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Resting heart rate (HR) is considered a powerful predictor of mortality both in healthy subjects and in cardiovascular (CV) patients, including those affected by heart failure (HF). Its reduction below 70 bpm is the treatment target in chronic HF with reduced ejection fraction (HFrEF) when sinus rhythm is present. In acute HF (AHF) HR is usually elevated but its role as risk marker is still unknown. Notably, in unstable patients, beta-blockers can be reduced or stopped, thus enhancing this phenomenon. Moreover, some data in literature suggest that HR reduction during hospitalization or HR at discharge or in the vulnerable phase after it are more predictive of early-term events and may be therapeutic targets. On the other hand, ivabradine is a pure HR-lowering drug with no effects on inotropism. Its role in the AHF setting has been recently investigated and is the object of this review.

Wellens' syndrome is a pattern of electrocardiographic T-wave changes seen in the precordial leads in patients with unstable angina. Two different patterns have been described. Type A presents with biphasic T-waves in V2-V3 and type B presents with symmetrical deep T-wave inversions in V2-V3. The etiology is related to a critical stenosis in the proximal left anterior descending artery (LAD). We describe a patient who presented at our emergency department with intermittent chest pain and showing Wellens' pattern T-wave inversions in the precordial leads of the electrocardiogram. She was found to have 95% stenosis in mid LAD.

Increasing survival from cystic fibrosis show untypical systems involvement, such as cardiocirculatory. In particular, the presence of CFTR in smooth muscle and endothelial cells, systemic inflammation and oxidative stress could explain vascular alterations in these patients. We aimed at noninvasely evaluating macro- and microvascular dysfunction in cystic fibrosis adults without cardiovascular risk factors. Twenty-twoadults affected by cystic fibrosis and 24 healthy volunteers matched for age and sex were enrolled. None had known cardiovascular risk factors. All people underwent blood pressure measurement, microvascular function assessment by EndoPAT-2000 device (calculating RH-PAT index) and macrovascular evaluation by pulse wave velocity (PWV). RH-PAT index was significantly lower in patients than in controls (1.74±0.59 vs 2.33±0.34; p<0.001). Thirteen patients of 22 had a value inferior to the threshold of 1.67 (59.1%), while no controls had (p<0.001). Carotid-femoral PWV did not differ between the two groups (5.2±1.5 m/s vs 5.4±1.1; p=0.9), while brachial-ankle one did (11.0±2.2 m/s vs 10.1±0.8 m/s; p=0.04).Adults patients affected by cystic fibrosis show peripheral endothelial dysfunction, which is the first alteration in atherosclerotic phenomenon. Moreover, arterial stiffness measured by PWV unclearly seems to differ respect of healthy people, perhaps because PWV alterations are typical of above 50 years old people. It is unclear what prognostic role of future developing of atherosclerotic disease these findings could be, but it seems evident that cystic fibrosis directly affects cardiovascular system itself.

Psoriasis is a systemic inflammatory disease with a great prevalence in general population. The inappropriate activation of the cellular immune system has been hypothesized to be an independent cardiovascular risk factor, given the higher incidence of cardiovascular disorders in psoriatic patients. Echocardiographic abnormalities have been demonstrated too: the aim of our study was to evaluate the presence of preclinical cardiac dysfunction in a cohort of psoriatic patients without cardiovascular risk factors. We enrolled 52 patients with the diagnosis of chronic plaque psoriasis, compared with a control group not affected by any relevant systemic diseases and inflammatory disorders. In all patients and control group, echocardiographic conventional and tissue Doppler (TDI) studies were conducted. The analysis of echocardiographic parameters revealed normal dimension, mass and systolic function of the left ventricle. Left ventricular diastolic dysfunction was found in 36.5% patients in the psoriasis group versus 0% in control group, and significant reduction of the E/A ratio was found also for the right ventricle. A significant increase of mitral regurgitation has been found in psoriatic patients (p=0.005). The early recognition of cardiovascular pre-clinic disease in psoriatic patients may guide a strict follow up and an early treatment, potentially improving cardiovascular prognosis.

The case deals with an anaphylactoid reaction to intravenous ampicillin/sulbactam resulting in cardiogenic syncope and myocardial damage. Symptoms and ECG modifications promptly disappeared after corticosteroids administration. The Kounis syndrome is an acute coronary syndrome, including coronary spasm, acute myocardial infarction and stent thrombosis, resulting from an anaphylactic or anaphylactoid or allergic or hypersensitivity insult. First described in 1991, it can be caused by a lot of substances, particularly antibiotics. The management should be directed to both the allergic reaction and the myocardial damage. The Kounis syndrome is a not rare disease that every physician should know because of the wideness of triggers and the possible fatal evolution if not promptly recognized.

Aim: Red cell distribution width (RDW) is a measure of anisocytosis. Higher values are robustly associated to adverse outcome in several conditions, including chronic heart failure (HF). The present study aimed to compared its prognostic role with that of echocardiographic parameters in this kind of patients., Methods: 32 stable and optimally treated chronic HF patients were enrolled. We excluded subjects suffering from valvular diseases or atrial fibrillation. They underwent blood sampling and echocardiographic examination. The primary endpoint of the study was cardiovascular death and/or HF hospitalization in the first year after enrolment., Results: 49 patients reached the primary endpoint. RDW best cut-off at ROC curve was 14.45%. Univariate analysis associated mitral regurgitation grade, left ventricular ejection fraction (LVEF), posterior wall thickness (PWT), LV mass index, and RDW>14.45% to the primary endpoint. Multivariate regression analysis showed that LVEF, PWT, and RDW>14.45% predict the primary endpoint. Area under ROC curve was 0.808 for LVEF, 0.762 for NYHA class, and 0.761 for RDW., Conclusion: In chronic HF patients RDW is a better predictor of adverse outcome than several echocardiographic parameters associated to outcome itself (LV mass index, mitral regurgitation grade), predicts prognosis even adjusting for those parameters, age and NYHA class, and is associated to several echocardiographic measurements. In conclusion, RDW can expand our tool bag in order to better follow-up these patients.

Aim: Rheumatoid arthritis (RA) shows a high risk for cardiovascular disease, including heart failure. Although TNF-α has been implicated in the pathogenesis of myocardial remodelling, TNF-α inhibition did not show any efficacy in patients with advanced heart failure and should be contraindicated in RA with cardiac complications. We aimed to assess global left ventricular (LV) systolic function using global longitudinal strain (GLS) as a measure of myocardial deformation, in a group of RA patients before and during anti-TNF-α treatment., Methods: 13 patients (female:male 7:6) affected by RA were prospectively followed for one year during anti TNF-α treatment. Every subject underwent echocardiography before starting anti-TNF-α drugs and after one year of treatment, to evaluate LV ejection fraction (EF), telediastolic diameter, telediastolic volume and global longitudinal strain (GLS) that was calculated using 2D speckle tracking as the mean GLS from three standard apical views (2, 3 and 4 -chambers). The patients showed a mean age of 43 years at RA onset (SD: 13) and a mean follow-up of 7.3 years (SD: 4.8). Steroid and methotrexate were used in 84.6% and 100%, respectively, in association with etanercept (6 cases), adalimumab (4 cases) and infliximab (3 cases)., Results: Patients globally showed a normal EF before and after one year of treatment (mean: 65% and 65.7%, respectively). GLS did not differ before or after anti-TNF-α treatment (mean: -15.8% and -16.7%, respectively)., Conclusion: Anti-TNF-α treatment did not significantly modify myocardial contractility after 12 months.

Myocardial infarction may be the result of embolism of calcified material from the aortic valve or thrombotic formations adhering to the same. We report a case of late myocardial infarction secondary to embolization from a thrombus adherent to the aortic valve jutting out in the ostium of the left main coronary artery.

Nonbacterial thrombotic endocarditis (NBTE), known as marantic endocarditis, is a phenomenon due to hypercoagulability with a complex pathogenesis. Originally described by Ziegler, the lesions of NBTE were considered to be fibrin thrombi deposited on normal or superficially degenerated cardiac valves. Numerous reports have identified the relationship between NBTE and a variety of different inflammatory states, including chronic diseases like malignancy and autoimmune disease. NBTE is a serious manifestation of prothtombotic state that is characterized by the deposition of thrombi on previously undamaged heart valves in the absence of a bloodstream bacterial infection and by the increased frequency of arterial embolic events in patients with chronic debilitating diseases. Although hypercoagulability is often seen in patients with pancreatic cancer, NBTE has rarely been reported antemortem. We report a case of marantic endocarditis in patient with pancreatic cancer, in which neurological symptoms preceded the diagnosis of pancreatic cancer.

Bromocriptine and cabergoline, ergot derived dopamine receptor agonists used to treat Parkinson's disease and prolactinomas, have been associated with increased risk of cardiac valve disease. Here we present a case of iatrogenic symptomatic severe mitral regurgitation due to these drugs.

Aortic atherosclerosis is the most common disease of the aorta. More than 50% of the plaques thicker than 4 mm are located along the descending aorta. The complex morphology of the plaque, such as ulceration or the presence of thrombi, is associated with increased embolic risk. The increasing use of transesophageal echocardiogram has enhanced the recognition of aortic atheromas. We describe a case of a male patient with complex atherosclerotic disease involving the coronary vessels and descending aortic tract with some embolic complications.

Erythropoietin is a hormone produced by the kidney, which regulates proliferation, differentiation and maturation of red cells. Recombinant human EPO (rH-EPO) is well known to correct anaemia in patients with chronic renal failure in terminal stage. However, recent studies showed the existence of several not haematopoietic effects of erythropoietin. EPO receptors have been found to be expressed in several tissues, included the cardiovascular system. An increase in cardiac systolic function has been observed in patients with chronic heart failure treated with EPO. Other beneficial effects appear to be related to the pro-angiogenic properties on endothelial cells and could be useful for treatment of ischemic heart disease. These findings suggest that EPO could provide potential therapeutic benefits in the management of cardiovascular diseases beyond anaemia correction. This review focuses its attention on the pleiotropic effects of EPO and its future promising applications in cardiovascular pathology.

Peripartum cardiomyopathy (PPCM) is a rare disorder in which left ventricular dysfunction and symptoms of heart failure occur in the peripartum period in previously healthy women. Incidence of PPCM ranges from 1 in 1300 to 1 in 15,000 pregnancies. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The diagnostic criteria are onset of heart failure in the last month of pregnancy or in the first 5 months postpartum, absence of determinable cause for cardiac failure, and absence of a demonstrable heart disease before the last month of pregnancy. Risk factors for PPCM include advanced maternal age, multiparity, African race, twinning, gestational hypertension, and long-term tocolysis. The clinical presentation of patients with PPCM is similar to that of patients with dilated cardiomyopathy. Echocardiography is central to diagnosis. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Treatment is similar to medical therapy for other forms of dilated cardiomyopathy. About half the patients of PPCM recover without complications. The prognosis is poor in patients with persistent cardiomyopathy. Persistence of disease after 6 months indicates irreversible cardiomyopathy and portends worse survival.