering a remote monitoring alert necessitating an increase in diuretic therapy. Despite a few months of clinical stability, in December 2022, he reported a progressive reduction in functional capacity, confirmed by an increase in the heart failure index.

Diagnosis and Management

Due to the onset of NYHA class III symptoms in February 2023, the patient was hospitalized. An echocardiogram revealed a continuous decline in right ventricular function (TAPSE 12 mm, RV S’ TDI 6 m/s). He underwent four biweekly infusions of Levosimendan, resulting in a transient clinical improvement. In March 2023, a device for modulating cardiac contractility was implanted without acute complications (Fig.1). Two months post–implantation, a progressive improvement in clinical conditions was observed, accompanied by a gradual decline in the heart failure index returning to baseline values (Fig.2). The echocardiogram showed stable left systolic function and a significant improvement in right ventricular functional indices (Fig.3). Since May 2023, the patient has not required Levosimendan infusion, maintaining a stable NYHA class II.

Conclusion

Cardiac contractility modulation proves to be an effective method in managing heart failure, reducing symptoms, and preventing hospitalizations. Improved patient management is evident with reduced volumes and enhanced contractile capacity of the right ventricle. The use of advanced algorithms integrated with defibrillation devices allows for the assessment of the method‘s efficacy even remotely
SGLT2i IN THE REAL WORLD: DATA FROM THE PONTE (bridge) HF PROJECT (PDTA FOR INTEGRATED TERRITORY HOSPITAL FOLLOW-UP OF PATIENTS WITH HEART FAILURE)
Authors: De Gennaro L , Grande D , Bulzis G , Carbonara R , Cataneo L , Correale M , De Masi De Luca G , Di Stolfo G , Ferraretti A , Galgano G , Gioia M , Leone M , Malerba L , Marazia S , Minielli V , Petruzzi P , Potenza A , Lamacchia O , Iacoviello M , Caldarola P
Published: May 2024

Background

Over the last few years, treatment with sodium glucose cotransporter 2 inhibitors (SGLT2i) dapaglifozin and empaglifozin was shown to reduce the combined risk of cardiovascular death and/or hospitalization for heart failure (HF) among patients with heart failure with reduced ejection fraction. Subsequent RCTs have demonstrated similar reduction in the combined endpoint also in patients with left ventricular ejection fraction (LVEF) >40%. Nevertheless, real world data on the current state of implementation of SGLT2i therapy in HF clinical practice are scarce.

The aim of the study was therefore to evaluate the impact of SGLT2i treatment in a real world population of HF patients.

Methods

527 consecutive patients with HF, treated with SGLT2i and with 6 months of follow-up already enrolled in the PONTE (PDTA FOR THE INTEGRATED FOLLOW-UP IN THE HOSPITAL TERRITORY OF THE PATIENT WITH HEART FAILURE) HF project, a care model implemented in Puglia region (Italy) based on hospital-territory integration aimed at the optimized management of patient with HF after hospitalization, were considered for the study.

Demographic, clinical, laboratory and instrumental characteristics, changes in NYHA class, creatinine, NT-proBNP, medications, LVEF after initiation of therapy with SGLT2i were evaluated.

Results

The 527 enrolled patients (mean age of 67,40 years, 75% hypertensive, 39% diabetic, 51% ischemic heart disease, 52% with ICD, 35% with atrial fibrillation) were in NYHA class I in 3,2% of cases, class II in 56,6%, class III in 38,5%, class IV in 1,7%. Mean LVEF was 34,20% (63% of patients had LVEF <35%), NT-proBNP 2606,86 pg/ml, creatinine 1,19 mg/dl. 95,1% of patients was on treatment with beta-blockers, 52,7% with ACE inhibitors, 55,1% with ARNI.

After a follow-up of 6 months, a reduction of patients in NYHA classes III+IV from 40,2 to 19,0% as well as an increase in patients in classes I+II from 59,8 to 81,0% (NYHA I increasing from 3,2 to 14,6%) were observed. Furthermore, mean LVEF increased from 34,20 to 37,68% and patients taking loop diuretics reduced from 83,9 to 77,4%. Creatinine remained stable (1,19 vs 1,21 mg/dl), while NT-proBNP lowered from 2606,86 to 1603,32 pg/ml.

Conclusions

Our real world data on SGLT2i in HF patients seem to confirm the efficacy of this class of drugs in a short term follow-up, with a positive effect on symptoms (improvement in NYHA class and fewer patients taking loop diuretics), NT-proBNP and LVEF.
IMPROVE THE EFFECTIVENESS OF PREDICTIVE MODELS FOR LENGTH OF HOSPITAL STAY (LOS) BY ADDING ELECTRONIC HEALTH RECORDS DATA: A RETROSPECTIVE STUDY IN PATIENTS WITH HEART FAILURE
Authors: Cocchieri A , Cesare M , Magliozzi E , Damiani G
Published: May 2024

Background

Length of hospital stay (LOS) is considered a key process that has a clinical, economic, and organizational impact representative of the quality of care. In particular, in patients with heart failure (HF), which is a life–threatening multifactorial syndrome and a major public health problem, when a prolonged LOS (PLOS) occurs, frequent readmission and high mortality are common, with worrying consequences for health systems. Although the LOS is often explained by standard medical data (e.g., comorbidities), it may depend on many other patient characteristics. Therefore, considering additional elements collected in electronic health records (EHRs) could be crucial to predict the occurrence of a LOS and correctly estimating this risk. The aim of this study is to demonstrate the predictive power of clinical and organizational data collected through an EHR on LOS in HF patients.

Methods

A descriptive, retrospective study was conducted in an Italian university hospital. Data related to HF inpatients consecutively admitted across 1 year were collected from the hospital’s HER. PLOS was defined as a stay ≥ 14 days. Sociodemographic data, administrative data, and clinical data (such as the number of active medical problems, the number of medications, frailty, and nursing dependency), were tested in a predictive model as potential determinants of LOS.

Results

A total of 608 HF patients were included. The mean age of patients was 76 ± 13.06 years (range: 23–102); 61.5% were male. Prolonged LOS was found in 25.2% of patients. The univariable linear regression model explained 10.2% of LOS variance. Being female, living without social support, having an increased number of previous admissions and nursing dependency, being dependent on functional status, having a worse behavior pattern and mobility, and experiencing a sensory deficit were significant determinants (p < .05) of LOS.

Conclusion

The inclusion of EHRs data in addition to clinical variables, can help clinicians and researchers to improve the predictive ability on LOS, ensuring its early identification and ultimately enhancing the patients’ health outcomes through the implementation of targeted interventions.
SARS–COV2 INFECTIONS IN HEART TRANSPLANT RECIPIENTS: VACCINES STILL ARE OUR GREATEST WEAPON
Authors: Tedeschi A , Ammirati E , Garascia A , Palazzini M , Masciocco G , Gentile P , Monticelli M , Leidi F
Published: May 2024

Long–term clinical follow–ups are needed to assess the effectiveness of vaccine and booster doses against severe acute respiratory syndrome coronavirus 2 (SARS–CoV2) infection for heart transplant (HT) recipients, particularly in an epidemiological landscape characterized by rapidly changing viral variants. Among patients who received HT at Niguarda Hospital from January 2008 to March 2022, we compared the clinical outcomes of those who developed SARS–CoV2 infection between March 2020 and January 2023, according to their vaccination status (vaccinated Vs unvaccinated). Of 377 patients, 98 (25,9%) developed SARS–CoV2 infection during the study period. 24 (27.5 %) developed infection before receiving the vaccination, whilst 74 (75,5%) almost after 2 weeks from receiving the first dose. The unvaccinated cohort demonstrated a higher incidence of death, pneumonia, requiring of oxygen supplementation, non–invasive and invasive ventilation therapy. Furthermore, we assess an additional protective effect against mortality offered from booster doses. Vaccine administration in HT patients is associated with a lower rate of death and severe disease, particularly in those patients who received one or two booster doses.
POOR IN–HOSPITAL CONGESTION IMPROVEMENT IN ACUTE HEART FAILURE PATIENTS CLASSIFIED ACCORDING TO LEFT VENTRICULAR EJECTION FRACTION: PROGNOSTIC IMPLICATIONS
Authors: Ruocco G , Girerd N , Rastogi T , Lamiral Z , Palazzuoli A
Published: May 2024

Background

Residual congestion in acute heart failure (AHF) is related to poor prognosis. However, we lack data on the prognostic value of changes in a combined assessment of in–hospital congestion. We sought evaluated the association of in–hospital congestion changes with subsequent prognosis according to LVEF classification.

Methods

Patients (N=244, 80.3±7.6 years, 50.8% male) admitted for acute HF in 2 European tertiary care centers underwent clinical assessment, echocardiography, lung ultrasound (LUS) ultrasound and natriuretic peptides (NP) measurement at admission and discharge. The primary outcome was the composite of All–cause mortality and/or HF re–hospitalization.

Results

In the 244 considered patients (95 HfrEF, 57 HFmrEF and 92 HFpEF), limited improvement in clinical congestion score (Hazard ratio 2.33, 1.51 to 3.61, p=0.0001), NP levels (2.29, 1.55 to 3.38, p<0.0001) and B–lines count (6.44, 4.19 to 9.89, p<0.001), had significnatly higher risk of outcome compared to patients experiencing more sizeable decongestion. The same pattern of association was observed when adjusting on confounding factors. A limited improvement in clinical congestion score and B–lines count was related to poor prognosis in all LVEF categories.

Conclusions

In AHF, the degree of congestion reduction assessed over the in–hospital stay period, can stratify the subsequent event risk. Limited improvement in both clinical congestion and B–lines count are related to poor prognosis irrespectively of LVEF.
QRS INDEX TO PREDICT CARDIAC RESYNCHRONIZATION THERAPY RESPONSE: A TRICENTRIC STUDY
Authors: Madaudo C , Coppola G , Mascioli G , D‘Ardia G , La Greca C , Prezioso A , Corrado E
Published: May 2024

Background

Several studies have evaluated the role of QRS duration (QRSd) or QRS narrowing as a predictor of response to cardiac resynchronization therapy (CRT) to reduce non–responders.

Purpose

The aim of our study was to determine the correlation between the relative change in QRS narrowing index (QI) compared to clinical outcome and prognosis in patients who underwent CRT implantation.

Methods

A three–center study involving 398 patients with a CRT device was conducted. Clinical variables, echocardiographic parameters and drug therapies, QRS duration before and after CRT implantation, and QRS index (QI) were measured.

Results

In a six–month follow–up, a significant improvement in left ventricle ejection fraction (EF), left ventricle end–diastolic and systolic volumes (LVEDV and LVESV) were observed. QI was significantly related to reverse remodelling (r = +0.22; 95% CI: 0.11 to 0.32, p= 0.001) and the cut–off value that best predicted LV reverse remodelling was 12.25% (AUC 0.7, p=0.001). At 24 months, a statistically significant difference was found between patients with a QI < 12.25% and those with a QI > 12.25%, regarding NYHA class worsening (p= 0,04). The mean of the QI of patients who died from cardiovascular causes was lower than patients who died of other causes (p=0,0179). A correlation between pre–CRT QRSd/LVEDV and QI was observed (r = +0.20; 95% CI: 0.09 to 0.30, p=0.0003). A higher QRSd/LVEDV ratio was associated with an improved LVEF, LVEDV, LVESV (p <0.0001) at follow–up.

Conclusions

QI narrowing after CRT was related to greater echocardiographic reverse remodelling and lower rate of adverse events. The QI can improve adverse events’ prediction in a population with CRT regardless of comorbidities according to the Charlson Comorbidity index. QI could be used to predict CRT response.
THE NURSING MANAGEMENT OF THE PATIENT WHO HAS UNDERGONE CORONARY ANTIOPLASTY
Authors: Lazzerini C
Published: May 2024

Coronary angiography consists of selective angiography of the coronary arteries obtained invasively. Coronary angioplasty (PTCA) consists of the mechanical reperfusion of the coronary arteries via a stent in patients with acute myocardial infarction (AMI). How is a patient who has undergone angioplasty surgery managed from a nursing point of view? In the immediate post–operative period the patient is transferred from the operating room to the inpatient department, subsequently the electrocardiogram is performed and the vital parameters are recorded, immediately afterwards the patient will be subjected to cardiac monitoring and must maintain bed rest. The patient undergoing angioplasty has mechanical compression on the right radial artery (in most cases) which will need to be managed by the nurse. Radial compression is necessary to allow the radial artery to heal the wound caused during the angioplasty procedure. The nurse will have to manage the compression of the radial artery by loosening it two hours after the end of the operation; subsequently, after two hours have passed since the compression has been loosened, it can be removed, after the wound has been carefully assessed by the nurse, there must therefore be no moaning present and the radial pulse must be appreciable. After 6/8 hours the post–PTCA blood sample must be performed, which includes the following blood tests: creatinine and troponin. The patient will have to maintain cardiac monitoring for a few days, he will begin to mobilize, and control blood tests will be performed in the following days. The role of the nurse has a great importance in terms of educating the patient on a healthy lifestyle once discharged. It is important to correctly explain to the patient what interventions to adopt to achieve a healthy lifestyle.
THE EFFICACY OF VERY LOW CALORIE KETOGENIC DIET (VLCKD) ON CARDIO–METABOLIC PROFILE IN PATIENTS WITH OBESITY
Authors: Trapanese V , Natale M , Vatalaro C , Giofrè F , Melina M , Cosentino F , Donato U , Armentaro G , Sciacqua A , Cloro C , Arturi F
Published: May 2024

Background

Obesity is associated with alterations in cardiac structure and haemodynamics leading to cardiovascular mortality and morbidity. Very low calorie ketogenic diet (VLCKD) has been proposed as an effective intervention to achieve a significant weight loss in obese patients in a short time period. Furthermore, hyperketonemia induced by VLCKD is associated with beneficial cardiovascular effects. In addition, ketogenic diet is able to prevent mitochondrial fission, improve mitochondrial function, suppress oxidative stress and attenuate cardiac myocytes apoptosis in the heart of mice.

Aim

To evaluate the role of VLCKD on cardio–metabolic risk factors, cardiac dysfunction and myocardial remodelling in obese patients.

Materials and Methods

Ten obese patients treated with VLCKD were enrolled. All patients were characterized from an anthropometric, cardio–metabolic and echocardiographic point of view at baseline and 8 weeks after VLCKD treatment. In addition, each patient underwent measurement of global myocardial work efficiency (GWE), a novel indicator that accounts for deformation and afterload, which may provide additional value for assessment of myocardial function. The insulin resistance (IR) was evaluated by HOMA–IR.

Results

As expected, all the patients showed a significant reduction in body weight and an overall improvement of body composition parameters after VLCKD. Weight (kg) (from 105.1 ± 18.2 to 83.7 ± 16.7, P <0.05), BMI (kg/m2) (from 40.1 ± 4.7 to 31.8 ± 4.8, P= 0.002) and waist circumference (cm) (from 115 ± 13.6 to 101.8 ± 12.4, p < 0.05) were significantly lower after VLCKD treatment. VLCKD treatment improved also significantly fasting glucose levels (P <0.05), fasting insulin levels (P =0.004), HOMA–IR values (P <0.001), lipid profile and systolic and diastolic blood pressure levels. In addition, the echocardiogram evaluation showed an improved in end–diastolic left ventricular volume, end–systolic left ventricular volume, left ventricular mass and left ventricular mass index. Interestingly, a significantly changes in GWE was observed (P<0.05).

Conclusion

Although preliminary, our data suggest that VLCKD treatment is able to reduce cardio–metabolic risk factors and to improve cardiac dysfunction and myocardial function.
TELECUORE: FEASIBILITY OF A HOSPITAL–TERRITORIAL TELEMEDICINE PROJECT IN CHRONIC HEART FAILURE
Authors: Matrone B , Novara P , Di Spigno F , Tedeschi A , Concetta S , Lisè G , Ballerio N , Auletta T , Pisati M , Aschieri D
Published: May 2024

Background

Since February 2023, Cardiology department of AUSL Piacenza has started a telemedicine project named “TeleCuore,” aimed at exploring the impact of a multiparametric telemonitoring system on the management of patients affected by chronic heart failure (CHF). OBJECTIVES assess organizational sustainability, satisfaction among involved figures, and the clinical impact at 9 months of an extensive telemonitoring project targeting patients with CHF.

Materials and Methods

250 patients with CHF and recent clinical instability were recruited and equipped with the Adilife device to monitor and transmit weight, temperature, blood pressure, heart and respiratory rate, oxygen saturation, and single–lead ECG. These data are managed by case manager (CM), cardiologists, respiratory and perfusion pathophysiology technicians (TFCPC), general practitioner to optimize patient therapy, empowerment, and reduce acute admissions through timely teleconsultations/televisits. Every 6 months, patients are asked to complete a Quality of Life questionnaire (KCCQ–23) and a satisfaction questionnaire regarding the project, which is also administered to healthcare professionals.

Results

Over 9 months, positive patient engagement is confirmed, with over 92,000 total transmitted measurements. The most monitored parameter is heart rate (4 times/week). At questionnaire analysis, 80% of patients believes TeleCuore helps them remember parameter measurements, and 70% adopt a correct lifestyle through phone conversations with CM. For over 50%of them the project contributes improving their relationship with healthcare professionals. For 90%of healthcare professionals there is better team collaboration and patient education. Both clinicians and patients (100%) believe that TeleCuore improves the effectiveness of follow–up visits: patients arrive more prepared (30%), and staff can dedicate more time to patients (30%) and access information before the visit (10%). The patients KCCQ score varies from a medium of 71 at baseline to a medium of 78 at 6 months analisys.

Conclusions

TeleCuore project demonstrates that telemedicine can facilitate patient management and empowerment. Professional figures (CM and TFCPC) are crucial for project execution, working alongside clinical cardiologists for proper alert management, patient education on therapy adherence, and correct lifestyle. An ongoing analysis aims to quantify whether TeleCuore can reduce hospitalizations related to acute heart failure.
THE OUTPATIENT CLINIC FOR PATIENTS WITH HEART FAILURE: A PROPOSAL FOR ADVANCED NURSING
Authors: Gastaldello C
Published: May 2024

In Italy, Heart Failure represents the leading cause of hospitalization in people over the age of sixty–five and is considered a public health problem of enormous importance, as it entails disabling consequences for the person, such as a significant reduction in the quality of life and the degree of self–sufficiency. Therefore, the person with heart failure requires adequate nursing care in each phase of transition from one care setting to another, as well as in the phase that goes from hospital discharge to the patient‘s return to the home. In the European Guidelines dedicated to Heart Failure it is not specified whether there is a nursing management assistance program dedicated to patients, and if present as it is declined in the various healthcare contexts. The aim of the thesis was to explore in the literature and in the national territory if there are advanced nursing care programs aimed at patients with heart failure and to develop the idea of ​​a nursing–managed clinic, where advanced nursing, which can be introduced into the integrated hospital–community care network for heart failure. For this purpose, a qualitative exploratory survey was developed, divided into two phases: a telephone exploratory survey which considered the cardiological clinics of all the Health Authorities of the Veneto Region and two other Italian Regions; a semi–structured interview addressed to a group of nurses who in the past managed a nursing clinic dedicated to patients with heart failure in a healthcare company in the Veneto Region. The results, especially from the literature review, showed a significant reduction in the risk of hospital readmission and in the mortality rate, an increase in the quality of life. However, differences emerged in the local context regarding the objectives, organization and activity of a Nursing Clinic dedicated to patients with heart failure. The challenge still remains open.
THE HF–ABCDE+FG APPROACH IN HEART FAILURE: A SIMPLIFIED DECISION– MAKING ALGORITHM FOR MANAGEMENT IN EMERGENCY DEPARTMENT
Authors: Pepe G , Vignani M , Casolo G , Sanna M , Ghiadoni L
Published: May 2024

The–HF– ABCDE+FG protocol is an easy to memorize algorithm for diagnosis and treatment of Heart failure (HF) in the setting of Emergency Department (ED). The acronym “ABCDE” recalls the more famous ABCDE sequence proposed in Advanced Life Support (ALS), the most widely used and standardized approach to critical patients in the ED. Using a similar approach, the algorithm here proposed can help to recall the main elements of the patient’s assessment presenting acute heart failure (AHF) concerning diagnosis and early therapy. It should be interpreted as a continuum since each step is partially overlapped and mnemonically linked to the previous and to the next one. As Acute heart failure can present with a variable pattern of signs and symptoms, diagnosis in the Emergency Department can be supported by a rapid and easy to memorize pathway made up of 5 steps: A (history assessment), B (blood exams/ blood gas analysis), C (Chest X–Ray), D (Dysfunction– lung anch heart ultrasound), E (Electricity– verify ICD or PM when implanted). On the other hand, with reference to the therapeutic algorithm, we suggest an extended protocol ABCDE+FG: each word of the acronym stands for a Class I recommendation coming from 2021 ESC Guidelines: A (ACE–i/ ARBs/ARNI), B (standing for Beta–Blockers), C (anti–choagulation) and D (Diuretics) which represent the standard desease–controlling therapy. In addiction, attention must be paid to associated conditions, like underlying electrical instability requiring PM or ICD (E standing for Electrical Therapy), iron deficiency (F standing for Ferric Carboxymaltose) and poor glycemic control (G standing for Glyfozines). In fact, it has been demonstrated that an optimyzed therapy from a very early stage can deeply impact on the evolution of desease and remarkably reduce further accesses for AHF. Thus, once the patient has been stabilyzed in the ED, we suggest to initiate the most appropriate therapy as soon as possible and eventually send the patient to the best setting of care (discharge, short observation, non intensive/intensive care).
A CASE OF DUAL–SITE LEFT VENTRICULAR PACING PERFORMED VIA A PERSISTENT LEFT SUPERIOR VENA CAVA IN A PATIENT WITH COMPLETE ATRIO–VENTRICULAR BLOCK AND RIGHT SUPERIOR VENA CAVA OCCLUSION
Authors: Quilico F , Sanzo A , Vicentini A , Vicini Scajola L , Savastano S , Baldi E , Petracci B , Rordorf R
Published: May 2024

Patient

A 64 year old male admitted for syncope. EKG presented 3rd degree AV block. Attempting to place temporary pacemaker was unsuccessful due to occlusion of the right femoral vein and the presence of a catheter for hemodialysis in the left femoral vein. He also has complete thrombosis of the right internal jugular vein, proximal superior vena cava and right femoral vein. He was referred to ICCU for monitoring, asymptomatic with no signs of congestion or hypoperfusion. Dopamine was started at 4 mcg/kg/min and then isoprenaline 0.06 mcg/kg/min. Initial work up Echocardiography showed depressed LV ejection fraction (LVEF 40%). Chest and abdomen angio–CT showed persistence of a superior left vena cava (PSLVC), which drained in the coronary sinus (CS). Right axillary and subclavian veins were occluded, and also right superior vena cava and right jugular vein. Left jugular, axillary and subclavian veins were pervious. Left femoral and right iliac–femoral veins showed significantly narrowing of the vessel lumen.

Diagnosis and Management

Our indication for this patient was CRT rather than RV pacing. The implant of a leadless AV pacemaker was also considered, but it was considered unfeasible due to limited access from the femoral veins. The presence of a PSLVC cava draining into CS was confirmed with angiography in the EP Lab. At the beginning of the procedure two episodes of asystole occurred. A first bipolar lead was rapidly placed in a postero–lateral branch of the CS, to obtain a stable temporary pacing. We then placed a quadripolar, active fixation, left ventricular pacing lead via the PSLVC into an antero–lateral branch of the CS. Finally, we placed a right atrium active fixation pacing lead in the right atrium again through the PSLVC. Vascular accesses were cephalic left vein and axillary vein. Acceptable sensing and pacing parameters were achieved. The bipolar LV lead was connected to the IS–1 RV port for sensing and the quadripolar lead was connected to the IS–4 LV port for pacing. Programming was DDDR 60–130 with active LV pacing only. Total procedural time was 180 minutes. No complications occurred. At discharge electric parameters were stable. Echocardiography showed an improvement in LVEF (45% vs 40%) and ECG showed atrio–ventricular LV pacing.

Conclusion

As far as we know this is the first reported case of a CRT delivered by two left ventricle pacing leads both placed via a PLSVC, with no need to place a pacing lead in the right ventricle.
RESIDUAL CARDIOVASCULAR RISK AND SEVERITY OF CORONARY DISEASE
Authors: Marino G , Spinelli A , Macchiusi A , Altamura V , Di Fusco S , Aquilani S , Aiello A , Colivicchi F
Published: May 2024

Background

The presence of residual risk in patients with a history of atherosclerotic cardiovascular disease (ASCVD) is a cause of additional cardiovascular events. The aim of this study is to correlate residual cardiovascular risk with the severity of coronary disease.

Methods

We enrolled 52 patients hospitalized with a diagnosis of acute coronary syndrome from September to October 2023 at the Clinical and Rehabilitation Cardiology of the San Filippo Neri Hospital. All patients were treated with percutaneous and/or surgical coronary revascularization and had a history of ASCVD. Thirty of these patients had a single–vessel coronary disease and 22 had a multivessel coronary disease. We analyzed the main cardiovascular risk factors and the received therapies in both groups.

Results

Triglyceride levels were significantly higher in the group with a multivessel coronary disease (132.94 ± 65.41 mg/dl vs 94.06 ± 37.63 mg/dl; p=0.01) as well as the levels of glycated hemoglobin (50.91 ± 15.23 mmol/mol vs 42.92 ± 6.65 mmol/mol; p=0.01) and high–sensitivity C–reactive protein (hs–CRP, 1.25 ± 1.48 mg/dl vs 0.65 ± 0.46 mg/dl; p=0.04). We found no significant differences between the two groups for the other main cardiovascular risk factors and the therapies.

Conclusions

Our data show that higher levels of triglycerides, glycated hemoglobin and hs–CRP, an inflammatory biomarker, are associated with a more extensive coronary disease. This finding suggests that a better metabolic control, in terms of glycated hemoglobin and triglyceride levels, and inflammation could contribute to the reduction of coronary disease extension.
TREATMENT OF OBESITY WITH SGLT–2: OUR RESULTS
Authors: Fazio G
Published: May 2024

SGLT–2 inhibitors were indicated to be able to reduce the weight of diabetic patients for around 4 kilograms. We investigated the possibility to reduce the weight of non–diabetic patients using SGLT–2.

Materials and Methods

A continuous series of 402 patients were enrolled in a prospective analysis. All patients started a therapy with SGLT–2 inhibitor for a cardiological (80%) or nephrological disease (20%). The 54% used dapagliflozin while the 46% used empagliflozin. In all patients affected by chronic heart failure the SGLT–2 – Inhibitor was added to optimal medical therapy without new symptoms in ambulatory. In nephrological patients the drug was added after a complete stabilization of disease. The recruitment period was long 6 months. After the recruitment the patient was follow for other 6 month. At the end of the follow–up, we evaluated the weight lost. The result was evaluated by an electrical balance, that was the same for all evaluations. The data was collected in excel and analysed by the Q–R–Calc program.

Results

The mean age of patients was 63 age, 54% female. None was diabetic patients. Hypertension was present in 73%, hypercholesterolemia in 43%. 11% was smokers. 94% were Caucasian patients. The mean of Weight was 75 kg at the first control. The mean height 174 cm. All patients performed a cardiological o nephrological control in which the medical doctor prescribed SGLT–2 inhibitor on top the optical medical therapy. All patients that presented during this control some causes of instability were excluded from the analysis. 90% of patients assumed RAAS inhibitors (ARNI 23%), 81% betablockers, 54% diuretics, 68% MRA. About the subtype of heart failure 60% was HFpEF and 40% HFrEF. The mean GFR of nephrological patients was 31 l/min. After 6 month the mean weight loss was 5,2 kgs with a standard deviation of 3,1 kgs. The reduction of weight was 6.6% of the initial weight. No statistical differences were evaluated comparing empagliflozin and dapagliflozin.

Conclusion

The SGLT–2 inhibitor in non–diabetic patients was. able to determinate a weight lost of 6.6% (mean 5,2).
ROLE OF VERY LOW DOSE STATIN THERAPY IN PCSK9 INIB. TREATED PATIENTS
Authors: Gentile G , Bentivoglio F , De Carlini C , Meles E , Gorgoglione M , Bucalo R , Bruni F , Masiello L , Maggiolini S
Published: May 2024

Female patient 62 years old Cardiovascular risk factors: Arterial hypertension, smoking, obesity, dyslipidemia, hypercholesterolemia, family history of cardiovascular diseases (father who died from miocardial infarction (MI) and brother with 3 MI). Intolerance to various statins (myalgia) Non–critical atherosclerosis of the supra–aortic trunks. Therapy with PCSK9 inib. started. (evolocumab 140 mg every 2 weeks). Subsequently the patient suffers from acute coronary syndrome (NSTEMI). CACG: fusiform aneurysm of proximal left anterior descending artery (LAD) The new LDL target to be reached < 55 mg/dl is far from the value achieved with the co–administration of PCSK9 inib. and ezetimibe (minimum LDL value reached with this therapy 123 mg/dl) Even with a certain time delay it was decided to introduce a statin at an extremely low dose (rosuvastatin 5 mg 3 times a week). The effect of this strategy is very effective, allowing a reduction in LDL by over 50% and up to a value of 60 (only slightly higher than the target value). However, the patient again suffers from myalgia (without an increase in CPK) and decides to suspend treatment with a new increase in LDL values to 112 mg/dl. The case emphasizes: 1) the synergistic effect of statin with PCSK9 inhibitor therapy. This synergy is already evident with extremely low doses of statin and should always be sought 2) the usefulness of an aggressive drug therapy that tends to bring LDL values within the therapeutic targets in the shortest possible time. Moreover this could highlight intolerances that make it impossible to continue with a specific therapeutic scheme so as to allow the study of new options.
PROGNOSTIC VALUE OF FOLLOW–UP MEAN PULMONARY ARTERIAL PRESSURE AND PULMONARY VASCULAR RESISTANCE IN PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION REACHING A LOW–RISK PROFILE
Authors: Dardi F , Cennerazzo F , Guarino D , Ballerini A , Donato F , Bertozzi R , Manes A , Palazzini M , Galiè N
Published: May 2024

Background

Hemodynamic variables such as right atrial pressure, cardiac index (CI), stroke volume index (SVI), and mixed venous oxygen saturation have consistently been associated with survival in pulmonary arterial hypertension (PAH). New PAH treatments are, however, able to improve short–term outcome reducing mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR) without increasing CI or SVI. The prognostic role of a mPAP <35 mmHg at follow–up and PVR values <5 WU in prevalent patients have been described.

Objective

The aim of this work was to define the incremental prognostic role of a mPAP <35 mmHg and PVR <5 WU in patients with idiopathic, hereditary, drug–induced PAH (I/H/D–PAH) and PAH associated with connective tissue disease (CTD–PAH) or congenital heart disease (CHD–PAH) reaching a low–risk profile at follow–up after first–line treatment strategy.

Methods

treatment naïve PAH patients were assessed at 1st follow–up (3–6 months after starting PAH–specific therapy; 1st F–UP) with 6–minute walk distance (6MWD), World Health Organization functional class (WHO–FC), brain natriuretic peptide (BNP)/NT–proBNP and right heart catheterization. Risk was assessed according to COMPERA 1.0, FPHR–invasive, Bologna and COMPERA 2.0 risk tools. The primary outcome was all–cause death and a combined endpoint of all cause death + need of treatment escalation. Analyses were performed using Cox regression method in patients reaching a low–risk at 1st F–UP. Data are expressed as median (IQR).

Results

794 patients with PAH were enrolled (54% I/H/D, 28% CTD, 18% CHD) and 706 have a complete re–evaluation 4 (3–6) months after starting first–line treatment. Death occurred in 54% of patients over a median follow–up duration of 5.8 (2.4–11) years. Univariate analyses for all–cause death in patients reaching a low–risk profile at 1st F–UP are shown in Table 1. Univariate analyses for all cause death + need of treatment escalation, together with the initial treatment strategy and the median time from 1st F–UP to death/need of treatment escalation in patients reaching a low–risk profile at 1st F–UP are shown in Table 2.

Conclusion

mPAP <35 mmHg and PVR <5 WU are not of incremental prognostic value for all–cause death in patients reaching a low–risk profile at 1st F–UP after first–line treatment strategy but predict the need of future treatment escalation (after a median time >3 years).
HEART DISEASE IN MICROGRAVITY: THE ROLE OF MICROGRAVITY IN METABOLIC PROCESSES IN MYOCARDIOCYTES
Authors: Giacinto O , Luisini M , Sammartini E , Sammartini D , Minati A , Mastroianni C , Nenna A , Pascarella G , Carassiti M , Chello M , Pelliccia F
Published: May 2024

Objective

Aim of this review is to examine the main molecular patterns alterations during and after exposure to microgravity and find a common molecular stream that may describe the aetiological processes that lead to atrophy of the heart.

Methods

We found 113 articles, and we included 25 studies that investigated physiological effects of weightlessness and artificial gravity in the space flight in animal cardiac muscle cells, in particular the modifications of the protein structure in the absence of gravity.

Result

Microgravity, through methylation on CpG island of the DNA reduces the gene expression of alpha–actinin–1, DNA methyltransferase–1. These molecular values were normal after 12 hours of microgravity suspension, while Histone deacetylase–1 (HDCA–1) resulted up regulated. With regard to cardiogenesis, we noted a reduction in fibronectin, an extracellular matrix glycoprotein that has a role in primordial heart formation to lead to mesodermal migration and differentiation, and in desmosomes which have a particular role in chemical communication between myofibrils; furthermore, an altered displacement of the myofibrils, an alteration of the geometry of these structures and a consequent reduction in cardiac mechanics were noted.Microgravity determines a downregulation of the AC/ cyclic adenosine monophosphate (cAMP) phosphodiesterase system and a secondary dysfunction of the Ca2+ channel; an increase in the levels of the protein Calpain –2 as contributing stressor to myocardial damage is considered an atrophy predisposing risk factor; this protein determines an increase calcium ions and a consequent cardiac remodeling, depression of the ejection fraction and apoptosis of cardiac cells.Another pathological molecular mechanism that leads to alteration of myocardial fibers inotropism is a shift of alpha– Myosin heavy chain to beta– Myosin heavy chain and consequent synthesis of altered titin molecules and a depressed actin/myosin ATPase function.

Conclusion

This review showed molecular patterns role in determining a low performance of the heart caused by a reduction on eject fraction and cardiac atrophy especially after long space flight, due to Microgravity as main risk factor. Future studies are needed to find farmacological and/or molecular approaches to treat these biochemical changes in order to interrupt the chain that leads to a flight and post flight cardiovascular syndromes.
SODIUM–GLUCOSE COTRANSPORTER 2 INHIBITOR DAPAGLIFLOZIN REDUCES SYSTEMIC H–FABP AND MONOCYTE–TO–LYMPHOCYTE RATIO IN PRECLINICAL MODELS OF ANTRACYCLINE INDUCED CARDIOTOXICITY
Authors: Quagliariello V , Bisceglia I , Iovine M , Giacobbe I , Maurea F , Giordano V , Barbato M , Arianna R , Izzo F , Canale M , Paccone A , Maurea N
Published: May 2024

Background

Anthracyclines are an effective and widely used chemotherapy agent in the treatment of multiple solid organ tumors and hematologic malignancies. The use of anthracyclines as a standard cancer therapy is limited by the potential for the development of cardiac dysfunction, arrhythmias, and clinical heart failure. Dapagliflozin exerts several cardiometabolic benefits in patients with and wthout T2DM through SGLT2–NLRP3 mediated pathways.

Purpose

In this study, we highlighted on new beneficial properties of Dapagliflozin in preclinical models of doxorubicin–induced cardiotoxicity.

Methods

Female C57Bl/6 mice were untreated (Sham, n=6) or treated for 10 days with doxorubicin i.p at 2.17 mg/kg (DOXO, n=6), DAPA at 12 mg/kg (DAPA, n=6) or doxorubicin combined to DAPA (DOXO–DAPA, n=6). After treatments, plasma levels of H–FABP and monocyte–to–lymphocyte ratio were determined through selective quantitative methods.

Results

Dapagliflozin associated to Doxorubicin reduces of 48,7% plasma levels of H–FABP compared to DOXO group (p<0.001). Myocardial expression of H–FABP were also reduced, indicating cardioprotective properties of SGLT2i. Moreover, monocyte–to–lymphocyte ratio was strongly enhanced after DOXO therapy, indicating systemic pro–inflammatory properties; notably, Dapagliflozin reduced of 32,8% the monocyte–to–lymphocyte ratio compared to only DOXO treated mice (p<0.005).

Conclusion

For the first time, Dapagliflozin demonstrated a significant reductions of monocyte–to–lymphocyte ratio during doxorubicin therapy, indicating new potential pathways of cardioprotection in cancer patients.
THE ROLE OF ADVANCED NON–INVASIVE CARDIAC IMAGING IN THE DIAGNOSIS AND THE MANAGEMENT OF ACUTE CHEST PAIN IN WOMEN
Authors: Dell‘Aversana F , Tedeschi C , Ferrandino G , Tuccillo A , Scotto di Uccio F , Tuccillo B , Liguori C
Published: May 2024

Over the last years the awareness of gender differences in cardiovascular disease has gradually increased. Gender differences can be highlighted in the spectrum of clinical manifestations of ischemic cardiovascular disease in women and in the higher incidence in female sex of specific pathologies such as Takotsubo Syndrome (TTS), myocardial infarction without significant coronary obstruction (MINOCA) and Spontaneous coronary artery dissection (SCAD). Advanced cardiac imaging is gaining a relevant role also in the acute patient scenario and it can allows the identification of the pathologies that can most frequently cause acute chest pain in women. We included 102 female patients admitted to our emergency department with acute chest pain who underwent advanced cardiac imaging examinations. 72 women had Cardiac Magnetic Resonance Imaging (CMR) for acute myocardial injury after excluding Acute Coronary Syndrome (ACS). 30 women underwent Coronary Computed Tomography Angiography (CCTA) for suspected ACS with low or intermediate risk of Coronary Artery Disease (CAD). In 25/72 patients undergoing CMR was found an ischemic pattern: 19 (26.4%) patients received a diagnosis of myocardial infarction with associated afferent coronary obstruction, in 5 (7%) patients the diagnosis was compatible with MINOCA and in 1 case (4%) the diagnosis of aborted heart attack was made. A non–ischemic pattern was found in 37 patients: 12 (16.7%) patients were diagnosed with Takotsubo Syndrome, 21 (29.2%) patients were affected by myocarditis and 4 (5.5%) patients had signs of pericarditis. In 10 (13.8%) cases CMR was negative. Of the 30 patients who underwent CCTA, 11 (36.7%) had normal coronary arteries, 9 (30%) had non–obstructive CAD (stenosis <50%), 8 (26.6%) had obstructive CAD (stenosis >50%) and 2 (6.6%) patients were diagnosed with SCAD. According to our experience, CMR can play a central role in the diagnosis and management of non–coronary ischemic heart disease which typically affects women. In fact, in females the etiopathogenesis of myocardial ischemia is much more complex and heterogeneous than in males, making non–invasive cardiac imaging decisive to identify the underlying causes of acute chest pain. Furthermore, the use of CCTA as a first–instance diagnostic test in an acute scenario allows us to improve the diagnosis of clinically significant CAD and to adequately direct the therapeutic process.
THE IMPACT OF DISOPYRAMIDE ON EXERCISE CAPACITY IN HYPERTROPHIC CARDIOMYOPATHY: IT IS NOT ALL ABOUT RELIEVING OBSTRUCTION
Authors: Dei L , Ciacci P , Giacalone G , Nardecchia G , Albi F , Sciarra L , Romano S , Gabrielli D , Halasz G , Re F
Published: May 2024

Introduction

Disopyramide has been extensively utilized since the late 1980s to decrease obstruction and improve symptoms in patients with obstructive hypertrophic cardiomyopathy (oHCM). Nevertheless, there is currently no evidence about the impact of this drug on functional capacity assessed with cardiopulmonary exercise test (CPET).

AIM

To investigate the impact of disopyramide on functional capacity and peak exercise gradient, assessed by CPET combined with stress echocardiography (Imaging–CPET).

Methods

21 disopyramide–treated oHCM patients were studied with Imaging CPET before and after 3 months of treatment starting at the cardiomyopathy unit of San Camillo Forlanini Hospital (Rome). After a baseline echocardiography, symptoms limited CPET was done on an upright bicycle ergometer utilizing a 10 Watt/min. ramp protocol. Cardiopulmonary variables were measured with breath–by–breath analysis. During CPET, Doppler Echocardiography was performed. LVOT velocities and trans–valvular gradient and diastolic function were taken at peak exercise and during recovery.

Results

21 patients (mean age 48.3 years; 57% male; average daily–dose 450 mg) were evaluated. Of those, 96% were taking concurrent b–blocker medication, whereas 4% were receiving a calcium antagonist. After 3 months of disopyramide, mean resting outflow gradient decreased from 40 to 29 mmHg (p =0.08) and from 63 to 41mmHg (p=0.014) at peak exercise. There was no notable reduction in EF (p=0.9) or improvement in diastolic function at rest (p=0.1) or at peak exercise (p=0.7). Mean heart rate significantly decreased both at rest (78 vs 68 bpm; p=0.02) and peak exercise (131 vs 113 bpm; p=0.001), along with a decrease in chronotropic response (predicted HR = 81% vs 70%; p=0.001). Furthermore, after treatment, mean functional capacity decreased significantly (20ml/kg/min vs 17ml/kg/min; p=0.02;) whereas neither VE/VCO2 (p=0.5) nor oxygen pulse(p=0.9) changed considerably. 19 patients (90%) reported improved quality of life despite no increase in NYHA class.

Conclusion

This study, for the first time, showed that although disopyramide decreases the exercise gradient, it does not improve functional capacity since it significantly alters the chronotropic response. These findings emphasize the value of heart rate response evaluation in patients with HCM and the importance of carefully adjusting the dose of negative chronotropic agents.