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Ejection fraction (EF) is still widely used to categorize heart failure (HF) patients but has limitations. Global longitudinal strain (GLS) has emerged as a new prognosticator in HF, independent of EF.We investigated the incremental predictive benefit of GLS over different risk profiles as identified by automated cluster analysis of simple echocardiographic parameters.In 797 HFrEF patients (age 66 ± 12y; mean EF 30 ± 7%), unsupervised cluster analysis of 10 routine echocardiographic variables (without GLS) was performed. Median follow-up was 37 months. End-point was all-cause mortality. Association between risk profiles, GLS, and mortality was assessed by Cox proportional-hazard modeling with interaction term. Cluster analysis allocated patients to 3 different risk phenogroups (PG): PG-1 (mild diastolic dysfunction [DD], moderate systolic dysfunction, no pulmonary hypertension, normal right ventricular [RV] function); PG-2 (moderate DD, mild pulmonary hypertension, normal RV function); PG-3 (severe DD, advanced systolic dysfunction, pulmonary hypertension, RV dysfunction). Compared to PG-1, PG-2 and PG-3 showed increased adjusted-hazard ratio (1.71; 95% CI:1.05-2.77, P = 0.30; and 2.58; 95% CI:1.50-4.44, P 0.001, respectively). GLS was independently associated with outcome in the whole population (adjusted-HR: 1.11; 95% CI: 1.05-1.17, P = 0.001); however, profile membership modified the relationship between GLS and outcome which was no longer significant in PG-3 (P for interaction = 0.003).Within HFrEF populations, clustering of routine echocardiography parameters can automatically identify patients with different risk profiles; further assessment by GLS may be useful for patients with not advanced disease.

Coronary artery disease is a major underlying etiology for heart failure. The role of coronary microvascular disease, and endothelial dysfunction, in the pathophysiology of heart failure is poorly appreciated. Endothelial dysfunction, induced by oxidative stress, contributes to the development of heart failure. Alterations of endothelial function and nitric oxide-cyclic guanosine monophosphate (NO-cGMP) pathway are involved in the pathophysiology of heart failure with both reduced and preserved ejection fraction. Indeed, an altered endothelium dependent vasodilatation, causing repeated episodes of ischemia/reperfusion, can induce a chronic stunned myocardium with systolic dysfunction and an increased diastolic stiffness with diastolic dysfunction. Moreover, the altered NO-cGMP pathway directly affects myocardial homeostasis. Endothelial dysfunction is associated with worse prognosis and higher rate of cardiovascular events. Potential therapeutic strategies targeting the NO-cGMP pathway in patients with HF will be discussed in this review article. Although clinical data are still inconclusive, the NO-cGMP pathway represents a promising target for therapy.

Background Patients with heart failure undergoing cardiac resynchronization therapy with or without defibrillator function may exhibit recovery of left ventricular ejection fraction (LVEF) during follow-up. Mechanical dispersion (MD; the SD of time to peak longitudinal strain by two-dimensional speckle-tracking echocardiography) is a known predictor of life-threatening ventricular arrhythmias (VAs). Relationships among LVEF recovery, changes in MD, and incidence of VA are still not extensively investigated. Methods In this retrospective study, recipients of cardiac resynchronization therapy defibrillation (n = 183) or implantable cardioverter-defibrillators only (n = 87) underwent conventional and speckle-tracking echocardiography, both at baseline and after 10 to 12 months, and were followed clinically. Both a ≥10% increase in LVEF and a final LVEF > 35% defined echocardiographic response (EchoResp). Reduction in MD ≥10 msec defined MD response (MDResp). Risk for appropriate implantable cardioverter-defibrillator therapy for VAs was assessed using a multivariable Cox hazard model. Results The prevalence of EchoResp+ and MDResp+ was 39% and 46%, respectively. During follow-up (49.8 ± 33.5 months), 74 VA events occurred. The incidence rate (per 100 patient-years) of VAs was lowest in the EchoResp+/MDResp+ group (1.66%; 95% CI, 0.69%-3.99%), highest in the EchoResp−/MDResp− group (12.8%; 95% CI, 9.53%-17.2%; P 71.4 msec) was associated with VAs independent of whether final LVEF was below or above the guideline-reported cutoff of 35% (P Conclusions Among ICD recipients, improvements in both left ventricular function and MD are associated with reduced risk for VAs. In patients whose follow-up LVEFs improved to >35%, risk for VAs, although substantially decreased, remained elevated in the presence of still elevated MD.

BACKGROUND: In a prior trial of late sodium channel inhibition (ranolazine) among symptomatic subjects without obstructive coronary artery disease (CAD) and limited myocardial perfusion reserve index (MPRI), we observed no improvement in angina or MPRI, overall. Here we describe the clinical characteristics and myocardial perfusion responses of a pre-defined subgroup who had coronary flow reserve (CFR) assessed invasively. METHODS: Symptomatic patients without obstructive CAD and limited MPRI in a randomized, double-blind, crossover trial of ranolazine vs. placebo were subjects of this prespecified substudy. Because we had previously observed that adverse outcomes and beneficial treatment responses occurred in those with lower CFR, patients were subgrouped by CFR

Objectives The aim of this study was to assess the relationship between gait speed and the risk for death and/or hospital admission in older patients with heart failure (HF). Background Gait speed is a reliable single marker of frailty in older people and can predict falls, disability, hospital admissions, and mortality. Methods In total, 331 community-living patients ≥70 years of age (mean age 78 ± 6 years, 43% women, mean ejection fraction 35 ± 11%, mean New York Heart Association functional class 2.7 ± 0.6) in stable condition and receiving optimized therapy for chronic HF were prospectively enrolled and followed for 1 year. Gait speed was measured at the usual pace over 4 m, and cutoffs were defined by tertiles: ≤0.65, 0.66 to 0.99, and ≥1.0 m/s. Results There was a significant association between gait speed tertiles and 1-year mortality: 38.3%, 21.9%, and 9.1% (p Conclusions Gait speed is independently associated with death, hospitalization for HF, and all-cause hospitalization and improves risk stratification in older patients with HF evaluated using the Cardiac and Comorbid Conditions Heart Failure score. Assessment of frailty using gait speed is simple and should be part of the clinical evaluation process.

Background Left atrial (LA) volume is a marker of cardiac remodeling and prognosis in heart failure (HF) with reduced ejection fraction (EF), but LA function is rarely measured or characterized. We investigated determinants and prognostic impact of LA reservoir function in patients with HF with reduced EF. Methods and Results In 405 patients with stable HF with reduced EF (EF, ≤40%) in sinus rhythm, we assessed LA reservoir function by both LA total EF (by phasic volume changes) and peak atrial longitudinal strain (PALS; by speckle tracking echocardiography); LA functional index was also calculated. During follow-up (median, 30 months; Q1–Q3, 13–52), 139 patients (34%) reached the composite end point (all-cause death/HF hospitalization). Median PALS was 15.5% (interquartile range, 11.2–20.6). By univariable analysis, all LA function parameters significantly predicted outcome ( P P =0.030). Adding PALS to a base model, including age, sex, LA volume, EF, E/E′ ratio, and global longitudinal strain, provided incremental predictive value (continuous net reclassification improvement, 0.449; P =0.0009). Conclusions In HF with reduced EF, assessment of LA reservoir function by PALS allows powerful prognostication, independently of LA volume and left ventricular longitudinal contraction.

Global right ventricular (RV) longitudinal strain (RVGLS) and free wall RV longitudinal strain (RVFWS) have both been advocated as sensitive tools to evaluate RV function and predict prognosis in patients with heart failure and reduced ejection fraction (HFrEF). However, because the interventricular septum is an integral part of the left ventricle (LV) also, RVGLS might be influenced by LV dysfunction. Thus, we compared the prognostic performance of either RV strain parameter in HFrEF patients, also taking into account the degree of LV systolic dysfunction.In 288 prospectively enrolled outpatients with stable HFrEF, RVGLS and RVFWS were assessed by speckle-tracking and LV systolic function by global longitudinal strain and LV ejection fraction. Patients were followed up for 30.2 ± 23.0 months; the primary endpoint was all-cause death/heart failure-related hospitalization. Prognostic performance was assessed by C-statistic and net reclassification improvement.There were 95 events during follow-up. By univariable analysis, both RVGLS (hazard ratio × 1 SD, 1.60; 95% CI, 1.29-1.99; P .0001) and RVFWS (hazard ratio × 1 SD, 1.82; 95% CI, 1.45-2.29; P .0001) were associated with outcome, and both remained significant after correction for EMPHASIS risk score, New York Heart Association class, natriuretic peptides, and therapy. However, after further correction for LV systolic function parameters, only RVFWS remained significantly associated with outcome (P .01). A basic prediction model was improved by adding RVFWS (net reclassification improvement 0.390; P .05), but not RVGLS.Although both RVGLS and RVFWS have prognostic value, RVFWS better predicts outcome in HFrEF patients, mainly because it is less influenced by LV longitudinal dysfunction.

Background and aims Elevated serum uric acid (sUA) concentrations have been associated with worse prognosis in heart failure (HF) but little is known about elderly patients. We aimed to assess long-term additive prognostic value of sUA in elderly patients hospitalized for HF. Methods and results Clinical and echocardiographic characteristics of 310 consecutive elderly patients hospitalized for HF were collected. During index period, 206 had sUA concentrations available, which were obtained within 24 h prior to discharge; 10 patients were lost to follow-up, leaving 196 patients available. Patients had a median age of 77 (IQR 69–83) years, and were mostly male (64.5%). sUA ranges for tertiles I–III were: 1.5–6.1, 6.2–8.3, and 8.4–18.9 mg/dl, respectively. During a median follow-up of 27 months (IQR 10.5–39.5), 122 combined events occurred (87 deaths and 73 HF rehospitalizations). Four-year event-free survival for the combined endpoint was 46 ± 7% for tertile I, 34 ± 7% for tertile II, and 21 ± 5% for tertile III (P = 0.001). By multivariable Cox backward analysis, sUA was retained as a significant predictor. Compared with the lowest sUA tertile, tertile III showed a strong association with outcome, also after adjustment for other predictors (HR 1.84, 95% CI 1.16–2.93; P = 0.01). Importantly, addition of sUA to the other significant predictors of outcome resulted in improved risk classification (net reclassification improvement 0.19, P = 0.017). Conclusions High sUA at discharge is a strong predictor of adverse outcome in elderly hospitalized for HF, and it significantly improves risk classification. Measuring sUA can be a simple and useful tool to identify high-risk elderly hospitalized for HF.

Background— In heart failure (HF) with reduced ejection fraction, right ventricular (RV) impairment, as defined by reduced tricuspid annular plane systolic excursion, is a predictor of poor outcome. However, peak longitudinal strain of RV free wall (RVFWS) has been recently proposed as a more accurate and sensitive tool to evaluate RV function. Accordingly, we investigated whether RVFWS could help refine prognosis of patients with HF with reduced ejection fraction in whom tricuspid annular plane systolic excursion is still preserved. Methods and Results— A total of 200 patients with HF with reduced ejection fraction (age, 66±11 years; ejection fraction, 30±7%) with preserved tricuspid annular plane systolic excursion (>16 mm) underwent RV function assessment using speckle-tracking echocardiography to measure peak RVFWS. After a median follow-up period of 28 months, 62 (31%) patients reached the primary composite end point of all-cause death/HF rehospitalization. Median RVFWS was −19.3% (interquartile range, −23.3% to −15.0%). By lasso-penalized Cox-hazard model, RVFWS was an independent predictor of outcome, along with Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure-HF score, Echo-HF score, and severe mitral regurgitation. The best cutoff value of RVFWS for prediction of outcome was −15.3% (area under the curve, 0.68; P P P Conclusions— In patients with HF with reduced ejection fraction with preserved tricuspid annular plane systolic excursion, RV free-wall strain provides incremental prognostic information and improved risk stratification.

No-reflow, i.e., the lack of distal myocardial perfusion to fully recover following recanalization of an acutely occluded coronary artery, is not only a mere consequence of ischemic injury, as substantial microvascular alterations may also develop subsequently, after initial restoration of perfusion. Since part of perfusion impairment is secondary to events set in motion by reperfusion, this gives way to the possibility of preventing it through adequate interventions. Duration and severity of ischemia influence the occurrence of reperfusion-mediated no-reflow, since severity of ischemic injury sets the stage for events which actually unfold after restoration of blood flow. Proposed mechanisms of no-reflow are impaired vasodilation, intravascular thrombosis, and accumulation of neutrophils in the microvasculature, orchestrated by activation of vascular endothelium. Experimental studies have unraveled much of mechanisms of noreflow, and delineated possible ways of intervention. Despite successful experimental data, in the clinical setting results have been much less encouraging, and no drug can be currently recommended for routine use to prevent or treat microvascular injury and no-reflow in patients. Reperfusion-mediated impairment of microcirculation in postischemic hearts remains a challenges for investigators and clinicians alike. Large multicenter studies, specifically aimed at evaluating the effects of the more promising interventions (adenosine, nicorandil, statins, ACE inhibitors or angiotensin II receptor blockers) need to be designed and performed, to test the effect of these promising interventions on microvascular alterations during postischemic reflow, and their ability to improve tissue perfusion, myocardial function and prognosis in patients with acute myocardial infarction.

Ischemic heart disease (IHD) is the leading cause of death among women in Western countries, and it is associated with higher morbidity and mortality than in men. Nevertheless, IHD in women remains underdiagnosed and undertreated, and the misperception that females are "protected" against cardiovascular disease leads to underestimation of their cardiovascular risk; instead, women with chest pain have a high risk of cardiovascular events. Women suffering from angina pectoris tend to have different characteristics compared to men, with a high prevalence of non-significant coronary artery disease. Angina in women is more commonly microvascular in origin than in men, and therefore standard diagnostic algorithms may be suboptimal for women. This different pathophysiology impacts clinical management of IHD in women. While response to medical therapy may differ in women, they are scarcely represented in clinical trials. Therefore, solid data in terms of gender efficacy of antianginal drugs are lacking, and particularly when angina is microvascular in origin women often continue to be symptomatic despite maximal therapy with classical antianginal drugs. Recently, new molecules have shown promising results in women. In conclusion, women with angina are a group of patients in whom it seems appropriate to concentrate efforts aimed at reducing morbidity and improving quality of life.

Background: Myocardial performance index (MPI), or Tei index, is an indicator of systolic and diastolic myocardial function. MPI increases in case of cardiac dysfunction; however, whether reversal of left ventricular dysfunction is also reflected by concomitant improvement (i.e., decrease) of MPI is unknown. Methods: Fifty-two patients with chronic ischemic cardiomyopathy and viable myocardium by dobutamine stress echocardiography were studied by echocardiography before and more than 4 months after cardiac revascularization. Patients were in optimal medical therapy, which remained unchanged following revascularization. Results: At baseline, ejection fraction (EF: 32 ± 6%) and wall motion score index (WMSI: 2.37 ± 0.32) were impaired, and MPI averaged 0.71 ± 0.19. Revascularization markedly improved EF (44 ± 10%, P < 0.0001) and WMSI (1.77 ± 0.44, P < 0.0001). MPI also improved (0.59 ± 0.26, P < 0.0001), and its decrease was significantly correlated with the improvement in EF (r =−0.68, P < 0.0001) and to the extent of viable myocardium (r =−0.45, P = 0.0007). Responders to revascularization (≥5% increase in EF at follow-up, n = 40% and 77%) achieved a significant improvement in MPI at follow-up in contrast with nonresponders (−23 ± 25% vs. 0.02 ± 0.18%, P = 0.001). Improvement in MPI was largely driven by a significant reduction in isovolumic contraction time (P < 0.001) with consequent prolongation of the ejection phase. Conclusion: In patients with chronic ischemic cardiomyopathy, MPI improves along with recovery of function, reflecting the intrinsic improvement of viable segments induced by revascularization. (Echocardiography 2012;29:298-306)

An "unhealthy" diet is considered as a main cause of increased atherosclerotic cardiovascular disease in the industrialized countries. There is a substantial interest in the potential cardiovascular protective effects of "nutraceuticals," that is food-derived substances that exert beneficial health effects. The correct understanding of cardiovascular effects of these compounds will have important implications for cardiovascular prevention strategies. Endothelial dysfunction is thought to play an important role in development and progression of atherosclerosis, and the characterization of the endothelial effects of several nutraceuticals may provide important insights into their potential role in cardiovascular prevention. At the same time, the analysis of the endothelial effects of nutraceuticals may also provide valuable insights into mechanisms of why certain nutraceuticals may not be effective in cardiovascular prevention, and it may aid in the identification of food-derived substances that may have detrimental cardiovascular effects. These findings further support the notion that nutraceuticals do need support from large clinical outcome trials with respect to their efficacy and safety profile for cardiovascular prevention, before their widespread use can be recommended. In fact, the term nutraceutical was coined to encourage an extensive and profound research activity in this field, and numerous large-scale clinical outcome trials to examine the effects of nutraceuticals on cardiovascular events have now been performed or are still ongoing. Whereas it is possible that single nutraceuticals may be effective in cardiovascular prevention, this field of research provides also valuable insights into which food components may be particularly important for cardiovascular prevention, to further advice the composition of a particularly healthy diet. The present review summarizes recent studies on the endothelial effects of several nutraceuticals, that have been intensely studied.

AIMS: Presentation with an acute coronary syndrome (ACS) on chronic aspirin therapy is an independent predictor of adverse short-term outcomes. Whether this finding applies to chronic thienopyridine use, and with the contemporary invasive management of ACS, is unknown. METHODS AND RESULTS: In ACUITY, 13819 patients with moderate and high-risk ACS were studied; patients transferred from an outside hospital were excluded from the present analysis, given uncertain preadmission antiplatelet status. Endpoints included major adverse cardiovascular events (MACE: death, myocardial infarction, or unplanned revascularization), major bleeding, and net adverse clinical events (NACE). Among 11313 study patients, 31 % were naive for antiplatelet agent, 49% were receiving aspirin alone, and 20% were on dual antiplatelet therapy. Chronic antiplatelet users were older and had a higher risk profile. After adjusting for baseline differences, chronic antiplatelet therapy (single or dual) was not associated with an increased incidence of 30-day MACE, bleeding, or NACE. However, patients on chronic aspirin or dual antiplatelet therapy at presentation had significantly higher 1-year rates of MACE [odds ratio (95% confidence interval) = 1.17 (1.01–1.36), P = 0.03 and 1.29 (1.02–1.64), P = 0.03, respectively]. Patients presenting on dual antiplatelet therapy had significantly greater adjusted MACE at 1-year than those on aspirin alone [odds ratio (95% confidence interval) = 1.34 (1.15–1.56), P

Myocardial reflectivity, as assessed by calibrated integrated backscatter (cIB) analysis, is a non-invasive surrogate for the amount of left ventricular (LV) fibrosis. The aim of this study was to assess the myocardial reflectivity pattern in patients with heart failure and preserved ejection fraction (HFpEF), and to evaluate its relationship with longitudinal systolic deformation of LV by 2D-speckle tracking echocardiography, and degree of diastolic dysfunction. Transthoracic echocardiography, myocardial Doppler-derived systolic (Sm) and early diastolic velocity (E'), global longitudinal strain (GLS), and tissue characterization by cIB, were obtained in 86 subjects, 46 with HFpEF, and 40 controls. GLS was significantly impaired in HFpEF patients (-15.4 ± 3.5 % vs -21.5 ± 2.9 % in controls; P

61 MicroRNA-216a: a cardiac-specific post-transcriptional regulator of capillary rarefaction associated with heart failure {#article-title-2} Background: While cardiomyocytes have been the main subject of extensive research in the past, the role of other cardiac cell types in the pathogenesis of heart failure received considerable less attention. Multiple other cell types, including fibroblasts, endothelial cells and vascular smooth muscle cells make up the heart and increasing evidence suggests that these cell types contribute to myocardial health and disease. Angiogenesis is an important adaptive mechanism of the myocardium to conditions of sustained increased demand. A select number of microRNAs were found to participate in post-myocardial angiogenesis but to date, it is unclear, however, if microRNAs regulate cardiac angiogenesis in the non-ischemic failing myocardium, which represents a clinically more relevant question. Purpose: Establish that non-coding RNAs are main orchestrators of vascular integrity and hemostasis in the heart and changes in expression of the non-coding RNA content in different cardiac cell types underlie defects in neovascularization and progression to heart failure. Results: To identify cardiac angiomiRs we recently completed a functional, genome-wide microRNA knockdown screen in cultured mouse cardiac microvascular endothelial cells. In this setup, we performed the scratch assay by fully automated scratch induction and image capturing and identified several candidate microRNAs. miR-216a, one of those candidates affecting endothelial cell migration, is consistently downregulated in a mouse model of cardiac pressure overload induced by transverse aortic constriction. We generated mice with a somatic gene deletion of miR-216a (miR-216-/-). Ablation of miR-216a induced dramatic effects on cardiac morphology and function. In addition to spontaneous development of pathological cardiac remodeling at baseline, miR-216-/- mice are also extremely sensitive to cardiac stress and die 1-2 weeks after pressure overload or develop severe cardiac phenotypes 3-4 weeks after myocardial infarction. Interestingly, the defects observed correlate with vascular defects including capillary rarefaction and reduced angiogen­­­­ic activity. By combining photoacoustics with high-frequency ultrasound we observed different levels of hypoxia throughout the cardiac tissue confirming lower oxygenation of the miR-216a-/- hearts. The observed effects of miR-216 modulation seem to be related to altered autophagic activity in cardiac endothelial cells. Conclusions: We identified a new angiogenesis-related gene regulatory network where miR-216a underlies the vascular changes associated with pathological cardiac remodeling and/or heart failure. # 62 Divergent effects of pre- and post-conditioning on microvascular function {#article-title-3} Background: A short period of ischemia/reperfusion (I/R) that occurs before a prolonged ischemia (preconditioning; preC) or at reflow (postconditioning; postC) reduces tissue necrosis through activation of regulatory kinases cascades, also reciprocally related, including the GPCR-PKG-PKC cascade and the RISK pathway. In this setting, an important role is played by nitric oxide (NO), which is also the main mediator of endothelium-dependent vasodilation. PreC may also protect microcirculation against I/R injury, while the impact of postC is less clear, and mechanism underlying these effects are not completely elucidated. Purpose: To study the influence of preC and postC on postichemic microcirculation, by specifically evaluating leukocyte recruitment and vasodilating reserve, and to correlate these effects with activation of regulatory kinases. Methods: In rats, cremaster muscle was prepared for in vivo videomicroscopy leaving vascular and neural connections intact. Animals were divided in 4 groups: 1- controls, in which muscle was subjected to 90 min of I and 90 min of R; 2- preC, in which preC was induced before I by 5 min of I and 10 min of R; 3- postC, in which postC was induced at R with 5 cycles of 10 seconds R and 5 seconds I; 4- sham, observed after surgery for an equivalent period of time. Leukocyte recruitment was monitored during I/R; at the end of R, vasodilating endothelium-dependent and -independent reserve was assessed by local superfusion with 10-4 µM acetylcholine and 10-5 µM sodium nitroprusside. Phosphorylation of ERK-1/2, Akt, eNOS, PKCe and GSK3β was measured by Western Blotting on muscle homogenates obtained at the end of experiment in a second set of experiments in which, to avoid possible confounding effects of acetylcholine and sodium nitroprusside on kinase activation, rats were divided in 4 groups as described above but vasodilating challenge was not performed. Results: I/R activated leukocyte recruitment (data not shown) and reduced vasodilating reserve, both endothelium-dependent and independent. Both preC and postC activated kinases and eNOS in a similar degree, and reduced leukocyte recruitment. However, only preC preserved vasodilating reserve (both endothelium-dependent and independent) (*=p

Aims Although many transthoracic echocardiographic (TTE) measurements have been shown to predict outcome in heart failure (HF), whether incremental risk prediction is afforded by their combination is unknown. We developed a simple echocardiographic risk score of mortality in HF patients. Methods and results We performed TTE in 747 systolic HF patients followed-up for 34 ± 23 months. The Cox hazard model was used to evaluate the association between 14 TTE parameters and death. The Echo Heart Failure Score (EHFS) was derived by assigning the value of 1 to each independent predictor when present, and 0 when it was absent, and then by summing the number. The 3-year risk prediction improvement was tested by adding the EHFS to a model containing clinical predictors, and by calculating the C index and net reclassification improvement (NRI). Five baseline TTE variables (end-systolic volume index, left atrial volume index, mitral E-wave deceleration time, tricuspid annular peak systolic excursion, and pulmonary artery systolic pressure) remained independent predictors of mortality. The mortality rate (per 100 patients/year) significantly increased with EHFS ranging from 0 to 5 (EHFS = 0, 2.7%; 1, 5.2%; 2, 10.1%; 3, 13.7%, 4, 29.7%; 5, 36.9%; P < 0.0001). Patients with EHFS ≥3 had a mortality hazard ratio of 3.58 (95% confidence interval 2.74–4.78) compared with EHFS

Metabolic syndrome results in a pro-thrombotic, pro-inflammatory condition that markedly favours the development of diabetes and cardiovascular disease. In patients with metabolic syndrome, many interrelated factors are thought to contribute to the development of vascular alterations; however, insulin resistance is regarded as the most relevant. In fact, in addition to its well-known activity on glucose metabolism, insulin exerts a wide spectrum of non-metabolic actions, including vasodilation, inhibition of platelet aggregation and thrombosis, anti-oxidant and anti-inflammatory effects, which result in anti-atherosclerotic and vascular protective effects. In this setting, clustering of multiple cardiovascular risk factors may reinforce their pro-atherogenic potential. Metabolic syndrome is also accompanied by endothelial dysfunction, and it has become appreciated that microvascular damage is a common finding in these subjects. In diabetic patients, impairment of microcirculation is recognized at the level of all circulatory districts, including coronary microvessels, and it has an important prognostic impact. Diabetes is accompanied by profound changes in energy metabolism, increased oxidative stress, derangement of adipokines synthesis, reduced mobilization and function of endothelial progenitor cells, which may lead to microvascular dysfunction. Features of the insulin resistance syndrome, including altered glucose tolerance, are more frequent in patients with microvascular angina. Taken together, these observations suggest that diabetes, along with each of the various components of the metabolic syndrome, has the capability of profoundly altering coronary microvascular reactivity, thus predisposing to myocardial ischemia even in the absence of coronary artery stenosis. When these alterations combine in the same patient to give rise to full-blown metabolic syndrome, their negative effects on myocardial perfusion are synergistically potentiated. While the pathophysiology of this condition has become to be substantially unravelled, much research is still needed to achieve a tailored therapeutic approach.

ObjectivesThe aim of this study was to evaluate whether, in patients with evidence of both electrical and mechanical left ventricular (LV) dyssynchrony, extensive LV dilation would affect response to cardiac resynchronization therapy (CRT).BackgroundCardiac resynchronization therapy is effective in heart failure patients with LV dysfunction and wide QRS complex. However, many patients still fail to respond. We hypothesized that presence of extensive LV dilation might prevent response to CRT, despite LV mechanical dyssynchrony.MethodsWe studied 78 heart failure patients (68 ± 9 years of age, 77% men) with both electrical (QRS width >120 ms) and mechanical intraventricular dyssynchrony (by tissue Doppler imaging and/or left lateral wall post-systolic contraction). Echocardiographic evaluation was performed at baseline and 6 to 8 months after CRT. As an indication of LV remodeling, end-diastolic volume index and end-systolic volume index (ESVI) and sphericity index were measured. Long-term (40 ± 23 months) clinical follow-up (events: cardiac death and hospital admission for heart failure) was also obtained.ResultsAt follow-up after CRT, in the overall population, ejection fraction increased from 26 ± 6% to 35 ± 11% (p < 0.0001), whereas end-diastolic volume index (from 144 ± 43 ml/m2 to 119 ± 55 ml/m2), ESVI (from 108 ± 37 ml/m2 to 82 ± 49 ml/m2, p < 0.0001 for both), and sphericity index (from 0.60 ± 0.22 to 0.53 ± 0.15, p = 0.0036) all significantly decreased. By multiple linear regression analysis, after controlling for confounding factors, change in LV ejection fraction at follow-up resulted independently and negatively associated with baseline ESVI (p = 0.001), with much lower improvement after implant in the highest tertile of baseline ESVI. During follow-up, 31 patients (39.7%) had a cardiac event. By Cox regression model, baseline ESVI was the most powerful predictor of events, with event-rate/year increasing with increasing tertiles of ESVI (6.3%, 10.1%, and 23.8%, respectively, p < 0.05).ConclusionsIn this nonrandomized, open-label clinical study, despite intraventricular electrical and mechanical dyssynchrony, extensive LV remodeling at baseline negatively impacted CRT results in terms of LV function improvement and incidence of cardiac events at follow-up.