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BACKGROUND Palpitations in athletes are usually benign, but the presence of major cardiac arrhythmias should be ruled out despite the infrequent appraisal of symptoms. External loop recorders (ELR) are promising to identify arrhythmias in these circumstances, but experiences in athletes are lacking. We aimed to investigate the feasibility and diagnostic yield of an ELR in athletes with unexplained palpitations in a cohort study. METHODS 122 consecutive subjects (61 athletes and 61 sedentary controls) with sporadic palpitations and inconclusive diagnosis were enrolled and equipped with an ELR. Findings were categorized as major and minor arrhythmic findings, non-arrhythmic findings or negative monitoring. RESULTS Long-term ELR monitoring was feasible in all subjects, with median duration of 12 (11; 15) days. Major arrhythmic events during palpitations were found in 9 (14.8%) athletes: 7 experienced sustained paroxysmal supraventricular tachycardia, and 2 had non sustained ventricular tachycardia. Minor arrhythmic events (premature supraventricular or ventricular beats) were observed in 13 athletes (21.3%). Non-arrhythmic findings (i.e., sinus rhythm or sinus tachycardia) were recorded in 28 athletes (45.9%), whereas 11 (18%) had negative monitoring. In the sedentary group, arrhythmic events were similar for types and frequency to athletes. The diagnostic yield of loop monitoring was 82.8% in the overall population and 82.0% in the athlete's group. CONCLUSIONS In the management of an athlete symptomatic with unexplained palpitations after 24-hour ECG monitoring and stress test, ELR is an efficient tool to identify major arrhythmic events, which can be present in up to 10% of symptomatic athletes during practice and competition.

Background Early repolarization pattern (ERP) is considered a common training‐related and benign ECG finding in young adult athletes. Few data exist on ERP in the pediatric athletes population. Therefore, we aimed to evaluate the ERP prevalence, characteristics, and prognosis in pediatric athletes aged ≤16 years. Methods and Results Eight‐hundred eighty‐six consecutive pediatric athletes engaged in 17 different sports (mean age, 11.7±2.5 years; 7–16 years) were enrolled and prospectively evaluated with medical history, physical examination, resting and exercise ECGs, and transthoracic echocardiography during their preparticipation screening. Known cardiovascular diseases associated with sudden cardiac death was considered exclusion criteria. Athletes were followed up yearly for 4 years. The prevalence of ERP was 117 (13.2%), equally distributed in both sexes ( P =0.072), irrespectively of body mass index and classification of sports. The most common ERP localizations were inferolateral and inferior leads (53.8% and 27.3%, respectively). Notching J‐point morphology was the most prevalent (70%), and rapidly ascending ST elevation (96%) was the most common ST‐segment morphology. Athletes with ERP were older ( P P P P P =0.006) in comparison with the athletes without ERP. Neither major cardiovascular nor arrhythmic events, nor sudden cardiac death were recorded over a median follow‐up of 4.2 years. One hundred seventeen (80.3%) athletes with ERP exhibited a persistent ERP. ERP localization and J‐point morphology changed during follow‐up in 11 (11.7%) and 17 (18%) of athletes, respectively. Conclusions ERP is common in pediatric athletes. It was mostly located in the inferolateral leads and associated with concave ascending ST segment with other training‐related ECG changes. The lack of either sudden cardiac death or cardiomyopathies linked to sudden cardiac death over follow‐up suggests that in pediatric athletes, ERP may be considered a benign training‐related ECG phenomenon with a potential dynamic pattern.

Objectives To assess changes in working patterns and education experienced by radiology residents in Northwest Italy during the COVID-19 pandemic. Methods An online questionnaire was sent to residents of 9 postgraduate schools in Lombardy and Piedmont, investigating demographics, changes in radiological workload, involvement in COVID-19-related activities, research, distance learning, COVID-19 contacts and infection, changes in training profile, and impact on psychological wellbeing. Descriptive and χ2 statistics were used. Results Among 373 residents invited, 300 (80%) participated. Between March and April 2020, 44% (133/300) of respondents dedicated their full time to radiology; 41% (124/300) engaged in COVID-19-related activities, 73% (90/124) of whom working in COVID-19 wards; 40% (121/300) dedicated > 25% of time to distance learning; and 66% (199/300) were more involved in research activities than before the pandemic. Over half of residents (57%, 171/300) had contacts with COVID-19-positive subjects, 5% (14/300) were infected, and 8% (23/300) lost a loved one due to COVID-19. Only 1% (3/300) of residents stated that, given the implications of this pandemic scenario, they would not have chosen radiology as their specialty, whereas 7% (22/300) would change their subspecialty. The most common concerns were spreading the infection to their loved ones (30%, 91/300), and becoming sick (7%, 21/300). Positive changes were also noted, such as being more willing to cooperate with other colleagues (36%, 109/300). Conclusions The COVID-19 pandemic changed radiology residents’ training programmes, with distance learning, engaging in COVID-19-related activities, and a greater involvement in research becoming part of their everyday practice. Key Points • Of 300 participants, 44% were fully dedicated to radiological activity and 41% devoted time to COVID-19-related activities, 73% of whom to COVID-19 wards. • Distance learning was substantial for 40% of residents, and 66% were involved in research activities more than before the COVID-19 pandemic. • Over half of residents were exposed to COVID-19 contacts and less than one in twenty was infected.

PurposeTo test the hypothesis that aerobic fitness is inversely related to the risk of atherosclerotic cardiovascular disease (ACVD) in athletes with locomotor impairments deriving from health conditions, such as spinal cord injury (SCI), lower limb amputation, cerebral palsy, poliomyelitis, and other health conditions different from the previous ones.MethodsA total of 68 male athletes who competed in either summer or winter Paralympic games were divided in two health conditions groups (35 with SCI, mean age 37.28.0 years, and 33 with different health conditions, mean age 37.89.9 years) and in four sport type groups (skill, power, intermittent-mixed metabolism-and endurance). They were evaluated through anthropometric and blood pressure measurements, laboratory blood tests, and graded cardiopulmonary maximal arm cranking exercise test, with oxygen uptake peak (VO2peak) measurement. Cardiovascular risk profile was assessed in each athlete.ResultsThe prevalence of ACVD-risk factors in the overall population was 20.6% for hypertension; 47% and 55.9% for high values of total and LDL cholesterol, respectively; 22.1% for reduce glucose tolerance; and 8.8% for obesity. No difference was found between athletes with and without SCI, while the prevalence of obesity was significantly higher in those practicing skill sports (22.7%, p=0.035), which was the sport type group with Paralympic athletes with the lowest VO2peak (22.5 +/- 5.70 ml kg(-1) min(-1)). VO2peak was lower in athletes with SCI than those with different health conditions (28.6 +/- 10.0 vs 33.6 +/- 8.9 ml kg(-1) min(-1)p=0.03), and in those with 3-4 risk factors (19.09 +/- 5.34 ml kg(-1) min(-1)) than those with 2 risk factors (27.1 +/- 5.50 ml kg(-1) min(-1)), 1 risk factor (31.6 +/- 8.55 ml kg(-1) min(-1)), or none (36.4 +/- 8.76 ml kg(-1) min(-1)) (p, Open access funding provided by Universita degli Studi dell'Aquila within the CRUI-CARE Agreement.

Demographic characteristics of patients with cardiac implantable electronic devices have significantly changed during the last few years, according to the ageing of the population and the consequent increase in the number of elderly individuals with indication for pacemaker implant and, on the other hand, to the increased number of young individuals implanted with an implantable cardioverter defibrillator for the primary prevention of sudden death. More and more often, both elderly and young patients ask the physician to deal with the device in their daily activities, which often include sport practice. This latter is advisable because of its recognized benefits on cardiovascular prevention, although there are many limitations for patients with a cardiac implantable electronic device. Hence, the need to balance the patient's request with the appropriate precautions emerging from existing evidence. The current article aims to provide an overview of the most recent data on this topic, derived from registries and observational studies. Over the years an attempt to standardize recommendations has been made, but robust evidence is still lacking. Substantial differences exist between countries based on their sports regulations. Official recommendations of European and American Scientific Societies are resumed. The future perspective is to obtain data to allow these patients a safer practice of sport activity also through technological advances in terms of device materials and programming improvement and the possibility of remote monitoring.

Since 1989, SIC Sport and a FMSI, in partnership with leading Italian Cardiological Scientific Associations (ANCE, ANMCO and SIC) have produced Cardiological Guidelines for Completive Sports Eligibility for athletes with heart disease (COCIS -- 1989, 1995, 2003, 2009 and 2017). The English version of the Italian Cardiological Guidelines for Competitive Sports Eligibility for athletes with heart disease was published in 2013 in this Journal. This publication is an update with respect to the document previously published in English in 2013. It includes the principal innovations that have emerged over recent years, and is divided into five main chapters: arrhythmias, ion channel disorders, congenital heart diseases, acquired valve diseases, cardiomyopathies, myocarditis and pericarditis and ischemic heart disease. Wherever no new data have been introduced with respect to the 2013 publication, please refer to the previous version. This document is intended to complement recent European and American guidelines but an important difference should be noted. The European and American guidelines indicate good practice for people engaging in physical activity at various levels, not only at the competitive level. In contrast, the COCIS guidelines refer specifically to competitive athletes in various sports including those with high cardiovascular stress. This explains why Italian guidelines are more restrictive than European and USA ones. COCIS guidelines address 'sports doctors' who, in Italy, must certify fitness to participate in competitive sports. In Italy, this certificate is essential for participating in any competition.

Background Electrocardiographic (ECG) pre-participation screening(PPS) can prevent sudden cardiac death(SCD) but the Interpretation of the athlete's ECG is based on specific criteria addressed for adult athletes while few data exist about the pediatric athlete's ECG. We aimed to assess the features of pediatric athletes' ECG and compared the diagnostic performance of 2017 International ECG recommendation, 2010 European Society of Cardiology recommendation and 2013-Seattle criteria in detecting clinical conditions at risk of SCD. Methods 886 consecutive pediatric athletes (mean age 11.7 ± 2.5 years; 7–16-years) were enrolled and prospectively evaluated with medical history, physical examination, resting and exercise ECG and transthoracic echocardiography during their PPS. Results The most common physiological ECG patterns in pediatric athletes were isolated left ventricular hypertrophy criteria (26.9%), juvenile T-wave pattern (22%) and early repolarization pattern (13.2%). The most frequent borderline abnormalities were left axis deviation (1.8%) and right axis deviation (0.9%) while T-wave inversion (0.8%) especially located in inferior leads (0.7%) was the most prevalent abnormal findings. Seven athletes (0.79%) were diagnosed with a condition related to SCD. Compared to Seattle and ESC, the International improved ECG specificity (International = 98% ESC = 64% Seattle = 95%) with lower sensitivity (ESC and Seattle 86%vs International 57%). The false-positive rate decreases from 36% of ESC to 2.2% of International but the latter showed a higher false-negative rate(0.34%). Conclusion Pediatric athletes like the adult counterpart exhibit a high prevalence of ECG abnormalities mostly representing training-related ECG adaptation. The International criteria showed a lower false-positive rate but at the cost of loss of sensitivity.

Introduction: Although pulmonary vein (PV) isolation (PVI) is very effective in paroxysmal atrial fibrillation (AF), in patients (pts) with persistent AF, PVI often is not sufficient. Many studies suggested that low voltage zones (LVZs) outside of the PV might be involved in the complex mechanisms perpetuating AF. However ablation strategies involving substrate modification (SM) did not show additional benefits in persistent AF pts. Those studies were performed before the introduction of contact force technology, and the most likely explanation for these results could be the inability to achieve effective transmural lesions and continuous linear ablation. Hypothesis: We hypothesized that the use of contact force technology would improve ablation efficacy. Therefore, we analyzed the long-term outcome after two different ablation strategies in pts with persistent AF depending on whether there was evidence of LVZs in the left atrium or not. Methods: The presence of LVZs were defined as sites of >3 adjacent low-voltage points 400g/s. Ablation was performed in a temperature-controlled fashion with energy of 30W except at the posterior wall (20-25W). Results: 121 consecutive pts with persistent AF (46 female, median age 66 [59-72] years, mean duration of AF 16 [7-73] months, CT derived LA volume index 66 [56-75]ml/m2) were included: pts without LVZs underwent PVI alone (n = 74), in pts with LVZs, PVI + SM (n = 47) was performed (mitral Isthmus line in 2, supero-septal line in 39, and roof line in 47; bidirectional block was achieved in 100%, 97%, and 100%, respectively). After a median follow-up of 13 [6-21] months, 86% of pts without and 78% with substrate were in sinus rhythm, mainly without antiarrhythmic drugs (89% PVI only, 84% PVI + SM). Conclusions: In patients with persistent AF without LVZs, PVI alone leads to excellent 2-year freedom from AF. In pts with LVZs, additional substrate modification with CF sensing technology is associated with improved success rates compared to previous studies.

Background Over the last years, several efforts have been made to refine the ECG criteria for interpretation of young (16–35 years) competitive athlete's ECG in order to improve specificity maintaining good sensitivity. However, few data exist about the efficacy of such interpretation criteria in master athletes (over 35 years). We aimed to assess the diagnostic performance of screening based on 2017 International ECG recommendation (2017-International), 2010 European Society of Cardiology recommendation (2010-ESC) and Seattle criteria in a cohort of master athletes competing at regional and national level. Methods 506 Caucasian master athletes (mean ages 47.9±8.7, 85,6% male, 65% endurance athletes) underwent standardized medical history, physical examination, resting and exercise ECG during their pre-participation screening. ECGs were retrospectively interpreted based on 2010-ESC, Seattle-criteria and 2017-International. For the purpose of the study we included also a transthoracic echocardiography as reference, to calculate the sensibility and specificity, area under the ROC curve (AUC) was estimated as measure of discriminative ability of each ECG criteria. Athletes with abnormalities underwent further examinations according to the European Guidelines. Results Twelve athletes (2,3%) were diagnosed with a condition potentially related to SCD (1 hypertrophic cardiomyopathy, 1 Type1 Brugada Syndrome, 4 Chronic Coronary Syndromes, 2 Dilated Cardiomyopathy, 3 Aortic Dilation, 1 Moderate aortic stenosis) during the pre-participation screening. International criteria failed to identify two athletes with DCM and left axis deviation on ECG while no athletes with complete right bundle branch block showed serious structural abnormalities. The most common ECG abnormalities were left axis deviation (7,1%), left atrial enlargement (4,2%) and T wave inversion (3%). 29 athletes (5,7%) exhibited a long QT interval according to 2010-ESC and 1 athlete according to International and Seattle criteria. The false positive ECG rate was 15% for 2017-International based screening, 21,9% for Seattle based screening and 30,40% for 2010-ESC based screening while the diagnostic accuracy for pathologies at risk of SCD was 0,73 (95% CI 0,69–0,77) for 2017 International based screening; 0,81 (95% CI 0,77–0,84) for Seattle Criteria based screening and 0,77 (95% CI 0,73–0,80) for 2010-ESC based screening. Conclusion In master athletes the 2017-International ECG criteria showed inferior accuracy compared to the Seattle criteria and 2010-ESC, the least showing a higher false positive rate mostly due to lower cut-off for long QT. Furthermore complete right bundle branch block may be considered a normal finding also in master asymptomatic athletes. Accuracy of ECG criteria Funding Acknowledgement Type of funding source: None

Background Patients with atrial fibrillation (AF) and severe chronic kidney disease (CKD) are at higher risk of both bleeding and thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) are licensed to be used in these patients, although they were excluded from phase III controlled randomized trials comparing NOACs vs warfarin in AF. Thus, current evidence on NOACs use in such setting of patients is not definitive. Purpose Aim of our multicenter study was to perform a real-world comparison of clinical outcome with NOACs vs vitamin K antagonist anticoagulants (VKAs) also in AF patients having an estimated glomerular filtration rate (eGFR) 15–29 mL/min. Methods We retrospectively included a total of 266 patients receiving NOACs (N=159) or VKAs (N=107). Primary outcome measure was the cumulative incidence of the net composite endpoint including ischemic stroke, systemic thromboembolism or any bleeding. Mean follow-up was 2.6 years. Results CHA2DS2-VASc and HAS-BLED scores at baseline were similar in the two groups (3.4±1.3 with NOACs vs 3.4±0.9 with VKAs and 3.1±1.0 vs 3.0±0.7, respectively); eGFR and hemoglobin values were also comparable (31.8±12.3 vs 32±11.9 mL/min and 10.2±2.1 vs 11.0±2.3 g/dL, respectively). NOACs were not inferior to VKAs for the primary net composite endpoint: incidence 20.7% vs 29.9%, p Conclusions Our real-world data indicate that in patients with AF and severe renal failure NOACs are not inferior to VKAs for both safety and efficacy. The use of NOACs was associated with a numerically lower incidence of minor bleeding. Funding Acknowledgement Type of funding source: None

Background and objectives: Electrocardiograph abnormalities (i.e., QT interval prolongation) have been described in inflammatory bowel diseases (IBD). We aimed to measure the QT interval in a cohort of patients with IBD and to analyze its relationship with clinical and inflammatory activity. Materials and Methods: We performed a cross-sectional study that included 38 IBD outpatients and 38 &ldquo, age- and sex-matched&rdquo, healthy controls. Nine patients had active IBD, and 29 were in clinical remission. Among the latter, 10 patients had sustained (lasting &gt, 1 year) and 19 had short-term remission (&le, 1 year). Corrected QT (QTc) interval was measured on standard 12-lead electrocardiograph. A systematic review of the literature on studies investigating the QT interval in patients with IBD was also performed. Results: QTc interval values were similar between IBD patients and healthy controls (417.58 &plusmn, 22.05 ms vs. 409.13 &plusmn, 19.61 ms, respectively, p: 0.479). Patients with active IBD had significantly higher QTc values (435.11 &plusmn, 27.31 ms) than both controls (409.13 &plusmn, 19.61 ms) and patients in remission (412.14 &plusmn, 17.33 ms) (p: 0.031). Post hoc analysis showed that the difference in QTc values between active IBD and remission was attributable to the group of patients with sustained remission (p &lt, 0.05). Lastly, a significant correlation between QTc interval and C-reactive protein (CRP) values was observed (Spearman test: r = 0.563, p: 0.0005). Conclusions: Our study demonstrates an association between QTc duration and both clinical and inflammatory activity in patients with IBD. The higher the CRP value, the longer is the QTc duration. For practical purposes, all patients with active IBD should undergo a standard ECG. Prescription of drugs able to modify the QT interval should be avoided in patients with active IBD. The systematic review of the literature indicated that this is the first published study demonstrating an association between the QTc duration and CRP values in patients with IBD.

Background Pulmonary vein isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). However, with advanced left atrial (LA) structural changes, additional targeted catheter ablation of low voltage zones (LVZs) has produced favorable results. Therefore, with the advent of single-shot techniques, it would be helpful to predict the presence of LVZs before an ablation procedure. Objective We hypothesized that computed tomography-derived (CT) left atrial volume index (LAVI), in combination with other objective parameters, could be used to develop a score able to predict the presence of LVZs. Methods In a large cohort of patients undergoing their first AF ablations, comprehensive echocardiographic evaluations and cardiac CT were performed. During the electrophysiological studies, LA geometry and electro-anatomic voltage maps were created. LVZs were defined as areas ≥1cm2 with bipolar peak-to-peak voltage amplitudes ≤0.5 mV. Results In a derivation cohort of 374 patients, predictors of LVZs were identified by regression analysis and used to build the ZAQ score (age≥65 years, female sex and CT LAVI≥57ml/m2). The ZAQ score of 2 points accurately identified the presence and the extent of LVZs (AUC 0.809, 95% CI 0.758-0.861, p Conclusions The ZAQ score identifies LVZs and may be useful for planning the ablation strategy ahead of time (single shot PVI vs 3D mapping-guided ablation) regardless of whether the AF pattern is paroxysmal or persistent. Figure legend. Proposed AF ablation workflow independent of the temporal pattern of AF (ie. paroxysmal vs. persistent). (CT) Computed Tomography, (LAVI) Left Atrial Volume Index, (PVI) Pulmonary vein isolation. *Low voltage zones, if present, could be targeted with additional substrate modification ablation Conflict of Interest None

Aims The purpose of this study was to assess the value of genetic testing in addition to a comprehensive clinical evaluation, as part of the diagnostic work-up of elite and/or amateur Italian athletes referred for suspicion of inherited cardiac disease, following a pre-participation screening programme. Methods Between January 2009–December 2018, of 5892 consecutive participants, 61 athletes were investigated: 30 elite and 31 amateur athletes. Elite and amateur athletes were selected, on the basis of clinical suspicion for inherited cardiac disease, from two experienced centres for a comprehensive cardiovascular evaluation. Furthermore, the elite and amateur athletes were investigated for variants at DNA level up to 138 genes suspected to bear predisposition for possible cardiac arrest or even sudden cardiac death. Results Of these 61 selected subjects, six (10%) had diagnosis made possible by a deeper clinical evaluation, while genetic testing allowed a definite diagnosis in eight (13%). The presence of >3 clinical markers (i.e. family history, electrocardiogram and/or echocardiographic abnormalities, exercise-induced ventricular arrhythmias) was associated with a higher probability of positive genetic diagnosis (75%), compared with the presence of two or one clinical markers (14.2%, 8.1%, respectively, p-value = 0.004). Conclusion A combined clinical and genetic evaluation, based on the subtle evidence of clinical markers for inherited disease, was able to identify an inherited cardiac disease in about one-quarter of the examined athletes.

Purpose: Electroanatomical mapping (EAM) could increase cardiac magnetic resonance imaging (CMR) sensitivity in detecting ventricular scar. Possible bias may be scar over-estimation due to inadequate tissue contact. Aim of the study is to evaluate contact-force monitoring influence during EAM, in patients with idiopathic right ventricular arrhythmias. Methods: 20 pts (13 M; 43 ± 12 y) with idiopathic right ventricular outflow tract (RVOT) arrhythmias and no structural abnormalities were submitted to Smarttouch catheter Carto3 EAM. Native maps included points collected without considering contact-force. EAM scar was defined as area ≥1 cm2 including at least 3 adjacent points with signal amplitude (bipolar

Physical activity is worldwide recommended for its benefits on cardiovascular system. There is an increasing number of people of all ages that approach sport activity both as leisure time physical activity and as competitive sport. It is always more frequent the request even from older subjects and cardiac patients to be allowed to practice physical activity. Some problems could arise when these subjects present or develop pathologic conditions that require specific pharmacological treatment, in particular an anticoagulation therapy. This review focalizes on the management of oral anticoagulant therapy (OAT) in patients practicing sport activity, especially due to atrial fibrillation and deep vein thrombosis, which represent two highly prevalent conditions, particularly with increasing age. Official recommendations in this field may appear limiting for patients, forbidding in the majority of cases sports at risk of trauma and consequent bleeding. These recommendations still resent the heritage of the "traditional" management of OAT, mainly represented by vitamin-K antagonists (VKAs). The non-vitamin K antagonist oral anticoagulants, with their more favorable pharmacokinetic-pharmacodynamic profile compare to VKAs, may now represent an opportunity to modify the approach to sport activity in patients with an indication to OAT. This review of the literature deals with possible strategies to overcome the present limitations for OAT subjects willing to pursue a healthy lifestyle, that include sport activity, minimizing at the same time their risk of bleeding.

BACKGROUND Pulmonary vein isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). However, with advanced left atrial (LA) structural changes, additional targeted catheter ablation of low-voltage zones (LVZs) has produced favorable results. Therefore, with the advent of single-shot techniques, it would be helpful to predict the presence of LVZs before an ablation procedure. OBJECTIVE We hypothesized that computed tomography (CT)-derived left atrial volume index (LAVI), in combination with other objective parameters, could be used to develop a score able to predict the presence of LVZs. METHODS In a large cohort of patients undergoing their first AF ablations, comprehensive echocardiographic evaluations and cardiac CT were performed. During the electrophysiological studies, LA geometry and electroanatomic voltage maps were created. LVZs were defined as areas ≥1 cm2 with bipolar peak-to-peak voltage amplitudes ≤0.5 mV. RESULTS In a derivation cohort of 374 patients, predictors of LVZs were identified by regression analysis and used to build the Zentralklinik Bad Berka and University of L'Aquila (ZAQ) score (age ≥65 years; female sex; and CT-LAVI ≥57 mL/m2 ). The ZAQ score of 2 points accurately identified the presence and the extent of LVZs (area under the curve [AUC], 0.809; 95% confidence interval [CI], 0.758-0.861; P

Radiation exposure is an important issue for interventional cardiologists that is often underevaluated. Our aim was to evaluate determinants of operator radiation exposure during percutaneous coronary procedures.The RADIANT (NCT01974453) is a prospective, single-center observational study involving 4 expert operators and 2 fellows performing percutaneous coronary procedures. The operator radiation dose was evaluated using dedicated electronic dosimeters in 2,028 procedures: 1,897 transradial access (TRA; 1,120 right and 777 left TRA) and 131 transfemoral access (TFA).In the whole population, operator radiation dose at the thorax did not differ between TFA (9μSv [interquartile range 5-18μSv]) and TRA (9μSv [4-21μSv]), but after propensity score matching analysis, TFA showed lower dose (9μSv [5-18μSv]) compared with TRA (17μSv [9-28μSv], P.001). In the whole transradial group, left TRA (5μSv [2-12μSv]) was associated with significant lower operator dose compared with right TRA (13μSv [6-26μSv], P.001).The use of adjunctive protective pelvic drapes was significantly associated with lower radiation doses compared with procedures performed without drapes (P.001). Among the operators, an inverse relation between height and dose was observed. Finally, left projections and the use of angiographic systems not dedicated for coronary and high frame rates were all associated with a significant higher operator radiation exposure.In a high-volume center for transradial procedures, TFA is associated with lower operator radiation dose compared with TRA. The use of adjunctive anti-rx drapes seems a valuable tool to reduce the higher operator radiation exposure associated with TRA.

The purpose of the study was to compare the EASI system with the standard 12-lead surface electrocardiogram (ECG) for the accuracy in detecting the main electrocardiographic parameters (J point, PR, QT, and QRS) commonly monitored in patients with acute coronary syndromes or heart failure. In this observational comparative study, 253 patients who were consecutively admitted to the coronary care unit with acute coronary syndrome or heart failure were evaluated. In all patients, two complete 12-lead ECGs were acquired simultaneously. A total of 6,072 electrocardiographic leads were compared (3,036 standard and 3,036 EASI). No significant differences were found between the investigate parameters of the two measurement methods, either in patients with acute coronary syndrome or in those with heart failure. This study confirmed the accuracy of the EASI system in monitoring the main ECG parameters in patients admitted to the coronary care unit with acute coronary syndrome or heart failure.

OBJECTIVE Evaluate if bariatric surgery can improve hypertension (HPT) control leading to both reduction of blood pressure values and antihypertensive therapy withdrawal. METHODS Eight-hundred and sixty-four consecutive patients who referred to our hospital, from March 2001 to February 2011, because of morbid obesity were initially enrolled in this retrospective study. To obtain two comparable groups, propensity-matching was applied. Finally, the study included 444 (51% out of initial 864 patients), 222 on diet (group D) and 222 patients undergoing surgery (group S). RESULTS In group D, sistolic blook pressure (SBP) showed a significant increase (135 ± 14 vs 138 ± 11 mmHg; P = 0.006); conversely in group S, SBP decreased (130 ± 14 vs 124 ± 9 mmHg; P = 0.001). In group D, diastolic blood pressure (DBP) showed a significant increase (80 ± 6 vs 82 ± 6 mmHg; P = 0.004); conversely in group S, DBP decreased (81 ± 9 vs 79 ± 8 mmHg; P = 0.015). Among 136 patients with HPT, 73 (53%) withdrew antihypertensive therapy: significantly more in group S (55/63, 87%) than in group D (17/56, 23%), P

Myocardin (MYOCD) is the founding member of a class of transcriptional coactivators that bind the serum-response factor to activate gene expression programs critical in smooth muscle (SM) and cardiac muscle development. Insights into the molecular functions of MYOCD have been obtained from cell culture studies, and to date, knowledge about in vivo roles of MYOCD comes exclusively from experimental animals. Here, we defined an often lethal congenital human disease associated with inheritance of pathogenic MYOCD variants. This disease manifested as a massively dilated urinary bladder, or megabladder, with disrupted SM in its wall. We provided evidence that monoallelic loss-of-function variants in MYOCD caused congenital megabladder in males only, whereas biallelic variants were associated with disease in both sexes, with a phenotype additionally involving the cardiovascular system. These results were supported by cosegregation of MYOCD variants with the phenotype in 4 unrelated families by in vitro transactivation studies in which pathogenic variants resulted in abrogated SM gene expression and by the finding of megabladder in 2 distinct mouse models with reduced Myocd activity. In conclusion, we have demonstrated that variants in MYOCD result in human disease, and the collective findings highlight a vital role for MYOCD in mammalian organogenesis.

BACKGROUND: The criteria for the interpretation of the electrocardiogram (ECG) of the athlete have reached remarkable levels of sensitivity and specificity; however, these studies were conducted on young adult athletes (mean age >16 years). The purpose of this study was to evaluate which are the main electrocardiographic features of a pediatric population of athletes aged between 8 and 16 years, and to verify if the Seattle criteria are valid also for the young population. METHODS: The study was conducted on a sample of 1395 athletes aged between 8 and 35 years, who mandatory cardiovascular screening for competitive and not competitive sports in 2014. The athletes were divided into two groups: a group of athletes aged between 8 and 16 and another between 17 and 35 years old. Each athlete underwent physical examination, spirometry, urinalysis, resting ECG, ECG during exercise and post exercise, standard echocardiographic examination. RESULTS: The ECG analysis confirms other studies’ results: the heart rate in the child is significantly higher than in the young adult, as well as the PR and QRS interval are shorter. The QTc interval is greater in the child than in the young adult. CONCLUSIONS: Our study showed that the ECG is an essential exam within the young athlete’s screening. The type and frequency of pathological changes are similar in the two populations. The Seattle criteria can also be applied to pediatric athletes.

Coronary artery fistulas are rare abnormal connections between a coronary artery and a cardiac chamber or a major vessel. Often, they are asymptomatic and the diagnosis is accidental. The case we present is the incidental finding of a fistula displayed with echocardiography during acute coronary syndrome (ACS). A 73-year-old man presented in the emergency room for non-ST-elevation ACS. Echocardiogram showed in a parasternal short axis view an abnormal diastolic flow inside the ventricular inferior wall. Angiography and CT confirmed the diagnosis of coronary fistula from the right coronary into the left ventricular cavity. A literature analysis with discussion about coronary fistulas classification and management was also performed.

Acute heart failure (AHF) after ST-segment elevation myocardial infarction (STEMI) is usually treated with inotropic support or vasoactive medications. In this study, we aimed at investigating the role of levosimendan on cardiovascular determinants of contractility and afterload in patients with AHF following STEMI treated with percutaneous coronary intervention (PCI).Forty-eight consecutive STEMI patients were retrospectively enrolled. Non-invasive assessment of left ventricular elastance (Ees) and arterial elastance (Ea) and their relationship, ventriculo-arterial coupling (VAC) was performed before and after levosimendan infusion.After infusion of levosimendan a significant increase in SV was detected in all patients (from 48 ± 17 to 60 ± 21 ml, p 0.001). VAC slightly decreased from 1.74 ± 0.8 to 1.66 ± 0.7 (p = NS) as a result of a profound reduction in arterial elastance (Ea 2.34 ± 1.09 to 1.74 ± 0.5 mm Hg/ml, p 0.001) and in ventricular elastance (Ees 1.57 ± 0.12 to 1.24 ± 0.09 mm Hg/ml, p = 0.021). Ejection fraction (EF) (from 0.29 ± 0.1 to 0.32 ± 0.1, p 0.01) and WMSI, (from 2.16 ± 0.47 to 2.05 ± 0.54, p 0.05) also, significantly improved. Finally, baseline VAC was able to predict the use of norepinephrine (NE) and early and one-year mortality of patients treated.In STEMI patients with AHF the use of levosimendan significantly increases stroke volume after 24-hour treatment through Ea reduction. Baseline VAC seemed to predict early and late mortality and early and prolonged use of NE, however, this needs to be tested in larger series of patients and multivariate adjustments for other prognostic predictors.

Haematological indexes of both inflammation and platelet activation have been suggested as predictive markers of cardiovascular disease (CVD), which has high prevalence in Paralympic athletes (PA). Different mechanisms could play a role in increasing CVD risk in PA with spinal cord injury (PA-SCI), lower limb amputation (PA-LLA), or upper limb impairment (PA-ULI). We compared, in 4 groups of PA competing in power, intermittent (mixed metabolism), and endurance sports, Framingham Risk Score (FRS), metabolic syndrome criteria (MetS-C), inflammation (INFLA) Score, 5 haematological indexes of platelet activation (mean platelet volume (MPV), platelet distribution width (PDW), and the ratios between MPV and platelet (MPVPR), between MPV and lymphocyte (MPVLR), and between PDW and lymphocyte (PDWLR)) and the endogenous antioxidants uric acid (UA) and bilirubin (BR). A retrospective chart review of PA from preparticipation examinations’ records (London 2012 and Sochi 2014 Paralympics) was performed. We included 25 PA-SCI (13 with high and 12 with low lesion, PA-SCI-H and PA-SCI-L), 15 PA-LLA, and 10 PA-ULI. FRS and INFLA Score did not differ among groups, but PA-SCI-H had lower HDL, compared to PA-SCI-L and PA-ULI. PA-LLA had more MetS diagnostic criteria with significant higher glucose levels than other groups. PA-SCI-H had significantly lower lymphocytes’ count compared to PA-LLA and higher MPV, PDW, MPVPR, MPVLR, and PDWLR. SCI-H had lower BR, haemoglobin, haematocrit, proteins, and creatinine. No interaction was found between the 3 kinds of sitting sports and the 2 groups of health conditions (PA-SCI and PA-LLA). In conclusion, PA-LLA had a higher cardiometabolic risk, whereas PA-SCI-H had a higher platelet-derived cardiovascular risk. Further larger studies are needed to investigate the relationship between indexes of inflammation/oxidation and dietary habit, body composition, and physical fitness/performance in PA with motor impairments.

ObjectivesTo assess differences in blood flow momentum (BFM) and kinetic energy (KE) dissipation in a model of cardiac dyssynchrony induced by electrical right ventricular apical (RVA) stimulation compared with spontaneous sinus rhythm.MethodsWe cross-sectionally enrolled 12 consecutive patients (mean age 74±8 years, 60% male, mean left ventricular ejection fraction 58%±6 %), within 48 hours from pacemaker (PMK) implantation. Inclusion criteria were: age>18 years, no PMK-dependency, sinus rhythm with a spontaneous narrow QRS at the ECG, preserved ejection fraction (>50%) and a low percentage of PMK-stimulation (ResultsCompared with sinus rhythm, BFM shifted from 27±3.3 to 34±7.6° (p=0.016), while RVA-pacing was characterised by a 35% of increment in KE dissipation, during diastole (p=0.043) and 32% during systole (p=0.016). In the same conditions, left ventricle global longitudinal strain (LV GLS) significantly decreased from 17±3.3 to 11%±2.8% (p=0.004) during RVA-stimulation. At the multivariable analysis, BFM and diastolic KE dissipation were significantly associated with LV GLS deterioration (Beta Coeff.=0.54, 95% CI 0.07 to 1.00, p=0.034 and Beta Coeff.=0.29, 95% CI 0.02 to 0.57, p=0.049, respectively).ConclusionsIn RVA-stimulation, BFM impairment and KE dissipation were found to be significantly associated with LV GLS deterioration, when controlling for potential confounders. Such changes may favour the onset of cardiac remodelling and sustain heart failure.

An increased prevalence of cardiovascular risk factors in rheumatoid arthritis (RA) is reported. The absolute cardiovascular risk in RA patients is higher than in the general population, and although the RA prognosis has gradually improved, premature cardiovascular (CV) mortality remains a matter of fact. The purpose of this review is to shed light on CV and metabolic involvement in RA, with the aim of defining its best management. Multiple lines of evidence have revealed common mechanisms behind inflammatory and CV diseases and clarified the metabolic and CV pathways involved in RA and the effects of different pharmacological treatments. CV risk assessment should be mandatory in all RA patients, taking into account the impact of both diseases on patient’s prognosis. Therefore, a multidisciplinary approach is the best management, and rheumatologists, cardiologists, and general practitioners must work together to significantly improve outcome and quality of life in RA patients. Future research could investigate the potential beneficial effects of a more aggressive pharmacological treatment of CV and metabolic risk factors.

Atrial Fibrillation (AF) is associated with an increased risk of stroke and development of cognitive impairment. Our cross-sectional study aims to identify risk factors for cognitive impairment in patients with permanent AF.212 consecutive outpatients with history of permanent AF lasting more than 1 year were enrolled and the Short Portable Mental Status Questionnaire (SPMSQ) was used to assess cognitive impairment (number of errors ≥5). The type of antithrombotic therapy, the time in therapeutic range (TTR) in case of treatment with warfarin and the degree of heart rate (HR) control (upon Holter ECG monitoring) were also assessed.ROC curve analysis indicated that TTR was associated with cognitive impairment (AUC 0.85 ± 0.03; 95% CI 0.77-0.88; p 0.0001). Multivariate logistic regression analysis showed an independent association of previous cerebrovascular or cardiovascular events (OR 7.24, 95% CI 1.37-38.25; p = 0.020), aspirin therapy instead of anticoagulant therapy (OR 24.74, 95% CI 1.27-482.12; p = 0.034), warfarin use with TTR ≤60% (OR 21.71 , 95%CI 4.35-108; p 0.001) and an average daily HR either60 bpm or100 bpm (OR 6.04, 95% 1.09-33.29; p = 0.039) with cognitive impairment.Among patients with permanent AF, cognitive impairment is more frequent in those with inadequate antithrombotic therapy (aspirin therapy instead of anticoagulant therapy) and with suboptimal oral anticoagulation (TTR ≤60%) or heart rate control. Efforts should be made to optimize therapies related to these parameters.

Dyslipidemia is one of the major cardiovascular risk factors, but beyond statin treatment-which represents the cornerstone of therapy-a relevant practical uncertainty regards the use of fibrate derivatives. In the lack of successful results from the main cardiovascular trials, guidelines recommend the use of peroxisome proliferator-activated receptor agonists in selected cases, i.e. patients with true atherogenic dyslipidemia. However, recent observations indicate that fenofibrate treatment may provide a reliable complementary support against residual cardiovascular risk. We therefore summarize current evidence on fenofibrate, seeking to provide an updated interpretation of recent studies in the field.

Background The aim of this retrospective study was to identify clinical, humoral and echocardiographic variables predicting rehospitalization and poor quality of life (QOL) in patients with reduced or mid-range ejection fraction heart failure. Methods From 2009 to 2012, 310 patients were admitted having signs and symptoms of heart failure with reduced ejection fraction. All the patients were followed by phone, calling the patients or the referring general practitioner. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used as the instrument to evaluate QOL: MLHFQ less than 24 is a good QOL, 24-45 is moderate QOL and more than 45 is poor QOL. The primary event was poor QOL and/or rehospitalization at 4 years. Results Seventy-nine patients died at median time of 21 months; 4-year survival was 72 ± 3%. Rehospitalization due to heart failure was recorded in 60 cases. Among 231 survivors, MLHFQ score was good in 99 (42%), moderate in 50 (21%) and poor in 88 (37%). Four-year freedom from death, poor QOL or rehospitalization was 51 ± 3%. Multivariable analysis identified the following risk factors: heart rate at discharge at least 70 bpm, ischemic heart disease, atrial fibrillation, hypercholesterolemia, chronic pulmonary disease, N-terminal pro brain natriuretic peptide at discharge, severe tricuspid regurgitation and mitral regurgitation more than moderate. Conclusion Clinical, laboratory and echocardiographic profile is crucial to predict long-term QOL of patients admitted for heart failure.

Objectives: The aim of this prospective study was to evaluate muscle force of the hand, thumb, and forefinger in patients with prolonged radial occlusion after transradial percutaneous coronary procedures. Background: There are no data on hand strength and function in patients with prolonged radial occlusion after percutaneous coronary procedures. Methods: Elective patients with chronic stable angina undergoing percutaneous coronary procedures were evaluated the day before the procedure for radial artery patency, Allen test, hand grip, and thumb and forefinger pinch tests. The same measures were performed the day after the procedure and at follow-up. At follow-up, patients were divided in two groups according to the radial patency (group 1) or occlusion (group 2). Results: Of the 99 patients included in the study, 90 patients had a patent radial artery (group 1), and nine (9.1%) patients had an occluded artery (group 2). At baseline, there were no significant differences in hand grip test between the two groups (42 ± 11 kg in group 1 and 41 ± 17 kg in group 2, P = 0.74). In both groups, after the procedure, the hand grip test values was significantly reduced compared with baseline values (40 ± 11 kg in group 1, P

The aim of this review article is to summarize current knowledge of the pathophysiology underlying right ventricular failure (RVF), focusing, in particular, on right ventricular assessment and prognosis. The right ventricle (RV) can tolerate volume overload well, but is not able to sustain pressure overload. Right ventricular hypertrophy (RVH), as a response to increased afterload, can be adaptive or maladaptive. The easiest and most common way to assess the RV is by two-dimensional (2D) trans-thoracic echocardiography measuring surrogate indexes, such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler velocity of the lateral aspect of the tricuspid valvular plane. However, both volumes and function are better estimated by 3D echocardiography and cardiac magnetic resonance (CMR). The prognostic role of the RV in heart failure (HF), pulmonary hypertension (PH), acute myocardial infarction (AMI), and cardiac surgery has been overlooked for many years. However, several recent studies have placed much greater importance on the RV in prognostic assessments. In conclusion, RV dimensions and function should be routinely assessed in cardiovascular disease, as RVF has a significant impact on disease prognosis. In the presence of RVF, different therapeutic approaches, either pharmacological or surgical, may be beneficial.

AIMS The aim of this study was to compare different radiation protection drapes in terms of radiation dose absorbed by operators during right or left transradial procedures. METHODS AND RESULTS Patients who underwent transradial coronary procedures were randomised initially into four groups: Group 1 (no drapes), Group 2 (drape on patient's arm), Group 3 (pelvic drape), Group 4 (combined arm and pelvic drapes). Subsequently, each group was further randomised to right or left radial access. The primary endpoint was the operator radiation dose at the thorax. A total of 452 procedures were included. The use of drapes was associated with a lower radiation dose compared to no drapes (8.6 µSv [4.1-17.9] Group 1, 5.8 µSv [3.4-13] Group 2, 3.6 µSv [2.1-6.9] Group 3, 3.7 µSv [1.9-10.3] Group 4, p

Objective The proper treatment of chronic ischemic mitral regurgitation (CIMR) is still under evaluation. The different role of mitral valve repair (MVr) or mitral valve prosthesis insertion (MVPI) is still not defined. Methods From May 2009 to December 2011 167 patients with ejection fraction (EF) ≤ 40% had MV surgery for CIMR, MVr in 135 (80.8%) and MVPI in 32 (19.2%). Indication to MVPI was a MV coaptation depth > 10 mm. EF was lower (26 ± 7 vs 32 ± 6, p = 0.0000) in MVPI, whereas MR grade (3.6 ± 0.8 vs 2.7 ± 0.9, p = 0.0000), left ventricle dimensions (end diastolic, LVEDD, 62 ± 7 vs 57 ± 6 mm, p = 0.0001; end systolic, LVESD, 49 ± 8 vs 44 ± 8 mm, p = 0.0018), systolic pulmonary artery pressure (51 ± 22 vs 41 ± 16 mm Hg, p = 0.0037) and NYHA Class (3.6 ± 0.5 vs 2.8 ± 0.6, p = 0.0000) were higher. Results In-hospital mortality was similar (3.1 vs 3.7%) as well as 3-year survival (86 ± 6 vs 88 ± 4) and survival in NYHA Class I/II (80 ± 5 vs 83 ± 4). One hundred thirty nine patients had an echocardiographic evaluation after a minimum of 4 months (13 ± 8). EF rose significantly in both groups (from 26 ± 7% to 30 ± 4%, p = 0.0122, and from 32 ± 6% to 35 ± 8%, p = 0.0018). LVESD reduced significantly in both groups (from 49 ± 8 to 43 ± 9 mm, p = 0.0109, and from 44 ± 8 to 41 ± 7 mm, p = 0.0033). MR grade was significantly lower in patients who had MVPI (0.1 ± 0.2 vs 0.3 ± 0.3, p = 0.0011). Conclusions With appropriate indications, MVPI is a safe procedure which provides similar results to MVr with lower MR return, even if addressed to patients with worse preoperative parameters., Highlights • Dynamics is built for rival firms choosing investment strategy by marginal profit. • Equilibriums of the dynamics are found and their local stability is discussed. • Stability condition of the interior equilibrium is given by Schur–Cohn Criterion. • Numerical simulations are used to show the complicated system evolution. • Time-delayed feedback control is used to control system chaos.

Objectives Several studies showed the close relationship between Rheumatoid Arthritis (RA) and cerebro-cardiovascular events (CVEs) and subclinical atherosclerosis. In this study, we investigated the occurrence of CVEs and subclinical atherosclerosis during the course of RA and we evaluated the possible role of both traditional cardiovascular (CV) and disease related risk factors to predict the occurrence of new CVEs and the onset of subclinical atherosclerosis. Methods We designed a single centre, bias-adjusted, prospective, observational study to investigate, in a homogeneous subset of RA patients, the occurrence of new onset of CVEs and subclinical atherosclerosis. Statistical analyses were performed to evaluate the role of traditional CV and disease-related risk factors to predict the occurrence of new CVEs and subclinical atherosclerosis. Results We enrolled 347 RA patients prospectively followed for 12 months. An increased percentage of patients experienced CVEs, developed subclinical atherosclerosis and was affected by systemic arterial hypertension (SAH), type 2 diabetes mellitus and metabolic syndrome (MS), at the end of follow up. Our analysis showed that the insurgence of both SAH and MS, during the follow up, the older age, the CVE familiarity and the lack of clinical response, were associated with a significantly increased risk to experience CVEs and to develop subclinical atherosclerosis. Conclusions Our study quantifies the increased expected risk for CVEs in a cohort of RA patients prospectively followed for 1 year. The occurrence of both new CVEs and subclinical atherosclerosis in RA patients may be explained by inflammatory burden as well as traditional CV risk factors.

Early detection of anticancer drug-induced cardiotoxicity (CTX) has been evaluated by most international scientific cardiology and oncology societies. High expectations have been placed on the use of specific biomarkers. In recent years, conventional biomarkers and molecules of more recent interest have been tested and compared in the context of anticancer drug-related CTX. Encouraging results were obtained from studies on molecules of myocardial damage, such as troponin and markers of myocardial wall stress, including circulating natriuretic peptides, as well as from the assessment of the products of inflammation or circulating levels of free radicals. However, clear guidelines on their sensitivity, specificity, and accuracy are not yet available, and many challenges, such as the optimal time of assessing, optimal schedule for evaluation, optimal cut-off point for positivity with the highest level of specificity, and optimal comparability of different assays for the measurements, remain unresolved. Given the importance of having a reliable and accurate tool for monitoring anticancer drug-induced CTX, this review will focus on the available data on the most effective and widely used biomarkers and the studies that are currently underway that aim to identify the effectiveness of new approaches in this therapeutic setting.

Background The aim of this retrospective study was to compare the early and midterm clinical outcomes of aortic root replacement in elderly patients receiving the Freestyle stentless bioprosthesis (FSB) (Medtronic Inc, Minneapolis, MN) with younger patients receiving a mechanical valve conduit. Methods From January 2001 to December 2010, 185 consecutive patients underwent aortic root replacement. Of these, 79 (43%) patients received the Freestyle bioroot (Medtronic Inc, Minneapolis, MN) (group F) and 106 (57%) patients received a mechanical valve conduit (group M). Target endpoints were 30-day mortality, 5-year survival, 5-year freedom from cardiac death, and 5-year freedom from major adverse valve-related and cardiovascular events (MAVCE) (cardiac death, cerebrovascular accident, myocardial infarction, heart failure, valve prosthesis dysfunction requiring reoperation, and thromboembolic and hemorrhagic events). A propensity score model was built to adjust the results according to preoperative and operative characteristics of both groups. Results Thirty-day mortality was similar in both groups (F group, 2.5% versus M group, 5.7%; p = 0.407). Unadjusted analysis showed no differences between groups, whereas adjusted analysis showed a significantly higher 5-year freedom from cardiac death and MAVCE in group F (group F, 98.6 ± 1.9 versus group M, 88.0% ± 3.0%; p = 0.038; group F, 97.4% ± 2.6% versus group M, 81.2% ± 3.6%; p = 0.010). Multivariate analysis confirmed a significantly higher risk for 5-year MAVCE in patients who did not undergo implantation with the Freestyle bioprosthesis (hazard ratio [HR], 6.87; 95% confidence limit [CL], 1.43–15.09; p = 0.016). Conclusions In elderly patients, the FSB seems to be as safe as mechanical composite grafts in the perioperative period but results in superior freedom from MAVCE at 5 years postoperatively.

OBJECTIVE The role of natriuretic peptides in the screening of left ventricular dysfunction is still unclear. The aim of this study was to assess the usefulness of N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement in asymptomatic patients at high risk of developing left ventricular dysfunction. METHODS One hundred and thirty-four consecutive ambulatory patients (mean age 56.1 +/- 7 years) were studied and selected on the basis of a history of hypertension of at least 5 years. Systolic dysfunction was defined as an ejection fraction of 45% or less. Statistical analysis was performed by both parametric and nonparametric approaches. Diagnostic accuracy was evaluated by receiver operating characteristic analysis. RESULTS Echocardiography showed normal left ventricular function in 40 patients, diastolic dysfunction in 80 patients and systolic dysfunction in 14 patients. NT-proBNP levels were significantly higher in patients with systolic dysfunction (356.1 +/- 294.8 vs. 85.2 +/- 85.8 pg/ml; P < 0.05). Receiver operating characteristic analysis showed a high value of the area under the curve (0.89) for the detection of systolic dysfunction with a sensitivity of 83% and a specificity of 80% for a cut-off value of 114 pg/ml and with a negative predictive value of 0.98. CONCLUSION In asymptomatic patients at high risk for heart failure because of a history of hypertension, the measurement of NT-proBNP levels may represent a useful screening test for left ventricular systolic dysfunction. Therefore, more expensive examinations, such as echocardiography, may be restricted only to patients with higher NT-proBNP levels.

Aims and objectives This study was carried out to verify the accuracy of 12-Lead ECG, obtained through a continuous ECG monitoring system with five cables positioned in EASI mode, to identify basic ECG alterations. Background This study concerns continuous ECG monitoring systems in Coronary Care Units. Continuous ECG monitoring is an important device for nursing surveillance and is useful in decreasing adverse events. Design and method Thirteen patients admitted consecutively to the Coronary Care Unit for Acute Myocardial Infarction underwent daily and simultaneous recording of a12-lead ECG using both procedures: EASI ECG and STANDARD ECG. A sample of 1,164 ECG leads acquired in EASI mode was compared with a sample of as many ECG leads acquired using the standard procedure with a traditional cardiograph. Results and conclusions In the Coronary Care Unit, Continous ECG monitoring with five cables positioned in EASI mode is a valid alternative to the standard 12-lead ECG for cardiac rhythm abnormalities detection and for acute myocardial ischemia and old myocardial infarction assessment. Therefore, the EASI system might be advantageous for long-term patient monitoring. Relevance to clinical practice The EASI system represents a valid device for the nursing surveillance of patients who need continuous ECG monitoring, improves clinical nursing practice in Coronary Care Units, supports the reduction of adverse events such as cardiac arrest and reduces the hospital costs.

Aims In dilated cardiomyopathy (DCM), attenuation of left atrial (LA) booster pump function has been observed, and attributed both to altered LA loading conditions owing to left ventricular (LV) diastolic dysfunction and to LA involvement in the myopathic process. The aim of the present study was to detect LA systolic dysfunction in DCM using speckle-tracking two-dimensional strain echocardiography (2DSE), and to assess the effects of cardiac resynchronization therapy (CRT) on LA myocardial strain during 6 month follow-up. Methods and results A total of 90 patients (aged, 52.4+10.2 years) with either idiopathic (n = 47) or ischaemic (n = 43) DCM underwent standard Doppler echo and 2DSE analysis of atrial longitudinal strain in the basal segments of LA septum and LA lateral wall, and in LA roof. The two groups were comparable for clinical variables (NYHA class: III in 72.2%; IV in 27.8%). LV volumes, ejection fraction, stroke volume, and mitral valve effective regurgitant orifice were similar between the two groups. No significant differences were evidenced in Doppler transmitral inflow measurements. LA diameter and maximal volume were also similar between the two groups. Conversely, LA active emptying volume and fraction were both lower in patients with idiopathic DCM. Peak systolic myocardial atrial strain was significantly compromised in patients with idiopathic DCM compared with ischaemic DCM in all the analysed atrial segments (P , 0.001). At follow-up, 64 patients (71.1%) (37 idiopathic and 27 ischaemic) were responders, and 26 (28.9%) (10 idiopathic; 16 ischaemic) were non-responders to CRT (responder: decrease of LV end-systolic volume .15%). A significant improvement in LA systolic function was obtained only in patients with ischaemic DCM responders to CRT (P , 0.001). By multivariable analysis, in the overall population, it was found that ischaemic aetiology of DCM (b-cofficient = 0.62; P , 0.0001) and positive response to CRT (b-cofficient = 0.42; P , 0.01) were the only independent determinants of LA lateral wall systolic strain. Conclusions Two-dimensional strain represents a promising non-invasive technique to assess LA atrial myocardial function in patients with DCM. LA pump and reservoir function at baseline and after CRT are more depressed in idiopathic compared with ischaemic DCM patients. Future longitudinal studies are warranted to understand further the natural history of LA myocardial function, the extent of reversibility of LA dysfunction with CRT, and the possible prognostic impact of such indexes in patients with congestive heart failure.

Author Summary Background. Anthracyclines and taxanes are effective drugs in breast cancer (BC), but their toxicity profiles limit their use in combination. A dose-finding study was performed to determine maximum tolerated doses (MTDs) of nonpegylated liposomal doxorubicin (TLC-D99) and docetaxel (DTX) as a dose-dense schedule, to maintain dose intensity, and to limit toxicity, particularly cardiac. Methods. Twenty-four patients were enrolled, 12 with metastatic BC, 5 with locally advanced BC, and 7 with early BC. An intra- and interpatient approach was planned in two sequential steps. In the first step, TLC-D99 was administered at dose levels of 40, 45, and 50 mg/m2 plus DTX at a fixed dose of 50 mg/m2. In the second step, TLC-D99 was administered at the dose established in the first step plus DTX at dose levels of 55, 60, and 65 mg/m2. Every treatment cycle was delivered on day 1 every 14 days. Pegylated granulocyte colony-stimulating factor was scheduled on day 2. Dose-limiting toxicities (DLTs) were defined as G4 hematological; G3 nonhematological; ≥10% or ≥20% left ventricular ejection fraction (LVEF) reduction if the final value was Results. Five DLTs occurred (20.8%). No cardiac event of congestive heart failure was reported; 2 events of grade 3 cardiac dysfunction (8.3%), including a ≥20% LVEF reduction in 1 patient and symptomatic arrhythmia in another; 2 incidences of G4 neutropenia (8.3%); and 1 occurrence of G3 asthenia (4.2%) were reported. MTDs were not reached. The recommended doses were established as TLC-D99 50 mg/m2 and DTX 65 mg/m2. Cumulatively, mild (G1–G2) cardiac dysfunction was observed in 58.4% of patients: G1 cardiac arrhythmia was noted in 50%, G1–G2 general cardiac toxicity occurred in 25%, and concomitant toxicity was present in 17%. cTnI never increased. pBNP was increased in 25% and was associated with limiting arrhythmia in 4% and cardiac dysfunction in 16%. Conclusion. Dose-dense TLC-D99 50 mg/m2 and DTX 65 mg/m2 can be safely administered in combination every 2 weeks for breast cancer, with the highest projected dose intensity for each drug at 25 and 32.5 mg/m2 per week, respectively.

Left ventricular surgical remodelling (LVSR) can be targeted to volume reduction (VR), (independently of the final shape) or to conical shape (CS). The aim of this study was to evaluate the long-term clinical and echocardiographic results of these two surgical strategies.From January 1988 to December 2012, 401 patients underwent LVSR: 107 in Group VR (1988-2001) and 294 in Group CS (1998-2012). The latter group of patients had lower ejection fraction (EF) and higher mitral and tricuspid regurgitation grade, with higher incidence of pulmonary hypertension. A propensity score model was built to adjust long-term results for preoperative and operative profiles.Thirty-day mortality was 6.0%. Median follow-up interval time was 100 (3-300) months. Overall 20-year and event-free survival were 36.1 ± 7.8 and 19.4 ± 7.2, respectively. No differences were found regarding 10-year survival (Group VR: 55.1 ± 4.8 vs Group CS: 64.2 ± 4.2, P = 0.16) and event-free survival (Group VR: 41.1 ± 4.8 vs Group CS: 50.5 ± 4.8, P = 0.12). However, Group CS provided better 10-year freedom from cardiac deaths (74.5 ± 3.7 vs 60.4 ± 4.8, P = 0.03) and from cardiac events (55.6 ± 5.0 vs 45.0 ± 4.9, P = 0.04). After propensity score adjustment, all the main outcomes were significantly better in Group CS. Multivariate Cox analysis confirmed this result; furthermore, to avoid any bias related to improved experience, 30-day mortality being higher in Group VR, we excluded the first month from Cox analysis: left ventricle VR (independently of the final shape) was still confirmed as the wrong approach. At the follow-up, Group CS showed significant improvement in EF (+18 vs +8%), end-systolic volume index (-35 vs -20%) and sphericity index (-6 vs +9%).LVSR should aim to provide a more physiological shape (conical) rather than simple VR.

Background: The aim of this study was to assess the value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in predicting late cardiotoxicity in patients treated with not-high-dose chemotherapy (NHDC), and to compare the predictive value of NT-proBNP and cardiac troponin I (cTnI). Methods: In 71 patients undergoing NHDC with anthracyclines, NT-proBNP and cTnI levels were measured before and 24 h after each NHDC cycle. Left ventricular (LV) function was assessed by echocardiography at baseline, every two NHDC cycles, at the end of chemotherapy, and at 3-, 6- and 12-month follow-up. Results: During NHDC, only NT-proBNP showed abnormal values. According to NT-proBNP behaviour, patients were divided into two groups: group A (n=50) with normal (n=23) or transiently elevated NT-proBNP levels (n=27), and group B (n=21) with persistently elevated NT-proBNP levels. At follow-up, LV impairment was significantly worse in group B than in group A. %Δ (baseline–peak) NT-proBNP was predictive of LV impairment at 3-, 6- and 12-month follow-up, with a cutoff of 36%. Conclusion: Serial measurements of NT-proBNP may be a useful tool for the early detection of patients treated with NHDC at high risk of developing cardiotoxicity.

Brian natriuretic peptide (BNP) is a peptide with important diuretic, natriuretic and vasodilating effects produced and released from ventricular myocytes in the healthy subjects and throughout the myocardium in heart failure. BNP was demonstrated to have an important diagnostic role in patients with isolated left ventricular diastolic dysfunction (ILVDD) [1]. This prospective studywas aimed to evaluate if the increment of BNP levels from baseline to follow-up might be predictive for exercise tolerance impairment over time in patients with LV diastolic dysfunction and preserved systolic function. Twenty-seven consecutive outpatients presenting in the heartfailure out-patient clinic of the University of L'Aquila and Hospital of Atri with ILVDD and preserved systolic function (EF>45%) were enrolled in this prospective study. Sixteen (59.2%) patients reported dyspnoea (NYHA class II) and 11 (40.8%) NYHA class I. Mean age was 61±9 years (38–75); 8 patients were females and 19 males. At the enrolment (baseline), diastolic dysfunction was assessed by trans-thoracic echocardiogram (MyLab 30, Esaote, Florence—Italy) and classified into 3 categories according to definition already reported [1]; BNP was measured using the commercially available Shionoria BNP (Shionogi USA, Inc) sandwich immunoassay Kit; 6 minute walking test (6MWT) was conducted as previously described by Guyatt et al. [2]: Covered distance (meters) and symptoms were considered. Echocardiogram, BNP assay and 6MWTwere repeated at follow-up (18±6 months). Exercise tolerance impairment (or improvement) was defined as the percent reduction (or increase) of 6MWT covered distance of at least 20% from baseline to follow-up [3]. The study conforms to the principles outlined in the Declaration of Helsinki and it was approved by the local ethics committee. Baseline echocardiography showed altered relaxation (pattern 1) in 10 (37.0%) patients, pseudonormalization (pattern 2) in 10 and restrictive pattern (3) in the remaining 7 cases (26.0%). Significantly different BNP levels were found among the 3 diastolic dysfunction

In patients with idiopathic dilated cardiomyopathy (DCM) a more depressed left atrial (LA) booster pump function has been observed compared to ischemic patients although under similar loading conditions, and attributed both to altered LA overload and to LA larger involvement in the myopathic process.To detect by speckle-tracking two-dimensional strain (2DSE) LA systolic dysfunction in patients with either idiopathic or ischemic DCM, and to assess in these patients possible correlation between LA myocardial function and exercise capacity during cardiopulmonary test.Three-hundred-fourteen patients (52.4+/-11.2 years) with either idiopathic (160 patients) or ischemic (154 patients) DCM underwent cardiopulmonary stress test, standard Doppler echo and 2DSE analysis of atrial longitudinal strain in the basal segments of LA septum and LA lateral wall, and in LA roof.The two groups were comparable for most of clinical variables. LV volumes, ejection fraction, stroke volume, and mitral valve effective regurgitant orifice were similar between the two groups. No significant differences were evidenced in Doppler transmitral inflow measurements. Also LA diameter and maximal volume were similar between the two groups. Conversely, LA active empting volume and fraction were both lower in patients with idiopathic DCM (0.001). Peak systolic myocardial atrial strain was significantly reduced in patients with idiopathic DCM compared with ischemic DCM at the level of all the analyzed atrial segments (p0.0001). By multivariable analysis, in the overall population, ischemic aetiology of DCM (p0.0001) and LA volume (p0.001) were the only independent determinants of LA lateral wall systolic strain. On the other hand, LA lateral wall systolic strain (p0.0001) and LA volume (p0.001) were powerful independent predictors of peak oxygen consumption during cardiopulmonary exercise testing.Two-dimensional strain represents a promising non-invasive technique to assess LA atrial myocardial function in patients with DCM. LA systolic deformation is more depressed in idiopathic compared with ischemic DCM, and is closely associated with functional capacity during effort. Future longitudinal studies are warranted to further our understanding of the natural history of LA myocardial function, the extent of reversibility of LA dysfunction with therapy, and the possible prognostic impact of such indexes in patients with congestive heart failure.

Atrial function is an integral part of cardiac function that is often neglected. The presence of left ventricule hypertrophy (LVH) due to arterial hypertension may impair atrial function. However, it has also been suggested that physical training attenuates the age-associated impairment of diastolic filling. This study investigated whether mechanical dysfunction in the left atrium (LA) is present in patients with either physiological or pathological LVH, using two-dimensional strain rate imaging (2D strain echocardiography; 2DSE).Standard echocardiography, exercise stress echo and 2DSE of the left atrium were performed in 40 patients with arterial hypertension, 45 age-matched elite athletes (40 years) and 25 healthy sedentary controls. Atrial longitudinal strain was performed from the apical views for the basal segments of the LA septum, lateral wall and roof.LV mass index and ejection fraction were comparable between patients with either physiological or pathological LVH. Elite athletes showed increased LV end-diastolic diameter, end-diastolic volume and stroke volume, whereas circumferential end-systolic stress was higher in patients with hypertension. LA diameter and maximum volume were increased but similar between the two groups of patients with LVH. LA active emptying volume and fraction were both higher in patients with hypertension. Conversely, peak systolic myocardial atrial strain was significantly reduced in patients with pathological LVH compared with controls and athletes for all the analysed atrial segments (p0.0001). Using multivariate analysis, LV end-diastolic volume/body surface area (BSA) (beta coefficient 0.52; p0.0001) and LV mass (beta = 0.48; p0.001) in athletes emerged as the only independent determinants of LA lateral wall peak systolic strain. In contrast, in patients with hypertension, an independent negative association of LA lateral wall peak systolic strain with both LV mass (beta = -0.42; p0.001) and circumferential end-systolic stress (beta = -0.43; p0.001) was found. In addition, in the overall population of patients with LVH, LA lateral wall systolic strain (beta = 0.49; p0.0001) was a powerful independent predictor of maximum workload during exercise testing.2DSE represents a promising, non-invasive, simple and reproducible technique to assess LA myocardial function in patients with either physiological or pathological LVH. LA myocardial deformation is impaired in patients with hypertension compared with age-matched sedentary controls and elite athletes, and is closely associated with functional capacity during effort.

Aims To evaluate the impact of right ventricular (RV) dysfunction on early and mid-term outcome of patients with ischaemic or dilated cardiomyopathy (DCM) undergoing mitral valve annuloplasty. Methods and results From January 1997 to December 2005, 111 patients with DCM (89 ischaemic, 22 non-ischaemic) were enrolled in this retrospective study. Mean age was 67 ± 10 years. Average pre-operative NYHA class was 3.0 ± 0.6. Tricuspid annular plane systolic excursion (TAPSE), tricuspid annular pleak systolic velocity (TAPSV), and RV fractional area change were considered as an index of RV function. A strong relationship between TAPSE and TAPSV were found ( r = 0.76). Thirty-day mortality was 10.8%. Five-year survival and possibility to be alive in NYHA classes I–II were 66.5 ± 5.0 and 59.5 ± 5.0%. TAPSE, TAPSV, and MV coaptation depth (MVCD) were found to be risk factors for worse early and mid-term outcome; functional class impaired mid-term outcome. ROC analysis identified TAPSE≤12 mm, TAPSV≤10 cm/s, and MVCD>10 mm as predictive cut-offs. Conclusion Pre-operative assessment of some echocardiographic parameters (TAPSE, TAPSV) is very easy, low cost, and provides accurate information on RV function. A good pre-operative clinical compensation has to be necessarily reached before the operation. MVCD should be evaluated to decide surgical strategy (repair or replace).

Numerous randomized clinical trials demonstrated the beneficial effects of cardiac resynchronization therapy (CRT) in the treatment of moderate to severe heart failure. Despite careful patient selection, there is still a percentage of non-responders, that is as high as 30-50%. Patients are selected mainly on electrocardiogram criteria. Recent studies have observed that the severity of mechanical systolic asynchrony is a much better predictor of a response after CRT. Echocardiography allows a non-invasive evaluation atrioventricular and inter- and intraventricular synchrony; furthermore, recent advances have provided direct evidence of wall motion resynchronization in patients receiving CRT. Nevertheless, although many authors tried to search for the best echocardiographic index to identify systolic asynchrony, and consequently responders to CRT before the procedure, this issue is still a matter of debate. Our aim was to make an updated review of the more recent studies on this topic.