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Cardiovascular diseases are the leading cause of death in high-income countries. Exercise prescription is an effective tool for primary and secondary cardiovascular prevention and the cardiovascular benefits of physical activity are well established, ranging from improving the quality of life to reducing mortality. A tailored approach based on patient's personal and clinical characteristics represents a cornerstone for the benefits of exercise prescription. The use of cardiopulmonary exercise testing is well-established for a tailored exercise prescription, as ventilatory thresholds allow to define exercise intensity in a highly individualized manner.

Adolescents and adults with cardiovascular disease who are engaged in sports activity have an increased risk of sudden cardiac death (SCD) related to the sports practice that acts as a trigger for life-threatening ventricular arrhythmias. Premature ventricular beats (PVBs) detected in athletes at the time of pre-participation screening may be a sign of heart disease at risk of SCD but are also found in athletes without cardiovascular abnormalities. Thus, the interpretation of PVBs could represent a clinical dilemma. However, while some characteristics of PVBs can be considered common and benign, others occur uncommonly in the athletic population and raise the suspicion of underlying cardiovascular disease. This review discusses the prevalence and the clinical significance of PVBs in the athlete, with a focus on exercise-induced PVBs, on the analysis of PVB's morphology at 12-lead ECG, and on the morphological substrates identified by imaging techniques. The implications on eligibility for competitive sports participation are also discussed, according to the relevance of PVBs detection for disqualifying athletes from competitions.

The worldwide spread of smartphones has radically changed the habits of human life, allowing a 24/7 connection with other people. These changes have involved also Medicine with smartphones being able to simplify the clinical practice of physicians. The development of new external devices that can be connected to smartphones has further increased their use with mobile phones converted in portable electrocardiogram or echocardiogram machines. This extraordinary technological improvement seems to be partly in conflict with the classical tools available for the cardiologist, such as the "old" stethoscope that in 2016 had its 200th anniversary. This article focuses on the smartphone as a new tool available for the physicians, describing the most important potential uses and reporting an analysis of pros and cons of the smart-cardiology.

Speckle tracking echocardiography (STE) has recently emerged as a quantitative technique to accurately estimate myocardial function. By the analysis of the motion of speckles in the two-dimensional ultrasonic image, this technique allows a non-Doppler angle-independent objective analysis of myocardial deformation, with the possibility to quantify thickening, shortening and rotation dynamics of cardiac function. Since this technique does not require Doppler imaging, the analysis is relatively angle-independent and is marginally affected by cardiac in-plane motion artifacts. Data regarding feasibility, reproducibility and diagnostic accuracy appear to be optimal in several clinical contexts. This review describes the fundamental concepts of deformation imaging, explains how to obtain myocardial deformation measurements in clinical practice and highlights current clinical applications of STE. In addition, in relation with the recent extension of STE to three-dimensional echocardiography with the potential for a more comprehensive analysis of global and segmental myocardial function, a window is also opened on the perspectives of three-dimensional STE.

We describe the case of a patient with a mitral bioprosthetic valve undergoing percutaneous closure with fluoroscopy and echocardiographic guidance of a rare left sinus of Valsalva‒left atrial fistula. The original aspect of this case is that the fistula was located at the level of the left sinus of Valsalva next to the mitral valve bioprosthesis with subsequent risk of prosthesis damage and/or occlusion of the left coronary artery at its origin during the procedure.

Pulmonary embolism is a major health problem. Clinical presentation may vary from cardiovascular emergency with high mortality risk to mild or atypical illness, and the diagnosis is not always easy. However, the timeliness of diagnosis and prognostic stratification are crucial because immediate treatment and thromboembolic prophylaxis are highly effective. Echocardiography can play a key role in pulmonary embolism regarding different aspects: diagnosis, risk stratification, and follow-up but sometimes it is not properly used. Therefore, it is important for a physician to know exactly how to utilize echocardiography in pulmonary embolism. The purpose of this paper is to review the role of echocardiography as part of the diagnosis, management and follow-up of acute pulmonary embolism in the light of current literature.

Atrial fibrillation is the most common arrhythmia encountered in clinical practice. Cardiologists are often called upon to manage atrial fibrillation both in the acute urgent setting for the presence of hemodynamic compromise and electively for rhythm and/or heart rate control as well as for anti-remodeling strategies. In all these cases echocardiography is generally used. In particular, different echocardiographic techniques (transthoracic, transesophageal) and modalities (two-dimensional, three-dimensional, speckle tracking) can be indicated depending on the stage of the arrhythmia management and the need for cardioversion or interventional procedures. The purpose of this review is to clarify the current role of echocardiography, including specific techniques and modalities, in the managing process of atrial fibrillation.

The introduction of three-dimensional echocardiography and its evolution from time-consuming and cumbersome off-line reconstruction to real-time volumetric technique (real-time three-dimensional echocardiography) are one of the most significant advances in ultrasound imaging of the heart of the past decade. This imaging modality currently provides realistic views of cardiac valves capable of demonstrating the anatomy of various heart valve diseases in a unique, noninvasive manner. In addition, real-time three-dimensional echocardiography offers completely new views of the valves and surrounding structures, and allows accurate quantification of severity of valve disease. This article reviews the advantages of real-time three-dimensional echocardiography in assessing heart valves and shows also technological limitations in order to provide the scientific basis for its clinical use.

Tricuspid valve (TV) morphology and function evaluation plays a key role in several cardiac diseases, including left-sided valvular diseases and heart failure. However, TV is structurally complex and, differently from aortic and mitral valves, cannot be visualized in a single two-dimensional echocardiographic view, neither transthoracic nor transesophageal (i.e., simultaneous imaging of the three TV leaflets and their attachment to the annulus is not feasible). Conversely, real-time three-dimensional transthoracic echocardiography allows complete visualization of the TV apparatus from multiple views. This can lead to an improvement of our understanding about the pathophysiological mechanisms underlying TV diseases and functional tricuspid regurgitation, and may suggest new surgical techniques in order to improve surgical outcomes. The present review focuses on the state-of-the-art of real-time three-dimensional transthoracic echocardiography in TV morphology and function evaluation with its clinical applications and limits.

The definition of the athlete's heart includes the mechanisms of cardiac adaptation to training, characterized by the increase of internal chamber dimensions, ventricular wall thickness, and atrial chambers. The morphology of the athlete's heart is intermediate between concentric and eccentric left ventricular hypertrophy (LVH), in relation to the large prevalence of mixed sports activities and training protocols (including both aerobic and anaerobic exercise). Echocardiography is the tool of choice for the assessment of the athlete's heart and also for the differentiation of physiologic and pathologic LVH (hypertrophic cardiomyopathy and LVH due to arterial hypertension). The initial echocardiographic approach includes the quantitative analysis of the left ventricle, in order to calculate left ventricular mass, left ventricular mass index and relative wall thickness for diagnosing concentric or eccentric LVH. Tissue Doppler (pulsed or color modality) and strain rate imaging (Doppler or two-dimensional modality) may give additional information to the standard indices of systolic function. Diastolic function can be evaluated not only by standard Doppler transmitral inflow measurements but also using pulsed tissue Doppler, which may allow to distinguish the athlete's LVH from diastolic impairment of hypertensive patients or hypertrophic cardiomyopathy by the simple determination of myocardial early diastolic velocity. Also the morphological and functional features of the left atrium and of the right ventricle can be assessed in the athlete's heart by combining standard echocardiography with new echocardiographic technologies.

Several studies have demonstrated the usefulness of B-type natriuretic peptide (BNP) dosage in patients referring for acute dyspnea in the emergency department. BNP is strongly associated not only with the evidence but even with the degree of heart failure, and BNP values are particularly increased in the advanced NYHA classes and in patients with poor prognosis. High BNP levels correlate with echocardiographic indexes of left ventricular and right ventricular systolic dysfunction but even better with diastolic dysfunction and degree of left ventricular filling pressure. However, in presence of some clinical confounders, such as obesity, renal insufficiency and anemia, BNP dosage itself cannot be interpretable. Under these circumstances, Doppler echocardiography is able to identify with better accuracy patients affected by heart failure. Algorithms built taking into account clinical and echocardiographic parameters as well as BNP measurements are already available in the guidelines of the European Society of Cardiology on heart failure with normal ejection fraction. They will lead to a better and earlier identification, better risk stratification and management of patients referring for heart failure.

In the last decades the introduction and development of echocardiography allowed a significant improvement in the diagnosis as well as in the morphological and functional evaluation of several heart diseases, and today many therapeutic decisions are taken based on the results of the echocardiographic examination. One of the most important development in the field of echocardiography is three-dimensional imaging, which has evolved from the slow and labor-intense off-line reconstruction techniques to the faster and simpler real-time volumetric imaging, which has the potential to be integrated in routine clinical practice. One of the major proven advantages of real-time three-dimensional echocardiography is the evaluation of left ventricular volume, mass and function, which is achieved by eliminating the need for geometric modeling and the errors caused by foreshortened views. In this review we discuss the state-of-the-art and anticipate future developments of real-time three-dimensional echocardiography that are relevant to its application to the left ventricle.

The possibilities of applying the laws of dynamics to the study of myocardial mechanics are remarkable and to some extent neglected to characterize ventricular performance by the imaging techniques. There are potentially useful applications derived from the analyses of Doppler flow velocity profiles of left ventricular outflow to be applied to the study of cardiovascular dynamics. They include ejection force, pressure-volume work and ventricular power. All these variables require measurements that are easy to obtain even during a standard examination, like stroke volume, ventricular outflow velocity, and the velocity-time integral.

The objective of this review was to explore the clinical relevance of Doppler echocardiographic techniques in the evaluation of right and left ventricular function. It is well known that echocardiographic and Doppler analysis are able to provide information about several hemodynamic parameters, such as cardiac output, diastolic filling pressure, vascular resistances and pulmonary arterial pressures. This integrated approach, completely reliable and non-invasive, could allow to obtain useful information not only from a diagnostic and prognostic point of view but also for a potential therapeutic management, either pharmacological or surgical. This review summarizes the current knowledge and the emerging applications of echocardiographic and Doppler techniques focusing on the close correlation between Doppler-derived data and those coming from invasive techniques. On the basis of these evidences, the importance, even in daily clinical practice, of a non-invasive catheterization laboratory is clear and able to supply key information about ventricular function and, at the same time, to avoid expensive and unpleasant invasive procedures for patients.

Syncope and pre-syncope represent common symptoms in patients with hypertrophic cardiomyopathy. The clinical scenario of recurrent and frequent syncopal episodes is one of the most challenging in the management of patients with hypertrophic cardiomyopathy. Syncope in hypertrophic cardiomyopathy patients usually recognizes two underlying mechanisms: arrhythmias or primary hemodynamic mechanism. The concomitant presence of myocardial ischemia is one of the potential triggers in the context of syncope due to hemodynamic mechanism. Myocardial ischemia is not generally related to epicardial coronary artery atherosclerotic disease but rather to the presence of partially obliterated intramural coronary arteries or narrowed vessels. We report the rare case of a patient with hypertrophic cardiomyopathy presenting with recurrent syncopal episodes due to myocardial ischemia secondary to severe stenosis of the left anterior descending coronary artery.

In cardiology, ventricular function has extensively been studied, whereas atrial function received less attention. For such a reason atrial function is less known. The aim of this review was to summarize the role of atrial function and to explain how echocardiography and new echocardiographic-derived techniques may be of help to better study atrial function.

Tissue Doppler is an ultrasound tool representing a useful completion of standard Doppler echocardiographic examination, The placement of pulsed tissue Doppler sample volume at the level of the different sites of the mitral annulus allows to obtain information on left ventricular global longitudinal (systolic and diastolic) function, whereas the sampling of tricuspid lateral annulus gives similar information on the right ventricular chamber. Myocardial early diastolic velocity (Em) is a marker of ventricular diastolic relaxation and the ratio obtainable between transmitral (or transtricuspid) E velocity and annular Em (E/Em ratio) is an accurate index of the level of filling pressure of the assessed ventricular chamber. Myocardial systolic velocity (Sm) as well as the frequency of acceleration of presystolic velocity, occurring during isovolumic contraction time, are indexes of systolic performance and their reduction is evident in several cardiac pathologies. Tissue Doppler-derived systolic and diastolic indexes have a recognized prognostic value in heart failure and after acute myocardial infarction. In these conditions they are able to predict both left ventricular remodeling and mortality.

In the last years the industry has created echocardiographic portable machines of reduced size, available for a growing number of operators. After the first experiences of the '70s, hand-held echocardiography (HHE) is earned interesting commercial positions. The transportability of these machines allows to perform examinations outside the echo-lab and provides diagnostic information in heterogeneous locations such as intensive care unit, emergency room and outpatient structures, at the bedside and even in ambulance. HHE can be useful for detection of several pathologies including aortic aneurysms and left ventricular hypertrophy, regional wall motion abnormalities, pericardial and pleural effusion. To date, four main kinds of HHE can be distinguished: a first, high-cost variety, including miniaturized machines, equipped with instrumentations of standard echocardiography and even new softwares for tissue Doppler and myocardial contrast echocardiography; a second kind of machines of high level but not miniaturized; a third (intermediate level and low cost), and a fourth one (basic level and very low cost), including "cardioscopes" corresponding to the ultrasound stethoscope, able to complete efficaciously the clinical examination. The introduction of HHE opens controversy about its diagnostic accuracy, the opportunity to establish the clinical scenario where it should be utilized and the identification of the potential users and the needed competence level. Preliminary experiences show the possibility of improving and anticipating the diagnosis of several cardiac diseases but also the need to plan specific ultrasound training to avoid inappropriate use of HHE.

To date, right ventricular function can be clinically assessed by Doppler echocardiography. Monodimensional and two-dimensional echocardiography provide information about right ventricular dimensions, wall thickness and tricuspid annular plane systolic excursion, which is an accurate estimate of longitudinal systolic function. Additional insights into right ventricular systolic function are given by Doppler interrogation of right ventricular outflow, measuring the duration of systolic time intervals. The Doppler recordings of the tricuspid inflow and hepatic venous flow allow the assessment of right ventricular diastolic properties. Also the new ultrasound technologies are clinically useful. The myocardial velocities and time intervals, detectable by pulsed tissue Doppler at the level of the tricuspid annulus, are markers of systolic and diastolic longitudinal motion of the right ventricle. The off-line strain rate imaging permits quantification of right ventricular myocardial contractility and may be particularly useful for the assessment of congenital cardiomyopathies. The right ventricular filling pressure and pulmonary arterial pressure may be derived by the combined analysis of the grade of tricuspid regurgitation and the respiratory reactivity of the inferior vena cava. The systolic time intervals, measured at the level of the right ventricular outflow, represent estimates of changes in pulmonary vascular resistance. The prognostic value of Doppler echocardiographic measurements of right ventricular function is demonstrated in various pathologies. This evaluation also provides additional value for the risk stratification of patients with chronic heart failure.

Background and Aims: The recreational use of cocaine is associated with cardiovascular pathologies, such as ischemic cardiopathy, myocarditis and cardiomyopathies, owing to the increased catecholamine stimulus, a propensity to coronary spasm, increased coagulative activity and inflammatory and degenerative phenomena of myocardiac cells. Early alterations of the diastolic phase may be visualised by evaluating the diastolic Doppler pattern of left ventricular filling., Methods: For this purpose the authors compared blood pressure, heart rate, heart mass, protodiastolic (E wave) and telediastolic (A wave) filling rate and their ratio (E/A) on the Dopper mitral diastolic profile in a group of 10 patients addicted to the recreational use of cocaine (mean age 33 +/- 7) with those of 10 normal subjects (mean age 34 +/- 2)., Results: Patients using cocaine presented mean systolic arterial blood pressures of 130 +/- 12 versus 127 +/- 8 in control subjects (p = ns); mean heart rate was statistically significant with 98 +/- 14 versus 76 +/- 12 in controls (p < 0.05). There were no differences in cardiac mass between the two groups. In cocaine addicts the speed of the E wave was significantly slower: 58.4 +/- 8.6 versus 73 +/- 7.4 cm/sec (p < 0.05), and the speed of the A wave was significantly higher: 70.5 +/- 10.5 versus 62.6 +/- 4.3 cm/sec (p < 0.05), when compared with normal controls subjects; the E/A ratio of cocaine addicts was lower (0.75 +/- 0.34) compared to normal subjects (1.07 +/- 0.7), (p < 0.05)., Conclusions: These data show that patients addicted to the recreational use of cocaine show preclinical alterations of the left ventricular diastolic phase prior to the onset of clinically evident pathologies.

Backgrounds: Various cardiac abnormalities have been described in patients with Behçet's disease. The number of reports remains small, but increasing awareness have widened the spectrum of manifestations. We report our evaluation of cardiac involvement in 15 patients affected by Behçet's disease, diagnosed according to the criteria for the International Study Group for Behçet's Disease., Patients and Methods: All the patients have been examined by a clinical, biochemical and instrumental point of view. Six patients resulted to be affected by heart diseases, in particular by mitral valve prolapse; moreover one of them presented an unexpected dilatative cardiomyopathy., Conclusions: The authors affirm that the pathological heart features are not so uncommon as previously reported in literature, emphasizing the necessity of a constant evaluation for the cardiovascular system also in the asymptomatic patients.

To assess the anti-arrythmic effect of L-carnitina, propafenone and mexiletine, we tested the drugs in 50 patients with effort angina and ventricular ectopic beats (VEB). The patients were randomized in 5 groups: Group A: was treated with oral L-carnitine at the dose of 2 g x 3 for two weeks. Group B: oral propafenone at the dose of 300 mg x 3 for two weeks. Group C: as group B+L-carnitine+g x 3 at the second weeks. Group D: oral mexiletine at the dose of 200 mg x 3 for two weeks. Group E: as group D+L-carnitine 2 gr x 3 at the second week. After 7 and 14 days of treatment, in all patients an Holter examination was performed. Our results show that L-carnitine exerts a significant reduction of the VEB and its administration potentiates the anti-arrythmic effect of propafenone and mexiletine.

Aim of this study is to point out a correct therapy for the treatment of poligenic hypercholesterolemia resistant to dietetic treatment. There have been studied 40 patients which, after repeated haematochemical controls, resulted affected by dyslipidaemia with prevalent increase of the cholesterol levels. After 30 days of standard hypo-caloric dietetic treatment were enrolled 23 patients, 13 males and 10 females, who presented a plasmatic cholesterol level superior to 250 mg% and LDL superior to 160 mg%. All the patients continued the dietetic treatment; 10 patients began pravastatin therapy at a dose of 20 mg/die while to the rest of them was given placebo. The 30th, 60th, 120th day were controlled the following haematochemical parameters: lipidic frame haematology, hepatic and renal function, glycemia and CPK. After 4 months of treatment the average plasmatic levels of cholesterol resulted different in the two groups: mg% (p < 0.001) in the pravastatin group and 262 mg% (P = ns) in the control group. Then, the pravastatin therapy was suspended and all 23 patients continued for 30 days, dietetic treatment and placebo. After 6 months a new control of the lipidic frame was performed. Our results showed that the hypocholesterolic therapy must be continued for ever. In fact, the suspension of the treatment is followed by an immediate rebound of the dislipidaemia which plasmatic cholesterol levels even superior to the basic levels with probable negative repercussion on the cardiovascular system.

In order to evaluate a possible antiarrhythmic action of L-carnitine (C) in ischemic heart disease, 30 patients (20 males, 10 females, average age 64 years +/- 11) with ischemic heart disease who at examination with 24-hour dynamic ECG showed extrasystolic ventricular multifocal arrhythmia with a mean hourly rate of > 300 were randomized into three groups, the first of which was given a daily oral dose of 6 g C in three divided doses; groups 2 and 3 were given propafenone (P), 900 mg daily in three divided doses. After one week, all patients were again submitted to 24-hour dynamic ECG after which treatment was continued for another week as follows: group 1 continued on C (6 g daily), group 2 continued on P (900 mg daily), group 3 continued on P (900 mg daily) plus C (6 g daily). At the end of the second week, a further 24-hour ECG was performed the results of which showed that L-carnitine can significantly reduce the antiarrhythmic activity of the ischemic myocardium. In addition, at the end of the second week, a further significant reduction of the number of premature beats compared to the first week was found in patients for whom L-carnitine had been added to propafenone treatment.

Every form of therapy must always aim at obtaining maximum benefit with minimum use of drugs; also for the purpose of ensuring maximum patient compliance. With this end in mind, 21 patients with ischemic heart disease and arterial hypertension were divided into three groups of seven subjects each and submitted to different drug treatments with single daily doses: group 1 received isosorbide-5-mononitrate (60 mg), group 2 amlodipine (10 mg), and group 3 a combination of both drugs at the same dosage, for four weeks. Statistical analysis showed blood pressure values to have been significantly reduced in subjects receiving amlodipine both alone and in combination (p less than 0.05) while no significant variation was observed (p = n.s.) in those treated with isosorbide-5-mononitrate only. A significant reduction of diastolic blood pressure (p less than 0.05) occurred only in patients talking the combination. No significant changes of heart rate (p = n.s.) were observed in any of the groups. Tests at the cycling ergometer revealed increased in any of the groups. Tests at the cycling ergometer revealed increased maximal effort tolerance for all three groups but the increase was more marked in patients taking the combination (who from 130 +/- 10 Watt increased to 160 +/- 20 Watt). This was confirmed also by the reduced consumption of trinitrine capsules which diminished in groups 1 and 2 from an average of 5/week to 2/week but was completely abolished in group 3. Also ST depression was significantly reduced (p less than 0.05) only in this latter group.(ABSTRACT TRUNCATED AT 250 WORDS)

We describe the case of a 51-year old, non cardiopathic patient, with recurrent attacks of supraventricular tachycardia induced by swallowing. In the existing literature we found several descriptions of hypokinetic arrhythmias, easily explained by a mechanism of vagal inhibition. The cases of predominantly hyperkinetic arrhythmias, however, are much less common. In these patients the origin of the disease seems to be due to sympathetic oesophageal fibers and superior and medium cardiac nerves. In the present case, as in the others reported in the literature, the drug of choice seems to be Amiodarone which appears to be the most effective in preventing tachyarrhythmias caused by swallowing.

The effect of a single oral dose (50 mg) of captopril was studied in 12 hypertensive patients divided into 2 groups: 6 had a normal hemodynamic profile; the other 6 had NYHA class III or IV heart failure. Medical history and clinical and laboratory investigation showed that the heart failure was due exclusively to arterial hypertension. Mean arterial pressure (MAP), aldosterone, plasma renin activity (PRA) and atrial natriuretic factor (ANF) were followed for 4 hours after administration of captopril. MAP values showed a similar decrease in the 2 groups but the variations in the 3 hormones were much greater in the second group. This group showed higher basal levels of PRA, aldosterone and ANF; after stimulation PRA increased sharply preceded by a substantial decrease in aldosterone and ANF. To explain this phenomenon, the Authors propose that the liver of the patients with heart failure is unable to rapidly compensate the reduction in synthesis of angiotensin II caused by the drug with a corresponding increase in angiotensinogen production; the consequent sharp drop in plasma aldosterone would lead to a rise in renin production by the kidney. The arteriolar and venous vasodilatation induced by the ACE-inhibitor, would explain the drop in intra-atrial pressure with reduced plasma levels of ANF. The decrease in ANF could also be caused by the inhibition of the renin-angiotensin system of the heart leading to improved blood supply and hence myocardial contractility.

The authors report the clinical history of a 56-year-old man with cardiomyopathy due to undiagnosed hypocalcemia. Heart dilation and hypokinesia were assessed by echocardiography. Cardiac failure was refractory to digitalis preparations and to diuretics. The restoration of serum calcium to normal levels obtained with adequate therapy dramatically improved the motion of ventricular walls and decreased the size of the left ventricle. The pathogenetic mechanisms of hypocalcemic cardiomyopathy are discussed and the importance of considering the possibility of hypocalcemia when dealing with the differential diagnosis of cardiomyopathies is underlined. In the presence of hypocalcemic cardiomyopathy, the correction of calcium deficiency with calcitriol is the treatment of choice.