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Abstract We assessed the value of 3 electrocardiographic (EKG) voltage criteria in detecting variations of left ventricular mass (LVM) over time, taking echocardiographic (ECHO) LVM as reference, in the Pressioni Arteriose Monitorate E Loro Associazioni study. In 927 subjects (age 47 ± 13 years on entry, 49.9% men) an ECHO evaluation of LVM and EKG suitable for measurement of EKG‐LVH criteria (Sokolow‐Lyon voltage, Cornell voltage and R‐wave voltage in aVL) were available at baseline and at a 2nd evaluation performed 10 years later. Δ (delta) LVM, Δ LVMI, and Δ EKG parameters values were calculated from 2nd evaluation to baseline. The sensitivity of the EKG criteria in the diagnosis of LVH, poor at baseline, becomes even worse after 10 years, reaching very low values. Only the sensitivity of R‐wave amplitude exhibited slight increase over time but with unsatisfactory absolute values. Despite the prevalence of ECHO‐LVH at the 2nd evaluation was threefold increased compared to baseline (29.3% and 33.7% for LVM indexed to BSA and height2.7, respectively), the prevalence of EKG‐LVH was unchanged when evaluated by Sokolow‐Lyon criteria, significantly reduced when assessed by Cornell voltage index, while significantly increased using R‐wave voltage in aVL criteria. Despite an ECHO‐LVM increase over the time, mean EKG changes were of opposite sign, except for R‐wave amplitude in aVL. Our study highlights the discrepancy between ECHO and EKG in monitoring LVM changes over the time, especially for Sokolow‐Lyon and Cornell voltage. Thus, EKG is an unsuitable method for the longitudinal evaluation of LVM variations.

Abstract The authors investigated the association between obstructive sleep apnea (OSA) and right ventricular (RV) systolic dysfunction trough a meta‐analysis of echocardiographic studies providing data on RV mechanics as assessed by longitudinal strain (LS). A systematic search was conducted using PubMed, OVID‐MEDLINE, and Cochrane library databases to search English‐language review papers published from inception to March 31, 2022. Only studies reporting data on RV free‐wall or global LS in patients with OSA of different severity and non‐OSA controls were reviewed. Data of interest were pooled to obtain standard means difference (SMD) with 95% confidence interval (CI). The meta‐analysis included 628 participants (436 with OSA and 192 controls) from eight studies. Compared to controls, RV free wall LS was significantly reduced in the pooled OSA group (SMD 1.02 ± .33, CI:.17/1.24, P

Abstract Current evidence on the effects of continuous positive airway pressure (CPAP) on cardiac mechanics in patients with obstructive sleep apnea (OSA) is based on a few single studies. The authors investigated this topic through a meta‐analysis of speckle tracking echocardiography (STE) studies that provided data on left ventricular (LV) and right ventricular (RV) mechanics as assessed by global longitudinal strain (GLS). The PubMed, OVID‐MEDLINE, and Cochrane library databases were systematically analyzed to search English‐language review papers published from inception to January 31, 2022. Studies were identified by crossing the following terms: “obstructive sleep apnea”, “sleep quality”, “sleep disordered breathing”, “continuous positive airway pressure therapy”, “noninvasive ventilation”, “left ventricular hypertrophy”, “systolic dysfunction”, “global longitudinal strain”, “left ventricular mechanics”, “right ventricular mechanics”, “echocardiography” and “STE echocardiography”. The meta‐analysis, including a total of 337 patients with OSA from nine studies (follow‐up 2–24 months) showed a significant GLS improvement in both LV and RV after CPAP, standard mean difference (SMD) being 0.51±0.08, CI:0.36–0.66, p = .0001 and 0.28±0.07, CI:0.15–0.42, p = .0001), respectively. Corresponding SMD values for LV ejection fraction (LVEF) and tricuspid annular plane systolic excursion (TAPSE) were 0.20±0.06, CI:0.08–0.33, p = .001 and 0.08±0.06, CI: ‐0.04/0.20, p = .21. Our meta‐analysis suggests that: I) CPAP treatment exerts beneficial effects on biventricular function in patients with OSA; II) the assessment of cardiac mechanics by STE should be routinely recommended for monitoring cardiac function in this setting, due to limitations of conventional echocardiography in evaluating biventricular performance.

Background and aim: Nitric oxide inhibits platelet aggregation by increasing the second messenger cyclic guanosine-3′,5′-monophosphate (cGMP) through the activation of soluble guanylyl cyclase in target cells. Within this context, the oxidative stress associated with the aldosterone excess impairs the nitric oxide availability. Thus, the aim of the present study was to assess the impact of chronic aldosterone excess on the platelet nitric oxide/cGMP pathway in humans. Methods: The levels of cGMP were evaluated in platelets of male patients, 12 with primary aldosteronism (PA) and 32 with uncomplicated essential hypertension (EH), matched for age and blood pressure (BP) values. Results: PA and EH patients were 52.8 ± 3 years old and 51.6 ± 1.6 years old, respectively. Systolic and diastolic BP were 158 ± 5.0 mmHg and 105.9 ± 2.3 mmHg in PA and did not differ compared to EH patients (156.6 ± 2.4 mmHg and 104.7 ± 1.2 mmHg). Mean aldosterone levels were significantly higher in PA (25.5 ± 8.8 ng/dL) compared toEH (8.11 ± 0.73 ng/dL), whereas potassium was significantly lower in PA (3.52 ± 0.18 mEq/L) compared to EH (4.08 ± 0.04 mEq/L). Aldosterone and potassium were inversely related (r = −0.49, p = 0.0006) in the whole study population (n = 44). Platelet cGMP was significantly lower in PA (5.1 ± 0.36 pM/109 cells) than in EH (7.1 ± 0.53 pM/109 cells), and in the entire study cohort, it was directly related to plasma potassium (r = 0.43, p = 0.0321). Conclusions: These results show an impairment of nitric oxide/cGMP signaling in platelets of PA patients. This effect is likely related to the potassium-depleting effect of chronic aldosterone excess. Future studies are needed to understand whether the platelet nitric oxide/cGMP system is involved in the atherothrombotic events in these patients.

Purpose The aim of this study was to examine myocardial performance using pressure-strain loops in hypertensive patients with different level of blood pressure control. Material and methods This cross-sectional study included 204 subjects (45 controls, 70 patients with well-controlled hypertension, 58 patients with uncontrolled hypertension and 31 patients with resistant hypertension) who underwent complete two-dimensional echocardiographic examination including two-dimensional speckle-tracking echocardiography. Pressure-strain curve was used to determine global myocardial work, constructive work, wasted work and work efficiency in all study participants. Results Left ventricular (LV) longitudinal strain gradually reduced from controls throughout well-controlled hypertensive patients, to patients with uncontrolled and resistant hypertension. Global myocardial work was higher in patients with uncontrolled and resistant hypertension than in controls and well-controlled hypertension. Constructive work was also higher in all hypertensive patients than in controls. Global wasted work and work efficiency were similar between different groups. Global myocardial work index was associated with peak oxygen consumption independently of sex, age, body mass index (BMI), LV structural and functional parameters in all hypertensive participants. Conclusions Myocardial work was significantly deteriorated in patients with uncontrolled and resistant arterial hypertension compared to controls and well-controlled hypertensive patients. Global myocardial work was associated with functional capacity independent of clinical and echocardiographic parameters.

Subclinical alterations in cardiac structure and function include a variety of abnormal phenotypes of recognized adverse prognostic values, such as left ventricular hypertrophy (LVH), concentric remodeling, systolic/diastolic dysfunction, left atrial dilatation, and alterations of LV geometry. The excess cardiovascular risk associated with these markers has been documented in multiple clinical settings, such as the general population, hypertensive cohorts, patients with coronary heart disease, diabetes mellitus, chronic heart failure, and chronic kidney disease. On the contrary, the value of aortic root (AR) and ascending aortic diameter in predicting cardiovascular outcomes and all-cause mortality in populations free from overt aortic pathology is still debated. The present review, aimed at pointing out the prognostic implications of thoracic aortic dimensions in populations free from known connective and aortic diseases, suggests that available evidence supporting an association between aortic diameter and cardiovascular events, and all-cause mortality is based on the limited number of studies, conducted with different imaging techniques and definition of the aortic phenotype.

Obstructive sleep apnea (OSA) syndrome is a very important sleep-related breathing disorder related to increased cardiovascular and overall morbidity and mortality. It is associated with multisystemic target organ damage due to micro- and macrovascular changes, resulting in carotid and coronary atherosclerosis, increased arterial stiffness, retinal damage, microalbuminuria, and cardiac remodeling. The latter consists of left ventricular (LV) hypertrophy, as well as diastolic and systolic dysfunction. The increasing burden of evidence shows that OSA also induces right ventricular (RV) remodeling that is more difficult to diagnose, but may also contribute to cardiovascular morbidity and mortality in these patients. Conventional echocardiographic parameters for assessment of RV systolic and diastolic functions are often not sensitive enough to detect subclinical and subtle changes in the RV function. Data published over last decade showed that the RV function, particularly systolic, is impaired in OSA patients and related with its severity. However, the introduction of speckle tracking echocardiography and the particularly longitudinal strain enabled the earlier detection of functional and mechanical changes even when conventional echocardiographic parameters of RV systolic function remained unchanged. The 3D echocardiography provided the possibility to evaluate the entire RV, with its unique shape, and determine 3D RV ejection fraction, which is comparable with results obtained by cardiac magnetic resonance. The use of this modality also provided a new insight into RV systolic (dys)function in OSA patients. In addition to weight loss, which has been proven very helpful in OSA patients, the only approved therapeutic approach is continuous positive airway pressure (CPAP) therapy. It is very important to assess if this therapy induces any improvement in cardiac structure and function. Limited data on this topic show that RV longitudinal strain is a more sensitive parameter rather than other conventional RV indexes in the detection of improvement in RV systolic function and mechanics. The aim of this review article is to summarize the current understanding of RV structural, functional, and mechanical changes in patients with OSA. Furthermore, we sought to provide the current knowledge regarding the effect of CPAP therapy on RV reverse remodeling in OSA patients.

Vascular and sympathetic abnormalities characterize chronic heart failure (CHF). Alterations include (1) a reduction in arterial distensibility, (2) endothelial dysfunction, (3) a decrease in arterial compliance and a parallel increase in arterial stiffness, and (4) sympathetic cardiovascular activation. Altogether, these alterations represent important targets in therapeutic interventions, because they display an independent negative impact on the disease prognosis, favouring disease progression and the development of cardiovascular complications with direct and indirect mechanisms. The present review will examine the effects of the different therapeutic interventions targeting the vascular/sympathetic alterations detected in CHF. Non-pharmacological, pharmacological and device-based treatments will be discussed in detail, highlighting the possible mechanisms responsible for the vascular/sympathetic effects of each intervention. Finally, the unmet goals in treatment in relation to endothelial and adrenergic targets will be also discussed.

Aim: Whether exaggerated blood pressure response (EBPR) to exercise represents a marker of masked hypertension (MH) in individuals with no prior history of hypertension is still unclear. We investigated this issue through a review and a meta-analysis of studies providing data on this association in normotensive individuals undergone both to dynamic or static exercise and to 24 h blood pressure monitoring (ABPM). Design: A systematic search was performed using Pub-Med, OVID, EMBASE, and Cochrane library databases from inception up to 31 December 2022. Studies were identified by using the following search terms: “masked hypertension”, “out-of-office hypertension”, “exercise blood pressure”, “exaggerated blood pressure exercise”, “exercise hypertension”. Results: Nine studies including a total of 387 participants with MH and 406 true normotensive controls were considered. Systolic BP (SBP) and diastolic BP (DBP) at rest were significantly higher in MH individuals than in sustained normotensives: 126.4 ± 1.4/78.5 ± 1.8 versus 124.0 ± 1.4/76.3 ± 1.3 mmHg (SMD: 0.21 ± 0.08, CI: 0.06–0.37, p = 0.007 for SBP; 0.24 ± 0.07, CI: 0.08–0.39, p = 0.002 for DBP). The same was true for BP values at peak exercise: 190.0 ± 9.5/96.8 ± 3.7 versus 173.3 ± 11.0/88.5 ± 1.8 mmHg (SMD 1.02 ± 0.32, CI: 0.39–1.65, p = 0.002 for SBP and 0.97 ± 0.25, CI: 0.47–1.96, p < 0.0001 for DBP). The likelihood of having an EBPR was significantly greater in MH than in their normotensive counterparts (OR: 3.33, CI: 1.83–6.03, p < 0.0001). Conclusions: Our meta-analysis suggests that EBPR reflects an increased risk of MH and that BP measurement during physical exercise aimed to assess cardiovascular health may unmask the presence of MH. This underscores the importance of BP measured in the medical setting at rest and in dynamic conditions in order to identify individuals at high cardiovascular risk due to unrecognized hypertension.

The hypertensive response to exercise testing, defined as exaggerated blood pressure response (EBPR), has been documented to be independently associated with unhealthy conditions, carrying an increased risk of future hypertension, cardiovascular (CV) morbidity and mortality. In treated hypertensives, EBPR is a marker of uncontrolled hypertension, a condition previously undetected by office blood pressure (BP) measurements at rest; EBPR may also detect masked hypertension, a phenotype characterized by normal BP values in the medical environment but elevated home or ambulatory BP monitoring (ABPM). The aim of the present review is to provide a comprehensive and up-dated information on the clinical importance of EBPR targeting the following issues: (I) definition and prevalence; (II) underlying mechanisms; (III) clinical correlates and association with subclinical organ damage; (IV) predictive value; (V) clinical decision making.

The injury of the left ventricle (LV) during anticancer therapy has long been recognized, and guidelines recommend a specific set of parameters for determination of LV impairment. The influence of anticancer therapy on the right ventricle (RV) has been insufficiently investigated, and there are only a few studies that have considered the effect of radiotherapy on RV remodeling. On the other hand, large number of patients with different types of cancers located in the chest are treated with radiotherapy, and the negative clinical effects of this treatment such as accelerated coronary artery disease, valve degeneration and heart failure have been documented. The anatomical position of the RV, which is in the front of the chest, is responsible for its large exposure during radiation treatment, particularly in patients with left-sided breast and lung cancers and mediastinal cancers (hematological malignancies, esophagus cancers, thymomas, etc.). For the same reason, but also due to its anatomical complexity, the RV remains under-investigated during echocardiographic examination, which remains the cornerstone of cardiac imaging in everyday practice. In the last decade many new echocardiographic imaging techniques that enable better evaluation of RV structure, function and mechanics appeared, and they have been used in detection of early and late signs of RV injuries in oncological patients. These investigations are related to some important restrictions that include limited numbers of patients, used parameters and imaging techniques. Many questions about the potential impact of these changes and possible predictions of adverse events remain to be evaluated in future large longitudinal studies. The current body of evidence indicates an important role of radiotherapy in RV remodeling, and therefore, the aim of this review is to summarize currently available data regarding RV changes in patients with various oncological conditions and help clinicians in the assessment of possible cardiac damage.

Abstract The study by Triantafyllidi et al. supports the view that regression of subclinical cardiac damage requires an effective 24‐hour blood pressure (BP) control along with a reduction in BP variability and suggests that the assessment of BPV and its modifications during the course of therapy may be an useful approach in predicting the beneficial effects of treatment on cardiac structure. However, some aspects and limitations of this study require caution in drawing firm conclusions. So, further investigation is needed to determine if reduction of BPV is actually associated with a regression in cardiac and extracardiac organ damage to identify which which classes of antihypertensive drugs are most effective in reducing BPV, and to elucidate whether those treatments provide additional clinical benefit, independent of the conventional BP targets.

Right ventricular remodeling has been neglected in patients with arterial hypertension as all studies have concentrated on the left ventricle and left atrial-ventricular and ventricular-arterial coupling. The development of novel imaging techniques has revealed significant impairment in the RV structure, systolic and diastolic function, and, afterwards, RV longitudinal mechanics. However, these changes are subclinical and can be detected only after comprehensive imaging analysis. The latest findings confirm the importance of RV hypertrophy, systolic, and diastolic dysfunction in the prediction of cardiovascular adverse events in the hypertensive population, representing an important clinical implication of these parameters. In clinical practice, 2D echocardiography is widely used for the evaluation of RV remodeling. However, existing techniques are largely underused and limited to a few basic parameters (RV thickness and TAPSE), which are not nearly enough for a detailed assessment of RV remodeling. In addition, 3D echocardiography provides the possibility of accurate evaluation of RV volumes and ejection fraction, which are comparable with results obtained by cardiac magnetic resonance (CMR)—a gold standard for the evaluation of the RV. The use of 3D echocardiography is limited due to its low availability, the lack of adequate software necessary for the calculation of results, and the necessity for a higher level of expertise. CMR provides all information required for a detailed assessment of RV structural, functional, and mechanical remodeling, and it is considered the reference method for this type of evaluation. Furthermore, it is the only technique that may provide tissue characterization and evaluation of the interstitial space, which is essential for hypertensive heart disease. The aim of this review is to provide the current level of evidence regarding RV remodeling in patients with arterial hypertension evaluated with different imaging techniques and various parameters from each method.

Aim: Current evidence on the effects of bariatric surgery on cardiac mechanics in patients with obesity is based on a few single studies. We investigated this issue through a meta-analysis of speckle tracking echocardiography (STE) studies that reported data on changes in left ventricular (LV) mechanics as assessed by global longitudinal strain (GLS). Methods: The PubMed, OVID-MEDLINE and Cochrane library databases were systematically analysed to search English-language articles published from inception to 31 May 2022. Studies were identified by using Me-SH terms and crossing the following terms: “obesity”, “bariatric surgery”, “left ventricular mechanics”, “left ventricular hypertrophy”, “systolic dysfunction”, “global longitudinal strain”, “echocardiography” and “STE echocardiography”. Results: The meta-analysis, including a total of 512 patients with obesity from 13 studies (follow-up 1–23 months), showed a significant GLS improvement after bariatric procedures, with standard mean difference (SMD) being 0.50 ± 0.08, CI: 0.34/0.65, p < 0.0001. Corresponding SMD value for LV ejection fraction (LVEF) was 0.15 ± 0.09, CI: −0.04/0.34, p = 0.11. A sensitivity analysis restricted to 11 studies with follow-up ≥ 6 months confirmed that GLS (SMD: 0.47 ± 0.08, CI: 0.30/0.63, p < 0.0001) but not LVEF (SMD: 0.14 ± 0.11, CI: −0.08/0.37, p = 0.21) improved after surgery. Conclusions: Our meta-analysis adds a new piece of information on the beneficial effects of bariatric surgery on LV systolic function and, more importantly, suggests that the assessment of myocardial strain should be routinely implemented for a comprehensive evaluation of cardiac functional changes associated with bariatric procedures.

Right ventricular (RV) systolic function has an important role in the prediction of adverse outcomes, including mortality, in a wide range of cardiovascular (CV) conditions. Because of complex RV geometry and load dependency of the RV functional parameters, conventional echocardiographic parameters such as RV fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE), have limited prognostic power in a large number of patients. RV longitudinal strain overcame the majority of these limitations, as it is angle-independent, less load-dependent, highly reproducible, and measure regional myocardial deformation. It has a high predictive value in patients with pulmonary hypertension, heart failure, congenital heart disease, ischemic heart disease, pulmonary embolism, cardiomyopathies, and valvular disease. It enables detection of subclinical RV damage even when conventional parameters of RV systolic function are in the normal range. Even though cardiac magnetic resonance-derived RV longitudinal strain showed excellent predictive value, echocardiography-derived RV strain remains the method of choice for evaluation of RV mechanics primarily due to high availability. Despite a constantly growing body of evidence that support RV longitudinal strain evaluation in the majority of CV patients, its assessment has not become the part of the routine echocardiographic examination in the majority of echocardiographic laboratories. The aim of this clinical review was to summarize the current data about the predictive value of RV longitudinal strain in patients with pulmonary hypertension, heart failure and valvular heart diseases.

Objective: We sought to investigate functional capacity, heart rate variability (HRV), as well as their relationship in the patients with uncomplicated type 2 diabetes. Methods: This cross-sectional observational study included 62 controls and 53 uncomplicated diabetic patients. Included subjects underwent laboratory analysis, 24-h ECG Holter monitoring and cardiopulmonary exercise testing. Results: All parameters of time and frequency domain of HRV were decreased in the diabetic patients. Oxygen uptake at ventilatory threshold (18.3 ± 3.9 vs. 14.6 ± 3.6 mL/kg/min, p

Sacubitril/valsartan represents the combination that became “sine qua non” in the treatment of heart failure with reduced ejection fraction (HFrEF) with significant positive effect on major cardiovascular events [...]

Coronavirus disease 2019 (COVID-19) has become a worldwide pandemic responsible for millions of deaths around the world. Hypertension has been identified as one of the most common comorbidities and risk factors for severity and adverse outcome in these patients. Recent investigations have raised the question whether hypertension represents a predictor of outcome in COVID-19 patients independently of other common comorbidities such as diabetes, obesity, other cardiovascular diseases, chronic kidney, liver, and pulmonary diseases. However, the impact of chronic and newly diagnosed hypertension in COVID-19 patients has been insufficiently investigated. The same is true for the relationship between blood pressure levels and outcomes in COVID-19 patients. It seems that the long discussion about the impact of angiotensin-converting enzyme inhibitors (ACEI) and blockers of angiotensin I receptors (ARB) on severity and outcome in COVID-19 is approaching an end because the large number of original studies and meta-analyses discarded the initial findings about higher prevalence of ACEI/ARB use in patients with unfavorable outcomes. Nevertheless, there are many controversies in the relationship between hypertension and COVID-19. The aim of this review article is to provide a clinical overview of the currently available evidence regarding the predictive value of hypertension, the effect of blood pressure levels, the impact of previously known and newly diagnosed hypertension, and the effect of antihypertensive therapy on the severity and outcomes in COVID-19 patients.

Aortic stenosis (AS) is the most frequent degenerative valvular disease in developed countries. Its incidence has been constantly rising due to population aging. The diagnosis of AS was considered straightforward for a very long time. High gradients and reduced aortic valve area were considered as “sine qua non” in diagnosis of AS until a growing body of evidence showed that patients with low gradients could also have severe AS with the same or even worse outcome. This completely changed the paradigm of AS diagnosis and involved large numbers of parameters that had never been used in the evaluation of AS severity. Low gradient AS patients may present with heart failure (HF) with preserved or reduced left ventricular ejection fraction (LVEF), associated with changes in cardiac output and flow across the aortic valve. These patients with low-flow low-gradient or paradoxical low-flow low-gradient AS are particularly challenging to diagnose, and cardiac output and flow across the aortic valve have become the most relevant parameters in evaluation of AS, besides gradients and aortic valve area. The introduction of other imaging modalities in the diagnosis of AS significantly improved our knowledge about cardiac mechanics, tissue characterization of myocardium, calcium and inflammation burden of the aortic valve, and their impact on severity, progression and prognosis of AS, not only in symptomatic but also in asymptomatic patients. However, a variety of novel parameters also brought uncertainty regarding the clinical relevance of these indices, as well as the necessity for their validation in everyday practice. The aim of this review is to summarize the prevalence of HF in patients with severe AS and elaborate on the diagnostic challenges and advantages of comprehensive multimodality cardiac imaging to identify the patients that may benefit from surgical or transcatheter aortic valve replacement, as well as parameters that may help during follow-up.

Studies show that patients with elevated triglycerides and well-controlled LDL levels under statin therapy still have a significant residual risk of cardiovascular (CV) events. Despite many attempts to reduce triglycerides with different hypolipidemic drugs, no therapeutic option has given satisfactory results so far. The initial enthusiasm that omega-3 fatty acids can effectively reduce triglycerides and CV risk was replaced with skepticism when the first large clinical trials failed to show any benefit in primary or secondary prevention. However, the latest studies succeeded in showing a positive effect of omega-3 fatty acids on CV outcome in patients with hypertriglyceridemia. The largest benefit was reported in secondary but not primary prevention. Interestingly, the reduction in triglycerides in some of these studies was disproportionately low to the relatively high CV risk reduction, which could indicate some other effects of omega-3 fatty acids that go well beyond hypotriglyceridemic action. This includes blood pressure reduction, antithrombotic effect, improvement of inflammatory status, endothelial function, and insulin resistance. Investigations also reported a significant and positive influence of omega-3 fatty acids on the composition and stabilization of coronary atherosclerotic plaques in patients with and without previous CV events. In addition to insufficiently known mechanisms of action and conflicting results about the effectiveness of omega-3 fatty acids, the safety problems, which include increased prevalence of atrial fibrillation and hemorrhage, were also reported. The aim of this clinical review was to summarize the current knowledge regarding the use of omega-3 fatty acids in CV patients, particularly those with coronary artery disease, and to present an overview of key clinical trial data.

Right ventricular (RV) systolic function represents an important independent predictor of adverse outcomes in many cardiovascular (CV) diseases. However, conventional parameters of RV systolic function (tricuspid annular plane excursion (TAPSE), RV myocardial performance index (MPI), and fractional area change (FAC)) are not always able to detect subtle changes in RV function. New evidence indicates a significantly higher predictive value of RV longitudinal strain (LS) over conventional parameters. RVLS showed higher sensitivity and specificity in the detection of RV dysfunction in the absence of RV dilatation, apparent wall motion abnormalities, and reduced global RV systolic function. Additionally, RVLS represents a significant and independent predictor of adverse outcomes in patients with dilated cardiomyopathy (CMP), hypertrophic CMP, arrhythmogenic RV CMP, and amyloidosis, but also in patients with connective tissue diseases and patients with coronary artery disease. Due to its availability, echocardiography remains the main imaging tool for RVLS assessment, but cardiac magnetic resonance (CMR) also represents an important additional imaging tool in RVLG assessment. The findings from the large studies support the routine evaluation of RVLS in the majority of CV patients, but this has still not been adopted in daily clinical practice. This clinical review aims to summarize the significance and predictive value of RVLS in patients with different types of cardiomyopathies, tissue connective diseases, and coronary artery disease.

We aimed to investigate the association between white-coat hypertension (WCH) and left atrial (LA) phasic function assessed by the volumetric and speckle tracking method. This cross-sectional study included 52 normotensive individuals, 49 subjects with WCH and 56 untreated hypertensive patients who underwent a 24-h ambulatory BP monitoring and complete two-dimensional echocardiographic examination (2DE). WCH was diagnosed if clinic blood pressure (BP) was elevated and 24-h BP was normal. We obtained that maximum, minimum LA and pre-A LAV volumes and volume indexes gradually and significantly increased from the normotensive subjects, throughout the white-coat hypertensive individuals to the hypertensive patients. Passive LA emptying fraction (EF), representing the LA conduit function, gradually reduced from normotensive to hypertensive subjects. Active LA EF and the parameter of the LA booster pump function increased in the same direction. Similar results were obtained by 2DE strain analysis. The LA stiffness index gradually increased from normotensive controls, throughout white-coat hypertensive subjects to hypertensive patients. Clinic systolic BP was associated with LA passive EF (β= −0.283, p = 0.001), LA active EF (β = 0.342, p

Aim: We examined the reduced blood pressure (BP) nocturnal fall in patients with obstructive sleep apnea (OSA) by a meta-analysis including studies that provided data on prevalence rates of non-dipping (ND) pattern during 24-h ambulatory blood pressure monitoring (ABPM). Design: The PubMed, OVID-MEDLINE, and Cochrane CENTRAL literature databases were searched for appropriate articles without temporal restriction up to April 2019 through focused and sensitive search methods. Studies were identified by crossing the search terms as follows: “obstructive sleep apnea”, “sleep quality”, “non dipping”, “reduced nocturnal BP fall”, “circadian BP variation”, “night-time BP”, and “ambulatory blood pressure monitoring”. Results: Meta-analysis included 1562 patients with OSA from different clinical settings and 957 non-OSA controls from 14 studies. ND pattern prevalence in patients with OSA widely varied among studies (36.0−90.0%). This was also the case for non-OSA controls (33.0% to 69.0%). Overall, the ND pattern, assessed as an event rate in the pooled OSA population, was 59.1% (confidence interval (CI): 52.0−65.0%). Meta-analysis of the seven studies comparing the prevalence of ND pattern in participants with OSA and controls showed that OSA entails a significantly increased risk of ND (Odds ratio (OR) = 1.47, CI: 1.07−1.89, p < 0.01). After the exclusion of patients with mild OSA, OR increased to 1.67 (CI: 1.21−2.28, p < 0.001). Conclusions: The present meta-analysis, extending previous information on the relationship between OSA and impaired BP dipping, based on single studies, suggests that this condition increases by approximately 1.5 times the likelihood of ND, which is a pattern associated with a greater cardiovascular risk than normal BP dipping.

Background: Data regarding cardiac remodeling in patients with alcoholic liver cirrhosis are scarce. We sought to investigate right atrial (RA) and right ventricular (RV) structure, function, and mechanics in patients with alcoholic liver cirrhosis. Methods: This retrospective cross-sectional investigation included 67 end-stage cirrhotic patients, who were referred for evaluation for liver transplantation and 36 healthy controls. All participants underwent echocardiographic examination including strain analysis, which was performed offline. Results: RV basal diameter and RV thickness were significantly higher in patients with cirrhosis. Conventional parameters of the RV systolic function were similar between the observed groups. Global, endocardial, and epicardial RV longitudinal strains were significantly lower in patients with cirrhosis. Active RA function was significantly higher in cirrhotic patients than in controls. The RA reservoir and conduit strains were significantly lower in cirrhotic patients, while there was no difference in the RA contractile strain. Early diastolic and systolic RA strain rates were significantly lower in cirrhotic patients than in controls, whereas there was no difference in the RA late diastolic strain rate between the two groups. Transaminases and bilirubin correlated negatively with RV global longitudinal strain and RV-free wall strain in patients with end-stage liver cirrhosis. The Model for End-stage Liver Disease (MELD) score, predictor of 3-month mortality, correlated with parameters of RV structure and systolic function, and RA active function in patients with end-stage liver cirrhosis. Conclusions: RA and RV remodeling is present in patients with end-stage liver cirrhosis even though RV systolic function is preserved. Liver enzymes, bilirubin, and the MELD score correlated with RV and RA remodeling.

Background: Previous studies have focused on left and right ventricular remodeling in cystic fibrosis (CF), whereas atrial function has not been assessed in detail so far. We sought to investigate left and right atrial (LA and RA) function in patients with CF. Methods: This retrospective investigation included 82 CF patients (64 survivors and 18 non-survivors) who were referred to CF department over the period of four years, as well as 32 control subjects matched by age and gender. All participants underwent an echocardiographic examination including a strain analysis, which was performed offline and blinded for groups. Results: LA and RA volume indexes were significantly higher in CF patients than in controls and were particularly high in CF non-survivors. LA conduit and reservoir functions were significantly worse in CF survivors and non-survivors, compared with control subjects. RA phasic function was not different between controls, CF survivors and non-survivors. The parameters of lung function (forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1)) and the LA and RA volume indexes were predictors of mortality in CF patients. However, in a multivariate analysis, only FVC was an independent predictor of mortality in CF patients. Conclusions: Our results suggest that both atria are enlarged, but only LA function is impaired in CF patients. LA reservoir and conduit function is particularly deteriorated in CF patients. Though statistical significance was not reached due to our limited sample size, there was a trend of deterioration of LA and RA function from controls across CF survivors to CF non-survivors. LA and RA enlargement represented predictors of mortality in CF patients.

Heart failure with preserved ejection fraction (HFpEF) represents the most frequent form of heart failure in women, with almost two-fold higher prevalence than in men. Studies have revealed sex-specific HFpEF pathophysiology, and suggested the possibility of a sex-specific therapeutic approach in these patients. Some cardiovascular risk factors, such as arterial hypertension, obesity, diabetes mellitus, coronary artery disease, atrial fibrillation, and race, show specific features that might be responsible for the development of HFpEF in women. These risk factors are related to specific cardiovascular changes—left ventricular diastolic dysfunction and hypertrophy, ventricular−vascular coupling, and impaired functional capacity—that are related to specific cardiac phenotype and HFpEF development. However, there is no agreement regarding outcomes in women with HFpEF. For HFpEF, most studies have found higher hospitalization rates for women than for men. Mortality rates are usually not different. Pharmacological treatment in HFpEF is challenging, along with many unresolved issues and questions raised. Available data on medical therapy in patients with HFpEF show no difference in outcomes between the sexes. Further investigations are necessary to better understand the pathophysiology and mechanisms of HFpEF, as well as to improve and eventually develop sex-specific therapy for HFpEF.

We aimed to explore left atrial (LA) remodeling in the patients with solid cancer before initiation of chemo- or radiotherapy. This retrospective investigation included 92 chemo- and radiotherapy-naive cancer patients and 40 age- and gender-matched controls with a similar cardiovascular risk profile as the cancer group. All participants underwent comprehensive echocardiographic examination before the start of chemo- or radiotherapy. LA phasic function was evaluated in volumetric and strain method. Indexed minimal and pre-A LA volumes were significantly higher in the cancer patients. Total and passive LA emptying fraction (EF) were significantly lower, whereas active LAEF was significantly higher in the cancer patients. LA total longitudinal strain was significantly lower in the cancer patients. Strain rate analysis of LA phasic function showed that LA function during systole and early diastole was reduced in the cancer group, while it was increased during late diastole. These findings indicated that LA reservoir and conduit functions, assessed with LA volumetric and strain analysis, were deteriorated in the cancer group. On the other hand, LA booster pump function was elevated in the cancer group in comparison with the controls. In the whole population, cancer was associated with reduced LA total longitudinal strain independently of age, gender, BMI, LV hypertrophy, E/e’ ratio, diabetes, and hypertension. LA phasic function was impaired in the chemo- and radiotherapy-naive cancer patients in comparison with the control group. Cancer, LV hypertrophy, and hypertension were associated with reduced LA longitudinal strain independently of other important clinical parameters.

Cesare Cuspidi1,2, Francesca Negri1,2, Valentina Giudici2, Anna Capra1, Carla Sala31Department of Clinical Medicine and Prevention, University of Milano-Bicocca, Milano; 2Istituto Auxologico Italiano, Milano; 3Thoraco-Pulmonary and Cardiocirculatory Department, University of Milano, Fondazione Policlinico di Milano, ItalyAbstract: Carotid intima-media thickness (IMT) and plaques have been shown to have a strong continuous relationship with cardiovascular (CV) morbidity and mortality; therefore, carotid atherosclerosis, as assessed by ultrasonography, can be regarded as a reliable surrogate end-point for therapeutic interventions. In this survey, we report the results of 16 double blind, randomized, controlled studies comparing: 1) antihypertensive drugs versus placebo/no treatment (five trials including 3,215 patients); 2) different active antihypertensive drug regimens (five trials including 4,662 patients); 3) angiotensin-II receptor blockers (ARBs) versus other antihypertensive agents (six trials including 841 patients). Our main findings can be summarized as follows: I) Long-term antihypertensive treatment has a blunting effect on carotid IMT progression, regardless of types of drugs. II) Calcium-channel blockers (CCBs) are more effective than other antihypertensive drugs including diuretics, beta-blockers, and angiotensin-converting enzyme (ACE)-inhibitors in this blunting effect; III) the effect of ARBs compared to other antihypertensive regimens (mostly based on atenolol) on carotid atherosclerosis progression needs to be further elucidated, as a protective effect was demonstrated by some, but not all studies examined. Thus, further studies are needed to clarify the role of ARBs in this therapeutic area. Keywords: ultrasonography, carotid atherosclerosis, antihypertensive drugs, angiotensin II receptor blockers

Cesare Cuspidi1,2, Francesca Negri2, Alberto Zanchetti31Department of Clinical Medicine and Prevention, University of Milano-Bicocca, Milan, Italy; 2Policlinico di Monza; 3Centro Interuniversitario di Fisiologia Clinica e Ipertensione, Università di Milano, and Istituto Auxologico Italiano, Milan, ItalyAbstract: Left ventricular hypertrophy (LVH) and atrial fibrillation (AF) are strong predictors of cardiovascular (CV) morbidity and mortality, independently of blood pressure levels and other modifiable and nonmodifiable risk factors. The actions of circulating and tissue angiotensin II, mediated by AT1 receptors, play an important role in the development of a wide spectrum of cardiovascular alterations, including LVH, atrial enlargement and AF. Growing experimental and clinical evidence suggests that antihypertensive drugs may exert different effects on LVH regression and new onset AF in the setting of arterial hypertension. Since a number of large and adequately designed studies have found angiotensin II receptor blockers (ARBs) to be more effective in reducing LVH than beta-blockers and data are also available showing their effectiveness in preventing new or recurrent AF, it is reasonable to consider this class of drugs among first line therapies in patients with hypertension and LVH (a very high risk phenotype predisposing to AF) and as adjunctive therapy to antiarrhythmic agents in patients undergoing pharmacological or electrical cardioversion of AF.Keywords: angiotensin II receptor blockers, left ventricular hypertrophy, atrial fibrillation