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We report the case of a 73-year-old male admitted for epigastric pain and syncope with increased troponin level and a rare electrocardiogram (a single‑lead ST-elevation). Coronary angiography showed multi-vessel coronary artery disease. The patient underwent coronary angioplasty with drug-eluting stenting on left anterior descending coronary artery and drug eluting ballooning on first diagonal ostium. Coronary revascularization was completed with a staged stenting on left circumflex artery and right coronary artery. In rare cases of acute coronary syndrome, even isolated ST single lead anomalies may underlie multivessel coronary disease., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Aim of the Study: The response to the increase in heart rate (HR) could be characterized by failure in both left ventricular (LV) and left atrial (LA) functions. This study aimed to evaluate the relationship between the increase in paced HR and the changes in LV and LA functions, assessed by two-dimensional speckle tracking analysis., Methods: In a group of patients with an implantable cardioverter defibrillator (ICD) or pacemaker, the atrial paced rhythm was progressively increased from 60 to 70, from 70 to 80, and from 80 to 90 beats per minute (bpm). For each paced HR, using two-dimensional speckle tracking analysis, LA reservoir (LAr), LA conduit (LAc), LA contraction (LAct), and LV global longitudinal strain (LV-GLS) were evaluated every 10 bpm., Results: Of the 45 patients enrolled, a significant reduction in LAr was observed at higher HR. However, when the patients were dichotomized according to the HR-related response of LV-GLS, the worsening of LAr was observed in those with LV-GLS worsening and not in those without (maximum LAR absolute changes -2.7 ± 7.2% vs. +2.7 ± 7.2%, respectively, p .028). Moreover, the worsening of LA and LV strain measures was associated with an increase in the estimated filling pressures., Conclusions: In patients with atrial paced rhythm, the increase in HR could be associated with worsening of LA and LV functions, as assessed by two-dimensional speckle tracking analyses. These results offer new data on HR-related atrioventricular function and could be useful for guiding the optimal HR responsiveness of the implanted devices., (© 2023 The Authors. Pacing and Clinical Electrophysiology published by Wiley Periodicals LLC.)

Background: In patients with recent ACS, the latest ESC/EAS guidelines for management of dyslipidaemia recommend intensification of LDL- C -lowering therapy ., Objective: Report a real-world picture of lipid-lowering therapy prescribed and cholesterol targets achieved in post-ACS patients before and after a specific educational program., Methods: Retrospective data collection prior to the educational course and prospective data collection after the course of consecutive very high-risk patients with ACS admitted in 2020 in 13 Italian cardiology departments, and with a non-target LDL-C level at discharge., Results: Data from 336 patients were included, 229 in the retrospective phase and 107 in the post-course prospective phase. At discharge, statins were prescribed in 98.1% of patients, alone in 62.3% of patients (65% of which at high doses) and in combination with ezetimibe in 35.8% of cases (52% at high doses). A significant reduction was obtained in total and LDL cholesterol (LDL-C) from discharge to the first control visit. Thirty-five percent of patients achieved a target LDL-C <55 mg/dL according to ESC 2019 guidelines. Fifty percent of patients achieved the <55 mg/dL target for LDL-C after a mean of 120 days from the ACS event., Conclusions: Our analysis, though numerically and methodologically limited, suggests that management of cholesterolaemia and achievement of LDL-C targets are largely suboptimal and need significant improvement to comply with the lipid-lowering guidelines for very high CV risk patients. Earlier high intensity statin combination therapy should be encouraged in patients with high residual risk., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors. Published by Elsevier B.V.)

Background: Catheter ablation (CA) is routinely used for the treatment of arrhythmias. Vascular complications are the most common complications during these procedures. Previous data reported that ultrasound (US)-guided puncture is a useful method to avoid vascular complications. We reported our experience using US-guided puncture in patients undergoing CA for arrhythmias., Methods: A total of 273 patients (mean age 57 ± 17 years; 58% male) were referred to our center for CA of arrhythmias from January 2016 to December 2019. All procedures were performed by expert operators, and US-guided vascular access was performed on all patients. Doppler sonography was performed the day after the procedure on all patients., Results: Eighty-four patients (31%) underwent atrioventricular nodal reentrant tachycardia ablation, 49 patients (18%) atrioventricular reentrant tachycardia ablation, 14 patients (5%) atrial tachycardia ablation, 25 patients (9%) atrial flutter ablation, 63 patients (23%) atrial fibrillation ablation, and 38 patients (14%) ventricular tachycardia ablation. Vascular pseudo-aneurysms and arteriovenous fistula were defined as major complications; furthermore, venous thrombosis and inguinal hematomas were as defined minor complications. The percentage of major vascular complications was 0.3% (1 arteriovenous fistula) and the percentage of minor vascular complications was 0.3% (1 venous thrombosis)., Discussion: Ultrasound-guided vascular puncture in patients undergoing CA is useful to improve procedural success and reduce complications., Competing Interests: Authors declare no conflict of interests for this article., (© 2022 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Heart Rhythm Society.)

Although children with Covid-19 generally present with mild symptoms or are often asymptomatic, there is increasing recognition of a delayed multi-organ inflammatory syndrome (MIS-C) following SARS-CoV-2 infection. We report the case of MIS-C associated arrhythmic myocarditis which recovered after anti-inflammatory therapy and immunoglobulin infusion., Competing Interests: Declaration of Competing Interest None to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The first approach for Type-2 myocardial infarction (T2MI) consists of the elimination of the condition determining the oxygen supply/demand mismatch. However, the long-term impact of medical therapy with beta blockers, statins, aspirin, and P2Y12 inhibitors, used in the case of Type-1 myocardial infarction has been poorly investigated and remains unclear. We, therefore, sought to assess the impact of medical therapy on 1-year mortality in patients with T2MI using a meta-regression analysis. A meta-regression analysis was performed with studies involving in patients with T2MI: 1-year all-cause mortality, rates of beta blockers, statins, aspirin, and P2Y12 inhibitors use were recorded and analyzed. After careful study selection, 8 observational studies were pooled in the analysis, including 3,756 in patients. During meta-regression analysis, a borderline correlation between rates of aspirin, P2Y12 inhibitors, and statins use and 1-year mortality (p = 0.087, p = 0.05, and p = 0.067, respectively) was found; no significant correlation was found at multivariable analysis. In conclusion, in a meta-regression analysis, no significant correlation was found between rates of use of usual drug therapy indicated for Type-1 myocardial infarction (statins, aspirin, P2Y12 inhibitors, β-blockers) and 1-year mortality in T2MI patients., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Percutaneous coronary intervention (PCI) represents the best therapeutic option for type-1 myocardial infarction (T1MI) in the majority of clinical settings; its role in the treatment of type-2 myocardial infarction (T2MI), however, remains unclear. We therefore sought to assess in a meta-regression analysis the impact of PCI rates on mortality in patients with T2MI according to available observational studies., Methods: We performed a meta-regression analysis including all the studies involving in-patients affected by T2MI. We excluded studies not reporting the rate of T2MI patients undergoing PCI and not specifying absolute in-hospital or 1-year all-cause mortality. In the meta-regression analysis we used the in-hospital mortality and 1-year mortality as dependent variables and the rate of PCI as independent; regression was weighted for studies' size., Results: After careful examination, 8 studies were selected for the assessment of in-hospital mortality and 8 for 1-year-mortality. We included 3155 and 3756 in-patients for in-hospital and 1-year mortality respectively. At meta-regression analysis, a borderline correlation between PCI rate and in-hospital mortality (p 0.05) and a statistically significant correlation with 1-year mortality (p < 0.01) in T2MI patients were found., Conclusions: In a meta-regression analysis higher rates of PCI on T2MI in-patients were associated with lower mortality rates both in-hospital and at 1 year. Whether this association is related to the direct effect of PCI or better general conditions of T2MI patients undergoing a PCI still remains unclear., Competing Interests: Declaration of Competing Interest None to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

In the recent past, low-molecular-weight heparin (LMWH) was the first choice in the treatment of cancer related venous thrombo-embolism (VTE). Evidence supporting the preferential use of direct anticoagulants (DOACs) in patients with cancer, instead, is less robust so far. We therefore aimed to assess in an updated meta-analysis of randomized controlled trials whether the use of DOACs may be associated with a more favorable profile when compared to LMWH. We performed a meta-analysis of RCTs enrolling patients with VTE and cancer. We assessed Mantel-Haenszel pooled estimates of risk ratios (RRs) and 95% CIs for recurrence of VTE, major bleeding, and mortality comparing subjects treated with DOACs with those with LMWH. After study selection, three RCTs (HOKUSAI-Cancer, SELECT-D and ADAM-VTE) were included for the analysis with an overall population of 1739 patients. DOACs patients had a lower incidence of 6-month recurrent VTE when compared to LMWHs (RR 0.56, 95% CI 0.40-0.79; p < 0.001). Incidence of major bleeding was not significantly different between DOACs and LMWH treated patients (RR 1.56, 95% CI 0.95-2.47, p = n.s.), and mortality rates were comparable (RR 1.03, 95% CI 0.91-2.47, p = n.s.). In a meta-analysis of RCTs therapy with DOACs was superior to LMWH in terms of efficacy and lower recurrence of VTE with a comparable safety profile in terms of bleeding events and complications.

Background: Dual antiplatelet therapy and anticoagulants may be required in the case of coexistence of coronary artery disease and atrial fibrillation (AF) undergoing (PCI), with associated increased bleeding rates. The introduction of direct oral anticoagulants (DOACs), however, significantly reduced the incidence of bleeding complications in this clinical setting of patients. We therefore sought to assess whether the recent publication of the AUGUSTUS and ENTRUST-AF PCI studies significantly impacted current evidence on the use of DOACs in AF patients treated with PCI., Methods: We performed a meta-analysis of randomized controlled studies enrolling patients with nonvalvular AF undergoing PCI. We assessed pooled estimates of risk ratios (RRs) and 95%CIs for any bleeding (AB), cardiovascular events (CVE), and death at follow-up: 12,542 patients have been included in the analysis. We particularly analyzed data comparing dual anti-thrombotic therapy (DOAC plus single anti-platelet therapy) with triple (DOAC plus dual anti-platelet therapy)., Results: When compared with patients receiving standard triple therapy with warfarin, patients receiving DOACs had a significantly lower risk of AB (RR 0.65; 95% CI, 0.61-0.70, p < 0.00001) and of MB (RR 0.63; 95% CI, 0.53-0.73, p < 0.00001). The risk of cardiovascular events and mortality were comparable between DOAC and VKA groups (RR 1.05, 95% CI 0.93-1.18, RR 1.14, 95% CI 0.94-1.37, respectively, p n.s.). Similar results were observed comparing triple therapy vs dual therapy., Conclusions: DOACs are safer than and as effective as warfarin when used in patients with AF undergoing PCI; dual therapy with DOACs is comparable to triple therapy in terms of safety and efficacy., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 The Author(s).)

Introduction: Catheter ablation (CA) of atrial fibrillation (AF) is an important rhythm control strategy for patients with drug-refractory AF. We aimed to perform an updated meta-analysis of direct oral anticoagulants (DOACs) vs vitamin K antagonists (VKAs) as uninterrupted anticoagulation in patients undergoing AF ablation to assess safety and efficacy of DOAC, after the publication of recent data on edoxaban in CA of AF., Methods: We performed a meta-analysis of RCTs enrolling patients undergoing AF ablation. We assessed Mantel-Haenszel pooled estimates of risk ratios (RRs) and 95% CIs for thromboembolic events, major bleeding (MB), and non-major bleeding (NMB)., Results: A total of 2118 patients have been included in the analysis. Compared with patients receiving VKA, patients receiving DOACs had a lower, although non-significant, risk of thromboembolic events (RR, 0.40; 95% CI, 0.09-1.76; P = 0.23). MB rates in patients treated with DOACs were statistically significantly lower than VKA (RR, 0.61; 95% CI, 0.39-0.93, P = 0.02). The incidence of NMB was not significantly different (RR, 0.98; 95% CI, 0.83-1.57, p n.s.)., Conclusions: In a meta-analysis of RCTs, an uninterrupted DOACs strategy for CA of AF appears to be superior to uninterrupted VKA in terms of safety; a non-significant trend favoring DOACs in terms of efficacy is also evident.

Thrombus-in-transit through a patent foramen ovale (PFO) in a patient with pulmonary embolism (PE) is a rare event with high mortality rates. We report the case a of 53-year-old woman admitted for dyspnea, cough, hemoptysis, presyncope, tachycardia, and hypotension. A recent fall down the stairs with costal trauma was also reported. At transthoracic echocardiography, dilated right atrium with the presence of a large floating thrombus was found, protruding into the left atrium through a PFO; lower extremity vascular ultrasound showed right great saphenous vein thrombosis extended over the saphenofemoral junction up to the common femoral vein. CT scan showed submassive thromboembolism; surgical thrombectomy was, therefore, performed with the closure of the PFO; an inferior vena cava filter was also positioned for the prevention of recurrent episodes of thromboembolism. The patient was discharged in therapy with apixaban 5 mg twice a day. Two-month follow up was uneventful. Large thrombi in transit through PFO can be found at transthoracic echocardiography. The management, either medical or surgical, should be aimed at preventing systemic thromboembolism., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Persistent ST-segment elevation in acute coronary syndrome is associated with both short and long-term complications. By contrast, there is limited information about ST-elevation and its evolution during takotsubo (stress) cardiomyopathy (TTC)., Aim: To evaluate whether persistent downsloping ST-elevation in the early stages of TTC might correlate with short and long-term clinical events., Methods: One-hundred fifty-eight consecutive subjects with TTC were prospectively enrolled and assessed by electrocardiogram. Patients were classified in two groups according to the presence of downsloping ST-elevation ≥5 mm lasting at least 24 hr ("lambda-wave" ST-elevation group vs. without downsloping ST-elevation) in at least one/two contiguous leads., Results: Five (3.2%) patients, all female with a mean left ventricular ejection fraction 32 ± 5%, were included in the lambda-wave ST-elevation group. These patients were characterized by a higher prevalence of physical stressor (100% vs. 49%, p = 0.04) and higher admission and peak levels of troponin-I levels during hospitalization. Peak of ST-elevation in the lambda-wave ST-elevation group was reached 6 hr after admission and gradually decreased after 24 hr. In-hospital complications were observed in all the patients presenting lambda ST-elevation (100% vs. 23%, p = 0.03, OR: 29.1, p = 0.04); one patient presented endoventricular thrombosis and two died of cardiogenic shock. At long-term follow-up (mean 443 days), adverse events were observed in 80% of patients with lambda-wave ST-elevation (RR of adverse events at follow-up 32, p < 0.01)., Conclusion: Persistent downsloping lambda-wave ST-elevation during the acute phase of stress cardiomyopathy may be associated with a higher risk of adverse events at short and long-term follow-up., (© 2018 Wiley Periodicals, Inc.)

We report the case of an incomplete diagnosis of chronic thromboembolic pulmonary hypertension, with relevant prognostic implications, missing the presence of a primary pulmonary artery angiosarcoma. After the late neoplasm diagnosis, the patient, treated for months with riociguat, was considered inoperable and died soon after. This case highlights the need to manage patients with suspected pulmonary arterial hypertension by expert referral centers with specific and multi-professional expertise (heart and thoracic imaging) in order to avoid incomplete or delayed diagnoses.

Assessing the efficacy of revascularization therapy in patients with ST-segment elevation myocardial infarction (STEMI) is extremely important in order to guide subsequent management and assess prognosis. We aimed to determine the relationship between corrected QT-interval (QTc) changes on standard sequential ECG and myocardial salvage index in anterior STEMI patients after successful primary percutaneous coronary intervention. Fifty anterior STEMI patients treated by primary percutaneous coronary intervention underwent quantitative ECG analysis and cardiac magnetic resonance. For each patient the difference (ΔQTc) between the QTc of ischemic myocardium (maximum QTc in anterior leads) versus remote myocardium (minimum QTc in inferior leads) during the first six days after STEMI was measured. The QTc in anterior leads was significantly longer than QTc in inferior leads (p<0.0001). At multivariate analysis, ΔQTC and peak troponin I were the only independent predictors for late gadolium enhancement while ΔQTc and left ventricular ejection fraction were independent predictors of myocardial salvage index <60%. The receiver operative curve of ΔQTc showed an area under the curve of 0.77 to predict a myocardial salvage index <0.6. In conclusion, in a subset of patients with a first occurrence of early revascularized anterior STEMI, ΔQTc is inversely correlated with CMR-derived myocardial salvage index and may represent a useful parameter for assessing efficacy of reperfusion therapy.

Background: Prolonged QT corrected (QTc) intervals are associated with adverse cardiovascular outcomes both in healthy and high-risk populations. Our objective was to evaluate the QTc intervals during a takotsubo cardiomyopathy (TTC) episodes and their potential prognostic role., Hypothesis: Dynamic changes of QTc interval during hospitalization for TTC could be associated with outcome at follow-up., Methods: Fifty-two consecutive patients hospitalized for TTC were enrolled. Twelve-lead electrocardiogram (ECG) was performed within 3 h after admission and repeated after 3, 5, and 7 days. Patients were classified in 2 groups: group 1 presented the maximal QTc interval length at admission and group 2 developed maximal QTc interval length after admission., Results: Mean admission QTc interval was 493 ± 71 ms and mean QTc peak interval was 550 ± 76 ms (P < 0.001). Seventeen (33%) patients were included in group 1 and 35 (67%) patients in group 2. There were no differences for cardiovascular risk factors and in terms of ECG findings such as ST elevation, ST depression, and inverted T waves. Rates of adverse events during hospitalization among patients of group 1 and 2 were different although not significantly (20% vs 6%, P = 0.22). After 647 days follow-up, patients of group 1 presented higher risk of cardiovascular rehospitalization (31% vs 6%, P = 0.013; log-rank, P < 0.01). At multivariate analysis, including age and gender, a prolonged QTc interval at admission was significantly associated with higher risk of rehospitalization at follow-up (hazard ratio: 1.07 every 10 ms, 95% confidence interval: 1.003-1.14, P = 0.04)., Conclusions: Prolonged QTc intervals at admission during a TTC episode could be associated with a higher risk of cardiovascular rehospitalization at follow-up. Dynamic increase of QTc intervals after admission are characterized by a trend toward a better prognosis., (© 2017 Wiley Periodicals, Inc.)

Background: To assess levels of kinesiophobia (fear of movement) in patients hospitalized for acute cardiovascular disease., Hypothesis: Increased levels of kinesiophobia can be found in subjects hospitalized for acute cardiovascular disease., Methods: Seventy-four consecutive patients admitted for acute coronary syndrome and 58 for acute heart failure were enrolled in the study and assessed by the Tampa Scale for the evaluation of kinesiophobia. Subjects were compared with a reference population with stable coronary artery disease and healthy controls., Results: No significant differences were found between acute coronary syndrome and acute heart failure in terms of kinesiophobia, even considering the rates of high kinesiophobia (Tampa score >37) and the 4 groups of questionnaire items (danger, fear, avoidance, dysfunction). Differences, however, were significant comparing our population with an historical population of subjects with stable coronary artery disease and controls (43 ± 5 vs 35 ± 7 vs 33 ± 6, P < 0.0001 in both cases). A significant correlation was found between the grade of kinesiophobia in the Tampa Scale and the age of subjects (r = 0.27, P = 0.001) and inversely with level of education (r = -0.33, P < 0.0001)., Conclusions: Increased levels of kinesiophobia can be found in subjects hospitalized for acute cardiovascular disease. Kinesiophobia is related to age and education. Kinesiophobia should be carefully considered in subjects hospitalized in acute cardiac care units., (© 2017 Wiley Periodicals, Inc.)

: We report the case of early recurrence of Tako-Tsubo cardiomyopathy in an elderly woman with amyotrophic lateral sclerosis triggered by different stressors. A first episode with typical apical ballooning was anticipated by an emotional stress; a second, characterized by systolic anterior motion of the mitral valve associated with mitral regurgitation and severe intra-ventricular gradient, was precipitated by surgical stress and hypovolemia. We therefore hypothesize both a possible link between amyotrophic lateral sclerosis and Tako-Tsubo cardiomyopathy, and between different stressors and different Tako-Tsubo patterns.

: We report a case of paroxysmal supraventricular tachycardia complicating Tako-Tsubo cardiomyopathy. We hypothesize that increased adrenergic tone supposedly underlying transient apical ballooning syndrome may facilitate the onset of paroxysmal supraventricular tachycardias in predisposed patients.

Background and Aims: Systemic inflammation has been hypothesized as a possible mechanism of Takotsubo cardiomyopathy (TTC). Aim of the study was to assess the role of interleukin (IL)-6 and IL-10 in subjects with an episode of TTC., Methods: Fifty-six consecutive subjects with TTC were prospectively enrolled in the study and followed for a mean of 178 days. Circulating levels of IL-6, IL-10, clinical condition and left ventricular ejection fraction were evaluated at admission. Incidence of death, re-hospitalization and recurrence of TTC during follow-up was also recorded., Results: 23% of patients experienced in-hospital complications while 20% of patients had adverse events at follow-up. IL-6 and IL-10 serum levels at admission were higher in subjects with adverse events at follow-up (120 ± 294 vs. 22 ± 40 pg/ml, p<0.05; 13 ± 35 vs. 2 ± 3 pg/ml, p=0.05, respectively). Increased serum levels of IL-6 and IL-10 were associated with higher adverse events rates at follow-up (Log-Rank p<0.001, <0.05, hazard ratio 8.6, 5.1, respectively) and mortality rates (Log-Rank p<0.001, p<0.05, hazard ratio 20.8, 7.1, respectively). Subjects with both increased IL-6 and IL-10 levels were characterized by an increased risk of adverse events when compared to subjects with only IL-6 or IL-10 increased levels or with values below cutoff values (Log-Rank p<0.01 for any event, <0.001 for death; hazard ratio 1.20 for any event, 1.31 for death), even after correction for age, LVEF and NTproBNP levels in multivariable Cox analysis., Conclusions: Serum IL-6 and IL-10 admission levels are associated with higher risk of adverse events during follow-up., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: The presence of viable stunned myocardium recovering after primary angioplasty is not easy to identify in the early phase of acute myocardial infarction (AMI) by noninvasive bed-side methods. We therefore aimed to assess whether a simple electrocardiogram parameter may be of help in identifying the presence of stunned viable myocardium recovering after reperfusion with primary angioplasty., Materials and Methods: A total of 14 consecutive patients with ST-elevation AMI (STEMI) were enrolled in the study and underwent QT duration assessment after admission: the difference between QT corrected (QTc) in the ischaemic areas and QTc values in nonischaemic areas was therefore calculated and compared with the presence and the extension of viable stunned myocardium, assessed by comparing akinetic/dyskinetic areas at admission echocardiography with akinetic/dyskinetic areas and extension of scar at 6-month cardiac magnetic resonance imaging (cMRI)., Results: In subjects with viable recovering myocardium, 75% had a QTc max > 440 ms (vs. 17%, P = 0·03); higher differential QTc values and smaller scar areas were found (33 ms vs. -17 ms, 14% vs. 27%, P = 0·03, 0·06 respectively). Differential QTc values > 0 were able to identify the presence of viable myocardium with an odds ratio of 35 (P < 0·05, sensitivity 88%, specificity 83%, positive predictive power 88%, negative predictive power of 83%). Differential QTc values were related to the extension of viable recovering myocardium (P < 0·001)., Conclusion: Viable myocardium recovering after primary angioplasty in STEMI may be predicted by the presence of increased QTc values in ischaemic areas in comparison with nonischaemic areas., (© 2016 Stichting European Society for Clinical Investigation Journal Foundation.)

Takotsubo cardiomyopathy is an acute reversible form of cardiac failure, firstly described in 1991, with a prognosis not favorable as previously thought. Although high levels of catecholamines have been suggested as the leading mechanism for the onset, the pathophysiology remains unclear. However, several pathophysiological explanations have been proposed, all not mutually exclusive. A complex chain of events is present, including the activation of the hypothalamic-pituitary-adrenal axis, the surge in circulating catecholamines and subsequent cardiovascular responses. This review addresses the diagnostic classification, short and mid-term prognosis, precipitating factors, classification into primary and secondary forms, and possible drug therapies for stress cardiomyopathy. Clinical and experimental studies are needed to further improve diagnosis and targeted therapies.

In patients with atrial fibrillation (AF), extensive atrial tissue fibrosis identified by delayed enhancement magnetic resonance imaging has been associated with early recurrence of AF after catheter ablation. We present a case of a patient with extensive atrial fibrosis and AF recurrence.The study of late gadolinium enhancement with cardiac magnetic resonance imaging in patients with AF could be a valuable noninvasive tool for the selection of patients suitable for successful catheter ablation., (© The Author(s), 2016.)

The aim of this study is to evaluate the possible role of carbohydrate-antigen(CA)-125 as prognostic marker at short- and long-term follow-up, in subjects with Takotsubo cardiomyopathy (TTC). Sixty-three consecutive subjects with TTC were enrolled in the study and followed for a median 139 days. Circulating levels of CA-125, NT-proBNP, and left ventricular ejection fraction (LVEF) were evaluated at admission. Duration of hospital stay, incidence of death, re-hospitalization and recurrence of TTC during follow-up were recorded. The mean hospital stay was 8.3 days, adverse events occurred during follow up in 17 % of cases. CA-125 levels at admission are inversely related to LVEF (r -0.30, p < 0.05) and directly related to hospital stay (r 0.29, p < 0.05). CA-125 levels at admission are higher in subjects with adverse events at follow-up (88.9 ± 200.0 vs 20.9 ± 30.0 U/mL, p < 0.05). Rates of incidence of adverse events are proportionally increased with CA-125 tertiles (0, 6, 11 % respectively, p for trend <0.01), at survival analysis (Log Rank p < 0.05) and after correction for age, gender, LVEF and NT-proBNP levels in multivariable Cox analysis (p < 0.05). CA-125 levels <10 U/ml are predictors of adverse events at follow up with 91 % sensitivity, 52 % specificity, 29 % positive predictive power, and 96 % negative predictive power. Increased CA-125 admission levels are associated with a longer hospital stay, a lower LVEF, and a higher risk of adverse events during follow up. CA-125 might be useful for early risk stratification of subjects with TTC.

The Brugada electrocardiogram pattern is characterized by coved-type ST-elevation (>2 mm) in the right precordial leads. We report the case of a 62-year-old man, with bipolar disorder, admitted to the emergency department because of dyspnea and chest discomfort. The patient was on treatment with pregabalin and quetiapine. Unexpectedly, electrocardiogram at admission showed diffuse ST-elevation, more evident in inferior leads, where a Brugada-like pattern was present. The patient underwent coronary angiography with a diagnosis of suspected acute coronary syndrome. Coronary angiography, however, showed mild coronary artery disease not requiring coronary angioplasty. Echocardiography did not reveal left ventricular dysfunction or pericardial effusion. Troponin levels remained normal over serial controls. Eventually, chest radiography showed lung opacities and consolidation suggestive for pneumonia. To the best of our knowledge, this is one of the first cases showing a transient Brugada-like electrocardiogram pattern in inferior leads, probably amplified by the administration of pregabalin and quetiapine.

Background: Left ventricular outflow tract obstruction (LVOTO) may complicate an episode of Takotsubo cardiomyopathy (TTC), potentially leading to cardiogenic shock. Beta-blockers are considered the most suitable treatment for such complication., Aim of the Study: The objective of this study was to evaluate the hemodynamic effects, safety, and feasibility of a selective beta-blocker (β1) with a short half-life, esmolol, in subjects with a TTC episode., Methods: Ninety-six consecutive patients with TTC were enrolled in a multicenter registry. The hemodynamic and echocardiographic effects of esmolol (0.15-0.3 mg/kg/min) were analyzed in nine consecutive patients with LVOTO. Clinical course of patients, hemodynamics, days of hospitalization, LV function, and adverse events at follow-up were recorded., Results: Left ventricular outflow tract obstruction was present in 10 (10.4%) of 96 patients. Patients with LVOTO were older and had higher values of troponin-I at admission. LV ejection fraction at admission (36.1 ± 8.4%) significantly improved at discharge (51.4 ± 6.9%, P = 0.001). Among patients treated with esmolol infusion, LVOT pressure gradient before treatment was 47.6 ± 16.6 mmHg and after 18.2 ± 2.3 mmHg (P = 0.0091). Systolic blood pressure decreased from 123.8 ± 29.1 to 112.6 ± 12.7 mmHg (P = 0.1537). Mean hospital stay was 9 ± 2 days. No adverse events were observed during hospitalization and at follow-up., Conclusions: Esmolol infusion was temporally associated with reduction in intraventricular gradient and systemic blood pressure in patients with TTC and LVOTO. Further controlled studies are warranted to confirm these preliminary findings., (© 2016 John Wiley & Sons Ltd.)

Objectives: The objectives were to ascertain the prevalence of renal impairment among patients with a takotsubo cardiomyopathy (TTC) episode and whether clinical outcomes are related to renal function., Methods: A total of 108 consecutive subjects with TTC were enrolled in a multicenter registry and followed for a mean period of 429 days. Renal function was evaluated during hospitalization in terms of acute kidney injury/failure and estimated glomerular filtration rate (eGFR). Incidence of death, rehospitalization, and recurrence of TTC during follow-up was recorded., Results: Raised creatinine levels can be found during hospitalizations for TTC episodes (analysis of variance P<.001). Incidence of acute kidney injury was 10%; that of acute kidney failure was 1%. Admission eGFR levels were proportional to the duration of hospitalization (r = -0.28, P<.01). Estimated GFR nadir values were related to adverse events at follow-up (log-rank P<.001). The hazard ratio of adverse events at follow-up in subjects with severe renal impairment (nadir eGFR <30 mL/[min 1.73 m(2)]) vs those with eGFR >60 mL/(min 1.73 m(2)) was 1.817 (95% confidence interval, 1.097-3.009; P<.05)., Conclusions: Raised creatinine levels and impaired renal function may be found in patients with TTC. Lower eGFR values during hospitalization are associated with longer hospitalizations and higher rates of adverse events at follow-up. Renal function during a TTC episode should be carefully evaluated., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Tissue Doppler imaging (TDI) may be useful in identifying subjects at higher risk among patients with chronic heart failure (CHF). The clinical role of newly developed TDI parameters, however, still needs to be documented., Methods: A total of 287 consecutive patients with CHF enrolled in the Daunia Heart Failure Registry underwent echocardiography assessment and were followed prospectively for a median 255 (204-316) days. Conventional echocardiography and TDI parameters were calculated. We also quantified by TDI a combined index (EAS index) of diastolic and systolic performance E'/(A'xS') and assessed its possible additional prognostic role in combination with 'traditional' parameters such as left ventricular ejection fraction (LVEF) and myocardial performance index (MPI)., Results: Subjects readmitted for worsening HF were characterized by higher levels of EAS index (median 0·14 (95% C.I. 0·12-0·21) vs. 0·11 (0·10-0·12, P < 0·05)). Increased rates of rehospitalization were found in subjects with EAS index >median (0·115) (21% vs. 10%, P < 0·05); higher EAS index values predicted the incidence of readmissions for worsening HF during follow-up, even at multivariable analysis. The assessment of EAS index in addition to LVEF and MPI showed an adjunctive prognostic value (log-rank P < 0·001 and P < 0·05, respectively)., Conclusions: EAS index assessed by TDI may be helpful in predicting the risk of rehospitalizations in subjects with CHF. EAS index may represent an independent adjunctive tool for the risk stratification of patients with CHF in addition to 'traditional' tools such as LVEF or MPI., (© 2015 Stichting European Society for Clinical Investigation Journal Foundation.)

We report the case of a 56-year-old woman with effort angina, dyspnea and a septal mass causing atrioventricular block, treated with pacemaker implantation, and left ventricular outflow tract obstruction (induced by septal mass protrusion into left ventricular cavity).

Background: Efficacy of chronic drug therapy in prevention of stress-induced cardiomyopathy recurrences is not well established. We therefore aimed to evaluate in this meta-analysis whether pharmacological treatment can effectively prevent takotsubo cardiomyopathy (TTC) recurrences, according to available studies., Hypothesis: There is no evidence for preventing TTC recurrence by drug therapy., Methods: After a PubMed search, we conducted a meta-analysis of available studies (clinical nonrandomized registries) on efficacy of drug therapy in preventing recurrence of TTC., Results: A total of 23 (4.5%) TTC recurrences occurred in the 511 patients included in the analysis. Seven studies on the effects of β-blockers on prevention of TTC recurrence were evaluated; the odds ratio (OR) was 0.44 and the 95% confidence interval (CI) was 0.15-1.31. In 5 studies on the effects of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, the OR was 0.42 and the 95% CI was 0.08-2.36; in 3 studies on statins, the OR was 0.74 and the 95% CI was 0.07-7.3; and in 4 studies on aspirin, the OR was 0.33 with a 95% CI of 0.05-2.17 (P value not significant in all cases)., Conclusions: A meta-analysis of the efficacy of different medications through the clinical TTC registries available showed no clinical evidence for a standard drug treatment in the chronic management of TTC. β-Blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, and aspirin do not seem to significantly reduce recurrences of TTC. Randomized, adequately powered studies are needed to further assess this issue., (© 2014 Wiley Periodicals, Inc.)

Background: Tissue Doppler imaging (TDI) may be useful in identifying subjects at higher risk among patients with chronic heart failure (CHF). The clinical role of new developed TDI parameters, however, still needs to be documented., Methods: A total of 113 consecutive patients with CHF enrolled in the Daunia heart failure registry underwent echocardiography assessment and were followed prospectively for 234 ± 262 days. Conventional echocardiography and TDI parameters were calculated. We also calculated peak myocardial acceleration during isovolumic relaxation time (pIVA[r]) derived from TDI (pIVV(r)/AT)., Results: Subjects readmitted for worsening HF were characterized by lower levels of pIVA(r) (0.8 ± 0.3 vs. 1.3 ± 0.5 m/s(2) , P < 0.001). pIVA(r) levels predicted the incidence of readmission for worsening HF during follow-up (HR 0.78, 95% confidence interval 0.64-0.96, P < 0.05), even after multivariable analysis. The assessment of pIVA(r) in addition to left ventricular ejection fraction (LVEF) and E/E' provided additional prognostic value (Log Rank P < 0.05). The presence of abnormal pIVA(r), LVEF, and E/E' levels identified subjects with a higher risk of hospitalization for worsening dyspnea during follow-up than those with 2 abnormal marker levels or 0-1 (Log Rank P < 0.05)., Conclusions: Peak myocardial acceleration during isovolumic relaxation time may represent an independent adjunctive tool for the risk stratification of patients with CHF., (© 2013, Wiley Periodicals, Inc.)

This article reviews the role of cardiac imaging in stroke prevention, defining how imaging tools can be useful in this field. Cardioembolic sources during atrial fibrillation are discussed. New closure devices can be implanted in the left atrial appendage and routinely monitored with imaging modalities. Acute and chronic left ventricular dysfunction is reviewed, identifying the possible mechanism of thrombus formation and its early detection. Valvular evaluation of native heart disease and possible implications for stroke risk are defined., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Levosimendan is a noncatecholamine inotrope that does not increase oxygen consumption, utilized for the treatment for acute heart failure with left ventricular (LV) systolic dysfunction. Its use in takotsubo cardiomyopathy (TTC), a disease that contraindicates the use of catecholamine inotropes, is not well known., Methods: We prospectively analyzed 13 consecutive patients with TTC, low ejection fraction (EF) (<35%), and additional Mayo Clinic risk factors who were treated with i.v. infusion of levosimendan. Clinical course of patients, electrocardiogram presentation, LV function, and adverse events at follow-up were recorded., Results: All patients showed an impaired LV function (LVEF at admission 28 ± 5%), which significantly improved at discharge (51 ± 8%, P < 0.001). Mean hospital stay was 10 ± 4 days. Troponin levels at admission were directly related to length of hospitalization (r = 0.6, P < 0.001). Male gender (relative risk (RR) 1.85, P < 0.05), physical stress (RR 1.90, P < 0.05), ST elevation at ECG (RR 1.87, P < 0.05), and absence of chest pain (RR 2.23, P < 0.01) were found to be the predictors of longer hospital stay. Only 15% of subjects had adverse events during hospital stay; two patients incurred noncardiovascular death at follow-up. Age was the only predictor of adverse event at follow-up (RR 2.13, P < 0.05)., Conclusions: The use of levosimendan may be safe and feasible in patients with TTC. Randomized studies are warranted to further confirm these preliminary results., (© 2013 John Wiley & Sons Ltd.)