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Background To minimize complications associated with the construction of the hand-sewn aortic anastomosis, alternative experimental methods have been pursued. This study aimed to evaluate the efficacy of experimental anastomotic devices in relation to time and point of rupture of the anastomosis in comparison to the conventional technique. Materials and methods An electronic search was performed using MEDLINE, Scopus, Science Direct, and Cochrane Library databases by two independent authors. Our exclusion criteria referred to studies reporting results solely from end-to-side anastomosis, results on vessels other than the aorta, studies that did not involve animal experiments, and non-English publications. The last search date was January 1, 2020. Results The meta-analysis included 22 studies with 34 anastomosis samples and a total of 316 animals. The pooled mean automated anastomosis time was 10.38 min, and the mean point of rupture was 32.7 N. In the subgroup analysis of automated anastomosis time by device category, the anastomotic stenting technique reported significantly lower anastomosis time but also showed significantly lower point of rupture. Comparing the efficacy of experimental devices and the hand-sewn technique, our pooled analysis showed that automated devices significantly decrease the time needed to perform the anastomosis (weighted mean difference −7.24 min). On the other hand, the automated anastomosis is also associated with decreased tensile strength (weighted mean difference −20.68 N). Conclusions Although experimental devices seem to offer a faster anastomosis, they lack endurance when compared with the hand-sewn technique. Further research is needed for the development of an “ideal” anastomotic technique.

Given the inconsistent results on the prognostic significance of triglycerides (TGs), the purpose of the present study was to investigate the association of plasma TGs with left ventricular mass (LVM) in hypertensive patients. We studied 760 never treated, non diabetic, hypertensive patients. Τransthoracic echocardiography was performed and LVMI was calculated according to the Devereux formula, adjusted to body surface area. Triglycerides were associated with LVMI after adjustment for age, gender, systolic blood pressure (SBP), smoking and fasting glucose (b = 0.08, p = 0.009). This relationship remained significant even after adjustment for BMI, LDL-C and ApoB/ApoA1 ratio (b = 0.07, p = 0.04). Gender-stratified analysis indicated that TGs were related to LVMI in men (p = 0.001) but not in women (p = NS). In addition, TGs were related with LV hypertrophy (LVH) in men, increasing the odds by 7% to present LVMI over 115 g/m2 (OR = 1.07 per 10 mg/dl increase in TGs, p = 0.01). In conclusion, TGs are associated with LVMI in hypertensive patients, independently of other risk factors, including LDL-C. Given the prognostic significance of LVH, it might be suggested that TGs may serve as a useful marker for indentifying hypertensive patients at high risk. The gender discrepancy may suggest a possible gender-specific modulatory effect of TGs on LV structure.

Background Despite continuous improvements of diagnostic and therapeutic algorithms for cardiovascular disease (CVD), mortality from CVD remains high suggesting unaddressed residual risk. Remnant cholesterol (RC) consists the cholesterol content of triglyceride-rich lipoproteins, which along with LDL cholesterol infiltrate the arterial wall, accumulate and cause atherosclerosis. Increased remnant cholesterol (RC) levels have been previously associated with future adverse cardiac events despite hypolipidemic therapy. However, a mechanistic association of RC levels with human atherosclerosis in vivo has not been proven in a clinical setting. Purpose To evaluate the association of RC levels with the presence and extend of subclinical carotid atherosclerosis. Methods In this retrospective cohort study, 438 subjects from the Athens Vascular Registry without clinically overt CVD or treatment with statin were recruited. Atherosclerotic burden was assessed by B-mode carotid ultrasonography using: 1. Maximal carotid wall thickness [maxWT, the highest intima-media thickness (IMT) or highest atherosclerotic plaque thickness (PLQ) if present derived from all carotid sites], 2. Total thickness (sumWT, sum of maximal wall thickness), 3) high plaque burden (PLQ ≥2) and 4) average carotid IMT (avgIMT). RC was calculated using the formula RC=total cholesterol-LDL-C-HDL-C. Results Mean (SD) age was 54.8±12.4 years old with 41% being males. Subjects with RC>median (=18mg/dl) had higher sumWT (6.12±0.7 vs 5.57±1.7, p=0.002), maxWT (1.61±0.7 vs 1.43±0.7, p=0.008) and avgIMT (0.88±0.16 vs 0.83±0.16, p=0.003) vs RCmedian was associated with higher odds for increased sumWT (highest tertile, OR: 2.15 95% CI 1.26–3.66, p=0.006) and maxWT (OR: 2.15 95% CI: 1.38–3.33, p=0.001), and a higher plaque burden (≥2 plaques, OR: 2.1 95% CI 1.93–3.1, p Conclusion In a statin-naive population without clinically overt CVD, increased RC levels were associated with the presence and extend of subclinical carotid atherosclerosis. These findings provide novel mechanistic insight into mechanisms associated with increased CVD risk in individuals with high RC levels. Funding Acknowledgement Type of funding sources: None.

Background Among high cardiovascular (CV) risk patients, there is emerging need to recognize those who will benefit from new treatments targeting residual risk. Readily available modalities providing reclassification value would be clinically useful in this setting. Preliminary data suggest that carotid ultrasonography using plaque burden but not intima-media thickness (IMT) is associated with very high risk. Objectives We aimed to assess the reclassification ability of two markers of carotid atherosclerosis in high-risk patients, reflecting total atherosclerotic burden and the most severe lesion and to compare them with the routinely used carotid indices IMT and number of carotid plaques. Methods In an ongoing registry of patients who visited a cardiovascular protection clinic for cardiovascular risk assessment, we enrolled 735 consecutively recruited patients (mean age 63.1 years, 68.8% male) classified as high or very-high CV risk according to 2019 European Society of Cardiology /European Atherosclerosis Society Guidelines. Sum of carotid wall thickness (sumWT) and maximal wall thickness (maxWT) using high-resolution ultrasonography at baseline were used to assess the total burden and the most severe carotid lesion, respectively. These markers integrate maximum plaque height or maximum IMT if no plaque is present. All patients were followed for a median of 41 months and the primary end-point consisted of CV mortality, acute myocardial infarction or coronary revascularization. Results After adjustment for traditional CV risk factors, maxWT and sumWT were associated with the primary end-point (hazard ratio [HR]=1.73 (95% confidence interval [CI]:1.39 to 2.17) and 1.19 (95% CI 1.10 to 1.30) respectively). Both markers were superior in terms of reclassification and discrimination to identify very high risk over validated CV risk scores including the Heartscore and the SMART score (net reclassification index [NRI]=0.624, p Conclusions The use of two novel cumulative markers of atherosclerotic burden improves risk stratification and discriminates high from very high CV risk. Given that carotid ultrasonography is a readily available modality, its clinical application for risk refinement of high-risk patients to facilitate treatment decisions merits further investigation. Funding Acknowledgement Type of funding sources: None.

Background Carfilzomib (CFZ) is a second generation irreversible proteasome inhibitor that has been shown to improve overall survival in patients with relapsed or refractory multiple myeloma (MM) but is associated with cardiac toxicity in MM. Because ubiquitin-proteasome system (UPS) is involved in cardiovascular homeostasis exploring the effects of proteasome inhibition on cardiac mechanics, in a clinical setting, would provide novel insight of the clinical role of UPS in cardiovascular disease. Aim To gain a thorough understanding of proteasome inhibition on myocardial mechanics in a clinical setting. Methods We prospectively evaluated 48 patients with relapsed or refractory MM and an indication to receive CFZ treatment [median age: 67.5, interquartile range (64–73), 66.7% men]. All patients underwent cardiac ultrasonography at an initial visit, at the first day of the 3rd month (C3D1, n=25) and at the last day of cycle 6 (C6D16, n=48). Pulse wave velocity (PWV) was used to assess arterial stiffness and calculate arterial-ventricular coupling (VAC) by the ratio (PWV/global longitudinal strain (GLS)). Carfilzomib was administered at 27mg/m2 on days 1 (C1D1) and 2 (C1D2) of cycle 1 and at 56mg/m2 thereafter. Blood was drawn at baseline, C3D1 and C6D16 to measure proteasome activity (PrA). Patients were followed up for carfilzomib–related cardiovascular adverse events. Results Regarding systolic function, between baseline and C6D16, we noticed deterioration in left ventricular ejection fraction (LVEF) (57.7±5.4% vs 56.1±7.19%, p=0.022), GLS (−20.51±2.78 vs −18.88±3.45%, p=0.003), S wave of LV longitudinal strain rate and radial strain (p Conclusion CFZ treatment was associated with global deterioration of markers of myocardial systolic and diastolic function and VAC. The observed association of changes in proteasome activity with VAC and left atrial function and structure supports a direct effect of proteasome inhibition on the cross-talk between LV and arterial function and LV diastolic function. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Amgen

Aims Reverse remodelling (RR) is the recovery from left ventricle (LV) dilatation and dysfunction. There are no established definitions of RR. We sought to identify RR criteria that better predicted cardiovascular death. Methods and results Forty-two studies used 25 criteria to define RR, most commonly (n=12) as LV end-systolic volume (LVESV) reduction ≥15%. We evaluated 927 patients with LV ejection fraction (LVEF) 10 U. The same 2 criteria yielded independent prognostic significance and improved reclassification also in patients with LVEF 10 U displayed a stronger prognostic value than LVESV reduction ≥15%, both in the whole population and the subsets with LVEF Funding Acknowledgement Type of funding sources: None.

Background Anti-Müllerian hormone (AMH) constitutes a marker of ovarian reserve and appears to have a predictive role regarding the time of menopause. Moreover, AMH is associated with adverse cardiac events. History of premature menopause and early onset of menopause have been associated with increased risk of cardiovascular (CV) disease. In addition, menopausal transition and duration of menopause have been associated with increased burden of subclinical atherosclerosis. However, the association between AMH as a marker of female reproductive age with atherosclerosis in premenopausal women is currently unknown. Purpose To investigate whether AMH concentrations are associated with markers of early atherosclerosis in healthy, normally menstruating women. Methods In a cross-sectional study, vascular structure and function were assessed by measurement of carotid and femoral intima-media thickness (IMT), lipid profile and serum AMH concentrations were assessed. Exclusion criteria were clinically overt CV disease, abnormal ovulatory cycles, polycystic ovarian syndrome, acute infection or chronic inflammatory disease, risk factors for CV disease and any medication Results Seventy premenopausal women, aged 32.7±6.5 years, were included. Mean AMH levels were lower in smokers than in non-smokers and negatively associated with total cholesterol (TC) levels. An inverse association between mean AMH concentrations and IMT in all segments was observed. No correlation with other markers of subclinical atherosclerosis or traditional CV risk factors was found. After multi-variable adjustment for traditional CV risk factors, the association between AMH concentrations combined IMT and carotid bulb IMT, remained significant. Conclusions In healthy, normally ovulating women, low AMH concentrations are associated with an adverse lipid profile and subclinical atherosclerosis, independently of traditional CV risk factors. This finding suggest a role of decreased follicular reserve with atherosclerotic disease. Funding Acknowledgement Type of funding source: None

Background Cathepsin S is an extracellular matrix degradation enzyme that plays an important role in atherosclerotic cardiovascular disease by inducing vasa vasorum development and atherosclerotic plaque rupture. Purpose To determine the prognostic and reclassification value of baseline serum cathepsin S after adjustment for the Global Registry of Acute Coronary Events (GRACE) score, which is a clinical guideline recommended risk score in non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Methods Serum cathepsin S was measured by ELISA in 1,129 consecutive patients presenting with acute symptoms to the emergency department for whom a final adjudicated diagnosis of NSTE-ACS was made. All-cause mortality or all-cause death/non-fatal myocardial infarction (MI) after a median follow-up of 21 months were evaluated as the primary or secondary study endpoint, respectively. The Net Reclassification Index (NRI) estimated the reclassification predictive value for risk of each end-point of cathepsin S over the GRACE score. Results After a median follow-up of 21 months 101 (8.95%) deaths were reported. The combined endpoint of death or non-fatal MI occurred in 176 (15.6%) patients. Dose-response curve analysis adjusted for the effect of age, gender, diabetes mellitus, high-sensitivity-cardiac troponin T, high-sensitivity C-reactive protein, revascularization and index diagnosis revealed a non-linear association of continuous cathepsin S with all-cause death (P=0.036 for non-linearity; adjusted HR=1.60 for 80th vs. 20th percentiles, P=0.038) or with the combined endpoint (P=0.008 for non-linearity, adjusted HR=1.53 for 80th vs. 20th percentiles, P=0.011). Serum cathepsin S maintained its predictive value for all-cause death (adjusted HR=1.70 highest vs. lowest tertile, 95% CI 1.03–2.82, P=0.039) after adjusting for the GRACE Score. Similarly, cathepsin S predicted the combined endpoint of all-cause death or non-fatal MI (adjusted HR=1.67 highest vs. lowest tertile, 95% CI 1.15–2.42, P=0.007) independently of the GRACE Score. When cathepsin S was added over the GRACE Score it correctly reclassified risk for all-cause death in 20% of the population (P=0.004). Similarly, serum Cathepsin S conferred a significant reclassification value over the GRACE score for all-cause death or non-fatal MI in 15.9% of the population. Conclusions Serum cathepsin S is a predictor of mortality and improves risk stratification over the GRACE score in patients with NSTE-ACS. The clinical application of cathepsin S as a novel biomarker in NSTE-ACS should be further explored and validated. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): German Heart Foundation

Background Hypertension and dyslipidemia are well-known risk factors for cardiovascular disease (CVD). In such patients, lowering blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) and targeting to values below pre-specified cut-offs prevents CV events and improves prognosis. However, the impact of both BP and LDL-C control as compared to control of only one and/or none of these two risk factors is not well-studied. Methods Among 2,380 treated patients with hypertension and no overt CVD at baseline, we assessed the trajectory of BP control in 1,142 subjects with 4 or more follow up visits; BP control was defined as BP Results Across a median follow up of 108 months, 26 deaths (2.44%) were recorded. Despite appropriate anti-hypertensive treatment, 376 patients (32.92%) did not achieve conventional BP control in half or more of follow-up visits. Respectively, 59.83% of the study population did not meet the LDL-C goals in at least one assessment. Patients with suboptimal BP control had almost 3-fold increased risk for all-cause mortality (HR=2.85, 95% CI 1.31–6.21, P=0.008) as compared to subjects with effective control. This association was not attenuated after taking into account age, gender, body mass index, smoking, and diabetes mellitus (adjusted HR=2.54, 95% CI 1.13–5.72, P=0.025). Ineffective LDL-C control was not related to death (HR=1.31, 95% CI 0.688–2.48). However, patients who did not reach treatment goals for both BP and LDL showed substantially increased risk for all-cause mortality (HR=5.42, 95% CI 1.09–26.9, P=0.039). Importantly, suboptimal BP control in our cohort of hypertensive patients was associated with death independently of the HeartScore (adjusted HR=2.65, 95% CI 1.22–5.77, P=0.014) and conferred incremental reclassification value on top of the baseline risk (continuous NRI=0.467, P=0.016). Conclusions Suboptimal BP control was related to all-cause mortality in our cohort of hypertensive patients; importantly, this association was substantially stronger in concurrent presence of LDL-C values above treatment targets, thus, highlighting the need for combined achievement of BP and LDL-C control. Moreover, association of suboptimal BP controlwith death was independent of the HeartScore, suggesting that BP control should be considered in risk stratification of hypertensive patients Funding Acknowledgement Type of funding source: None

Objective Aging and menopause are associated with an adverse cardiometabolic profile, predisposing to cardiovascular disease. Diet may also affect their cardiometabolic risk. The aim of this study is to assess dietary habits and patterns of postmenopausal women and their association with adiposity measures, cardiometabolic parameters and subclinical atherosclerosis. Study protocol The study will include two parts. The first part consists of cross-sectional evaluation of 750 postmenopausal women recruited consecutively from the Menopause Unit of an academic hospital. Dietary intake will be assessed by a food frequency questionnaire. Nutrient and food group intake will be calculated and adherence to the Mediterranean diet and other dietary patterns will be evaluated. A-priori and a-posteriori defined dietary patterns will be tested for associations with major and minor outcome measures. The second part consists of a prospective follow-up of all women recruited at baseline and re-assessment of the same variables after 3 years. Adherence to predefined or a-posteriori defined dietary patterns over these 3 years will be evaluated in association with changes in obesity indices and lipid levels, as well as in the progression of subclinical atherosclerosis. Major outcome measures Body mass index, lipid profile, carotid and femoral artery intima-media thickness and plaques. Minor outcome measures Waist circumference, waist-to-hip ratio, abdominal fat layers, incident hypertension and diabetes, homeostasis model assessment of insulin resistance (HOMA-IR), c-reactive protein and markers of subclinical arterial disease, including flow-mediated dilation, pulse wave velocity, augmentation index and ankle-brachial index. Results The study is expected to complete baseline enrolment by the end of 2018 and follow-up assessment by the end of 2021. The results of the study will address the question of whether dietary patterns and eating habits are associated with cardiometabolic risk as well as with accelerated subclinical arterial disease and arterial aging in postmenopausal women.

There is limited and inconsistent evidence regarding longitudinal effects of macronutrients on blood pressure (BP) haemodynamics and arterial aging in populations without cardiovascular disease (CVD). We aimed to prospectively investigate potential association of dietary macronutrients with long-term changes in peripheral and central haemodynamics and arterial stiffness. One hundred and fifteen subjects (46.7 ± 8.73 years, 70 women), free of clinically overt CVD were consecutively recruited. Dietary macronutrient intake was evaluated using 3-day food records at baseline. Aortic stiffness and arterial wave reflections were assessed at baseline and in one follow-up visit 5 years later by pulse wave velocity (PWV) and augmentation index (AI), respectively. Individuals with the highest consumption of saturated fatty acids (SFA) presented the highest rate of progression in PWV, AI and aortic diastolic BP (p

Introduction: The American College of Cardiology Foundation (ACCF) along with the American Society of Echocardiography (ASE) have enabled an accurate and clinically oriented evaluation of echocardiography indications by introducing Appropriate Use Criteria (AUC). Aim: This study was designed to evaluate the degree of implementation of AUC for transesophageal echocardiography (TEE) during daily clinical practice in a tertiary university hospital in Greece during the era of economic recession. Materials and Methods: From November 2014 to May 2014, we prospectively enrolled 300 patients who were examined in the Echocardiography Laboratory of the First University Cardiology. We recorded the participants' demographic and clinical characteristics using questionnaires and followed a scoring process according to ACCF guidelines to classify patients into an appropriate, inappropriate or uncertain category. The primary endpoint was to assess the association between the class of appropriateness and abnormal TEE results. Results: In 89.4% of patients labelled appropriate, TEE was abnormal and significantly higher compared to patients of uncertain eligibility (50%) and to patients for whom TEE was considered to be inappropriate (35%) (p

Background Eating frequency (EF) has been associated with generalized obesity. Aim We aimed to prospectively investigate potential associations of frequency of eating episodes with regional fat layers. Design EF was evaluated at baseline in 115 subjects free of clinically overt cardiovascular disease (54 ± 9.1 years, 70 women) in a prospective, observational study. Methods Metabolic parameters known to be associated with dietary factors and anthropometric markers including ultrasound assessment of subcutaneous (Smin) and pre-peritoneal (Pmax) fat and their ratio Smin/Pmax (AFI) were evaluated at baseline and at follow-up, 5 years later. Results EF at baseline positively correlated with Pmax, even after adjustment for potential confounders. EF above median was also an independent predictor for Pmax (beta coefficient = -0.192, P = 0.037) and AFI (beta coefficient = 0.199, P = 0.049) at follow up. Multivariable linear mixed models analysis demonstrated that subjects with increased EF presented a lower progression rate of Pmax (beta = -0.452, P = 0.006) and a higher progression rate of AFI (beta = 0.563, P = 0.003) over time, independently of age, sex, progression of BMI, energy intake, smoking and changes in parameters of glucose metabolism. Conclusions High EF is associated with lower progression rate of pre-peritoneal fat accumulation. Future interventional studies should further investigate the clinical utility of these findings.

Background Aging is characterized by an insidious decline in cognitive function. Several genetic and lifestyle factors have been implicated in the increased risk or early onset of dementia. Aim We sought to assess the role of tumor necrosis factor (TNF) and angiotensin-converting enzyme (ACE) polymorphisms on the development of impaired mental health in respect to indices of arterial aging in nonagenarian individuals. Design 178 consecutive subjects above 75 years that permanently inhabit in the island of IKARIA, Greece were recruited. Methods Aortic distensibility (AoD) was calculated and genetic evaluation was performed on the ACE Insertion/Deletion gene polymorphism (intron 16) and the G/A transition (position -308) of the TNF gene. Cognitive function was evaluated using the Mini-mental State Examination (MMSE). Results The DD genotype for ACE was independently associated ( b = -0.44, P = 0.007) with AD while AoD remained an independent determinant of mental status (OR = 1.82, P = 0.036). Interestingly though, when a combined genetic index (GI) was calculated for both genes (ACE and TNF), subjects being double homozygous (DD for ACE and GG for TNF) for these loci presented significantly decreased MMSE (adjusted OR = 0.259, P = 0.033). This GI independently associated with AD (beta coefficient = -0.785, P = 0.002). When AoD was included, GI lost its predictive role (OR = 0.784, P = 0.783) towards MMSE. AoD has marginal indirect mediating effect in the association of the GI with MMSE ( P = 0.07). Conclusion Vascular aging may modulates the genetic substrate of elderly subjects on the risk for developing dementia.

Background Left ventricular (LV) pacing is unsuccessful in a significant number of patients, mainly due to sub-optimal LV pacing location. Nevertheless, data about the impact of different pacing sites on LV function in ischaemic myocardium are scarce. The purpose of this study was to investigate the effect of combinations of alternative LV pacing sites on LV mechanics after experimental acute anterior myocardial infarction (AMI), in order to define the optimal configuration. Methods Atrioventricular epicardial pacing at alternative pacing sites was performed in 16 healthy pigs simultaneously, after experimental AMI. Standard right ventricular (RV) apical pacing was combined with: i) LV apex lateral wall; ii) LV basal posterior wall; iii) LV basal anterior wall, and; iv) LV basal anterior wall + LV basal posterior wall. Moreover the pacing configurations of, v) LV basal posterior wall + LV apex lateral wall; vi) LV basal posterior wall + LV basal anterior wall, and; vii) LV basal anterior wall + LV apex lateral wall were also investigated. Haemodynamic parameters, together with classic and novel echocardiographic indices were used, to evaluate the effect of each pacing combination. A speckle tracking technique using EchoPAC software was used. Results After AMI, the pacing combination of LV apex lateral wall and LV basal posterior wall had the most favourable effect on LV function, leading to similar haemodynamic and torsional effects with sinus rhythm (all variables p>0.05). Conclusions In pig hearts after AMI, the combination of pacing LV apex lateral wall and LV basal posterior wall managed to maintain the LV function at a level comparable to the sinus rhythm.

The aim of this study was to compare the predictive ability of clinical risk scores (ACEF, EuroSCORE and EuroSCORE II) to angiographic (SYNTAX score) and combined risk scores (Global Risk Score and Clinical SXscore) towards cardiovascular death and/or major adverse cardiac events (MACE) in patients with ST-segment elevation acute myocardial infarction (STEMI) managed with primary percutaneous coronary intervention (pPCI).A total of 685 patients successfully treated with pPCI were evaluated and the risk scores were calculated. The primary endpoint was the 2-year incidence of fatal cardiac events. Secondary end points were target lesion failure (TLF), repeat revascularization (RR) and MACE.Patients distributed in the highest tertile of EuroSCORE II presented increased rates of CV death (CVD), all-cause mortality and MACE (p0.001 for all). EuroSCORE II was associated with increased C-statistics (0.873, 95% CIs: 0.784-0.962 and 0.825, 95% CIs: 0.752-0.898 respectively) for predicting CVD and MACE over competing risk scores (p0.05). EuroSCORE II conferred incremental discrimination (Harrell's C, p0.05 for all, apart from CSS for predicting CVD) and reclassification value (Net Reclassification Index, p0.05 for all, apart from CSS for reclassifying MACE) over alternative risk scores for study's main endpoints. EuroSCORE II independently predicted CVD (HR=1.06, 95% CIs: 1.03-1.09, p0.001) and MACE (HR=1.07, 95% CIs: 1.04-1.10, p0.001).EuroSCORE II has the best predictive ability of CVD and/or MACE after successful pPCI for the treatment of STEMI.

Medical management of atrial fibrillation (AF), the most common arrhythmia in the general population, has had modest efficacy in controlling symptoms and restoring and maintaining sinus rhythm. Since the seminal observation in 1998 that pulmonary veins host the triggers of AF in the majority of cases, electrical isolation of all pulmonary veins constitutes the cornerstone of ablation in patients with symptomatic AF. However, due to the elaborate and tedious technique of the conventional point-by-point method with radiofrequency ablation guided by electroanatomical mapping, newer, more versatile single-shot techniques, such as cryoballoon ablation, have been sought and developed over recent years and are progressively prevailing. Cryoballoon ablation appears to be the most promising practical and effective approach, and we review it here by presenting all available relevant data from the literature as well as from our own experience in an attempt to apprise colleagues of the significant progress made over the last several years in this important field of electrophysiology.

Background There is increasingly recognized undetected residual cardiovascular (CV) risk in postmenopausal women, suggesting the need for new risk biomarkers in this population. We have previously shown that amyloid-beta (1–40) (Aβ1–40), a proinflammatory and pro-atherosclerotic peptide, is associated with concurrent subclinical cardiovascular disease (CVD) in the general population and with major adverse cardiac events in patients with established cardiac disease. However, the clinical value of Aβ1–40 in menopause or whether this peptide is linked with an increased rate of progression of atherosclerotic disease is unknown. Purpose To examine the association of Aβ1–40 levels with the rate of progression of carotid intima-media thickness (IMT) in postmenopausal women. Methods In the settings of a Menopause Clinic, postmenopausal women (n=140) without clinically overt CVD or diabetes were consecutively recruited and re-evaluated after a median follow-up period of 24 months. IMT in the carotid arteries was measured by ultrasonography. The average of maximal IMT (mean cIMT) measured at both left and right common carotid, carotid bulb (cb)and internal carotid (ic) artery were used as the main end-point of the analysis. Aβ1–40 was measured in plasma samples at baseline and follow up. Fasting insulin resistance was assessed using the homeostasis model assessment of insulin resistance (HOMA-IR). Results Women with increased plasma levels Aβ1–40 in the highest tertile presented the highest probability to have increased mean cIMT (adjusted OR=2.97, 95% CI 1.18–7.52, p=0.021) independently of age, smoke, hypertension, and hyperlipidemia. After adjustment for HOMA-IR, this association remained significant. Similarly, Aβ1–40 levels were associated with increased mean cb and icIMT (adjusted OR=3.34 for highest versus lower tertile, 95% CI 1.27–8.81, p=0.015). Mean cIMT significantly increased across the follow up period (0.73mm (0.065–0.08) to 0.77mm (0.07–0.089), median increase rate per year 0.024mm, p Conclusion Aβ1–40 is an independent predictor of the rate of progression of subclinical carotid atherosclerosis in menopausal women. This finding supports the clinical value of Aβ1–40 in menopause and warrants further investigation for its prognostic role in this population.

Background Amyloid-beta (1-40) (Aβ1–40), a proinflammatory and pro-atherosclerotic peptide, is associated with accelerated atherosclerosis and major adverse cardiac events. Abeta1–40 production is mainly dependent on the cleavage of amyloid precursor protein by β-amyloid cleaving enzyme-1 (BACE1), known as beta-secretase. BACE1 antisense (BACE1-AS) is a long noncoding RNA that enhances BACE1 stability. Objectives To evaluate the clinical value of plasma amyloid-beta levels and its upstream regulatory pathway BACE1/BACE1-AS in patients with subclinical and established atherosclerotic cardiovascular disease. Methods Plasma levels of Aβ40 were measured in 642 consecutively recruited patients with and without clinically overt coronary artery disease (CAD). BACE1-AS lncRNA and BACE1 mRNA expression were measured in peripheral blood mononuclear cells derived from 214 study participants. Intima-media thickness and atheromatous plaques by ultrasonography, markers of arterial wave reflections and pulse wave velocity were used as surrogate markers of subclinical CVD. Cardiovascular risk factors (CVRFs), including impaired glomerular filtration rate (2 mg/l) were assessed as a measure of CVRF burden. Results Both in non-CAD (n=369) and CAD (n=273) patients, Aβ1–40 was associated with age, aortic and peripheral systolic and pulse pressure, and low GFR (p2 CVRFs. Among CAD patients, BACE1-AS was associated with decreased LVEF ( Conclusions Circulating Aβ1–40 and increased expression of its upstream regulators BACE1/BACE1-AS are intercorrelated and associated with the presence and severity of subclinical and clinically overt atherosclerosis. These findings suggest that BACE1-AS/BACE1-mediated increased availability of Aβ1–40 may play a pivotal role in its adverse cardiovascular effects.

Background Blood-based biomarkers may be useful in the identification of residual risk for death or acute myocardial infarction (AMI) in patients with a previous acute coronary syndrome. Cathepsin S (CTSS) is a lysosomal cysteine protease with potent elastolytic and collagenolytic activity, which plays an important role in cardiovascular disease through extracellular matrix degradation, vasa vasorum development and atherosclerotic plaque rupture. The aim of the present study was to determine the prognostic and reclassification value of baseline circulating levels of CTSS after adjustment for the Global Registry of Acute Coronary Events (GRACE) score, which is widely recommended for risk stratification in non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Methods CTSS was measured in blood samples collected from 1,129 consecutive patients with adjudicated NSTE-ACS presenting at an acute chest pain unit for evaluation of a possible acute coronary syndrome. Cardiovascular (CV) death and a composite of all-cause mortality and AMI were evaluated as the primary and secondary endpoints of the study, respectively. The additive prognostic value of CTSS over the GRACE score was estimated by the Net Reclassification Index (NRI) that examines the net upward and downward reclassification into correct pre-defined risk categories. Results After a median follow-up of 21 months, 101 (8.95%) deaths were reported, of which 63 (5.6%) were of cardiac origin. The combined endpoint occurred in 176 (15.6%) patients. Patients with CTSS in the highest tertile presented the greatest risk for all-cause mortality (HR=1.84 for highest versus lowest tertile of CTSS distribution, 95% CI 1.1–3.08, P=0.02) and CV death (HR=2.5 for highest versus lowest tertile of CTSS distribution, 95% CI 1.24–5.05, P=0.011) after adjustment for age, gender, diabetes mellitus, hs-cTnT, hsCRP, revascularization and index diagnosis. Similarly, CTSS was associated with increased risk of cardiovascular death after adjusting for the GRACE Score (adjusted HR for highest versus lowest tertile of CTSS distribution=2.34, 95% CI 1.18–4.64, P=0.015). Further, CTSS predicted the combined endpoint of all-cause death or non-fatal MI independently of the GRACE Score (adjusted HR for highest versus lowest tertile of CTSS distribution=1.67, 95% CI 1.15–2.42, P=0.007). When CTSS was added over the GRACE Score, it conferred significant reclassification value for CV death (NRI=21.4%, P=0.008). Similarly, CTSS correctly reclassified risk for all-cause death or non-fatal MI (P=0.006) in 15.9% of the population. Conclusions Circulating CTSS predicts mortality and improves risk stratification of patients with NSTE-ACS over the GRACE score recommended by clinical guidelines. The clinical application of CTSS as a novel biomarker in NSTE-ACS should be further explored and validated.

Background Despite therapeutic advances, mortality rates following ST-segment elevation myocardial infarction (STEMI) are still alarmingly high. There is conflicting evidence regarding the prognostic role of high-sensitivity cardiac troponin T (hs-cTnT) measurements before and after primary percutaneous coronary intervention (PPCI) over traditional predictors of mortality in STEMI patients. Purpose To determine the additive prognostic value of pre- and 12h post-PPCI hs-cTnT levels in STEMI patients Methods Retrospective longitudinal study including 3,113 consecutive STEMI patients treated with PPCI at a university hospital covering a population of 1.6 million in the North East of England. Clinical, procedural, and laboratory data were prospectively collected during patient hospitalization while hs-cTnT measurements were performed at admission to the catheterization laboratory and at 12h post-PPCI. Median follow-up was 53 months. The study endpoints were in-hospital and overall mortality. Mortality data were obtained from the UK Office of National Statistics. Results Admission hs-cTnT >515ng/L (4th quartile) was independently associated with in-hospital mortality [HR=2.39 per highest to lower quartiles; 95% CI: 1.44 to 3.97; p=0.001] after multivariate adjustment for a core clinical model of in-hospital mortality prediction. Likewise, admission hs-cTnT >515ng/L independently predicted overall mortality (HR=1.25 per highest to lower quartiles; 95% CI: 1.00 to 1.57; p=0.044) after adjustment for covariates significantly associated with this endpoint. Admission hs-cTnT correctly reclassified risk for in-hospital death [net reclassification index (NRI)=44.1%, p Conclusion Admission, but not 12h post-reperfusion, hs-cTnT predicts mortality and improves risk stratification in the PPCI era. These results support the role of hs-cTnT in risk stratification of post-STEMI patients and challenge the cost-effectiveness of routine 12h hs-cTnT measurements.

Background/Introduction Predictive and prognostic ability of muscle mass in CVD settings is increasingly discussed. Purpose The sex-specific effect of skeletal muscle mass index (SMI) on 10-year recurrent fatal/non fatal cardiovascular disease (CVD) event of acute coronary syndrome (ACS) patients was evaluated. Methods In 2006–2009, n=1,000 consecutive patients (n=222 females), hospitalized at a cardiology clinic with ACS diagnosis and with symptoms and left ventricular function indicative of heart failure were selected. SMI was created to reflect skeletal muscle mass through appendicular skeletal muscle mass (indirectly calculated through population formulas) divided by body mass index (BMI). Results In 10-year follow-up (2016), 55% of ACS patients exhibited recurrent fatal/non fatal CVD events (53% in females vs. 62% in males, p=0.04). Patients in 2nd SMI tertile (mostly overweight) had 10% lower risk for CVD recurrence (female:male rate ratio=0.87) over their counterparts at 1st (mostly normalweight) and 3rd tertile (mostly obese). Multivariate analysis revealed that ACS patients in 2nd SMI tertile presented 46% and 85% lower CVD event risk over their counterparts in 1st tertile (Hazard Ratio (HR)=0.54, 95% Confidence Interval (95% CI) 0.30, 0.96, p=0.002) and 3rd tertile (HR=1.85, 95% CI 1.05, 2.94, p=0.03). Sex-related sensitivity analyses revealed that even if U-shape association was retained in both males and females in crude and age- adjusted models, further adjustment for clinical, lifestyle and sociodemographic factors resulted in a significant trend only in females (HR=1.85, 95% CI 1.05, 2.94, p=0.03). Mean (95% confidence interval) survival (free-of-CVD) time (years) in females patients at 1st, 2nd and 3rd tertile was 7.4 (6.5, 8.2), 8.2 (7.1, 9.2) and 6.7 (5.5, 7.9), respectively. Inflammatory markers i.e. C-reactive protein (CRP) and white blood cells (WBC) had strong confounding effect on the association between SMI and 10-year recurrent CVD event rate in females. A significant inverse linear association between the examined factors was observed only in females (ρ(CRP)=-0.490, p Conclusion AU-shape association between SMI and 10-year CVD event especially in females was highlighted. This work reveals sex-specific remarks for “obesity-lean paradox” in secondary prevention, implying that high muscle mass accompanied by obesity and excess adiposity may not guarantee better prognosis. Acknowledgement/Funding None

Background Human Antigen R (HuR) is a stabilizing RNA-binding protein that regulates the expression of several pro-inflammatory molecules. However, its regulation in human atherosclerotic cardiovascular disease remains unknown. Purpose To determine the association of peripheral blood mononuclear cell HuR expression with established markers of increased cardiovascular risk and atherosclerosis burden in patients with subclinical or clinically overt coronary artery disease (CAD). Methods HuR mRNA expression was measured in peripheral blood mononuclear cells derived from 289 patients with stable CAD or acute myocardial infarction (AMI) and 373 individuals without clinically overt cardiovascular disease (CVD). Structural and functional vascular measurements including intima-media thickness (IMT) and number of atheromatous plaques by carotid and femoral artery ultrasonophaphy, markers of arterial wave reflections by pulse wave analysis and pulse wave velocity were used as surrogate markers of subclinical CVD. The number of angiographically confirmed diseased coronary arteries (>50% stenosis) was used to assess the extent of CAD. Results HuR mRNA expression was significantly increased in patients with CAD (both stable and AMI) compared to controls (p=0.039). Subgroup analysis revealed that STEMI patients (n=107) had increased levels of HuR expression compared to NSTEMI (n=49, p=0.03). Among patients with stable CAD (n=133), high HuR expression was independently associated with the number of diseased coronary arteries (OR=1.35 for 1-SD increase in HuR, 95% CI 1.07–1.72, p=0.012), as well as with reduced ejection fraction (EF Conclusion HuR expression is associated with early subclinical arterial disease in individuals without clinically overt CVD and with the presence and severity of cardiac and vascular dysfunction in patients with clinically overt CAD. These findings imply a clinical role of the HuR pathway in cardiovascular disease and warrant further investigation.

Background: A simple score was proposed recently for Predicting Early Mortality from Ischemic Stroke (PREMISE) derived from the Austrian Stroke Unit Registry. This score could be useful in clinical practice and research. However, its generalizability is uncertain, as it was validated internally only. Aims: We aimed to validate the PREMISE score externally. Methods: The analysis was performed in the Athens Stroke Registry. The PREMISE score was calculated as described in the original publication. The outcome was death within 7 days after stroke. Logistic regression analysis was used to estimate the relative death risk in different strata of the PREMISE score using the lowest values of the score (ie, 0-4) as the reference category. We assessed the score's calibration by the Hosmer-Lemeshow goodness-of-fit test and its discriminatory power by calculating the area under the receiver operating characteristics curve (AUC). Results: In 2608 consecutive patients (median age 71 years, 38.8% women) with acute ischemic stroke treated in the stroke unit, mortality increased with increasing PREMISE score from .1% (95% confidence intervals [95% CI]: 0%-.2%) in patients with a score of 0-4 to 28.2% (95% CI: 14.1%-42.3%) in patients with a score of ≥10. The risk for death was more than 6 times higher in patients with a PREMISE score of ≥10 compared to patients with 0-4 points (odds ratio [OR]:6.21, 95% CI:4.13-8.29). Τhe PREMISE score showed excellent calibration (Hosmer-Lemeshow χ2: .01, P= .99) and good discriminatory power (AUC .873, 95% CI: .844-.901). Conclusions: The present study confirms the prognostic accuracy of the PREMISE score in an independent cohort of patients with acute ischemic stroke treated in the stroke unit.

Background and aims Predictive and prognostic ability of muscle mass in CVD settings is increasingly discussed. The gender-specific effect of skeletal muscle mass index (SMI) on 10-year recurrent fatal/non fatal cardiovascular disease (CVD) event of acute coronary syndrome (ACS) patients was evaluated. Methods and results In 2006–2009, n = 1000 consecutive patients (n = 222 women), hospitalized at the First Cardiology Clinic of Athens with ACS diagnosis and with symptoms and left ventricular function indicative of heart failure were selected. SMI was created to reflect skeletal muscle mass through appendicular skeletal muscle mass (indirectly calculated through population formulas) divided by body mass index (BMI). In the 10-year follow-up (2016), 55% of ACS patients experienced recurrent fatal/non fatal CVD events (53% in women vs.62% in men, p = 0.04). Patients in the 2nd SMI tertile (mostly overweight) had 10% lower risk for CVD recurrence (women:men rate ratio = 0.87) over their counterparts in the 1st (mostly normalweight) and 3rd tertile (mostly obese). Multivariate analysis revealed that ACS patients in the 2nd SMI tertile presented 46% and 85% lower CVD event risk over their counterparts in the 1st tertile (Hazard Ratio (HR) = 0.54, 95% Confidence Interval (95% CI) 0.30, 0.96, p = 0.002) and 3rd tertile (HR = 1.85, 95%CI 1.05, 2.94, p = 0.03). Gender-based analysis revealed that this trend remained significant only in women. Inflammatory markers had strong confounding effect. Conclusion A U-shape association between SMI and 10-year CVD event especially in women was highlighted. This work reveals gender-specific remarks for “obesity-lean paradox” in secondary prevention, implying that high muscle mass accompanied by obesity and excess adiposity may not guarantee better prognosis.

Background: A simple score was proposed recently for Predicting Early Mortality from Ischemic Stroke (PREMISE) derived from the Austrian Stroke Unit Registry. This score could be useful in clinical practice and research. However, its generalizability is uncertain, as it was validated internally only. Aims: We aimed to validate the PREMISE score externally. Methods: The analysis was performed in the Athens Stroke Registry. The PREMISE score was calculated as described in the original publication. The outcome was death within 7 days after stroke. Logistic regression analysis was used to estimate the relative death risk in different strata of the PREMISE score using the lowest values of the score (ie, 0-4) as the reference category. We assessed the score’s calibration by the Hosmer-Lemeshow goodness-of-fit test and its discriminatory power by calculating the area under the receiver operating characteristics curve (AUC). Results: In 2608 consecutive patients (median age 71 years, 38.8% women) with acute ischemic stroke treated in the stroke unit, mortality increased with increasing PREMISE score from .1% (95% confidence intervals [95% CI]: 0%-.2%) in patients with a score of 0-4 to 28.2% (95% CI: 14.1%-42.3%) in patients with a score of >= 10. The risk for death was more than 6 times higher in patients with a PREMISE score of >= 10 compared to patients with 0-4 points (odds ratio [OR]: 6.21, 95% CI: 4.13-8.29). The PREMISE score showed excellent calibration (Hosmer-Lemeshow chi(2): .01, P=.99) and good discriminatory power (AUC .873, 95% CI: .844-.901). Conclusions: The present study confirms the prognostic accuracy of the PREMISE score in an independent cohort of patients with acute ischemic stroke treated in the stroke unit.

Background: Maternal obesity is associated with adverse cardiometabolic outcome in the offspring. We aimed to assess whether prenatal exposure to metformin can improve the cardiovascular profile and body composition in the offspring of obese mothers. Methods: In 151 children from the MOP trial we measured body composition, peripheral blood pressure and arterial pulse wave velocity. Central haemodynamics (central blood pressure and augmentation index) were estimated using the Vicorder device. Left ventricular cardiac function and structure were assessed by echocardiography. In 39 children from each group the metabolic profile was assessed. Findings: Children were 3.9±1.0 years of age and 77 were exposed to metformin prenatally. There was no significant difference in peripheral blood pressure, arterial stiffness and body composition apart from gluteal and tricep circumferences which were lower in the metformin group (p

Introduction: Several reports have indicated that left ventricular (LV) lead placement at an optimal pacing site is an important determinant of short- and long-term outcome. This study investigated the effect of pacing mode (atrioventricular [AV] or ventricular) and site (LV apical or lateral) outside the ischemic region on the LV hemodynamic, torsional and strain indices in the ischemic myocardium. Methods: Experiments were conducted in anesthetized open-chest pigs (n = 15) 30 min after LAD ligation to investigate the hemodynamic effects of temporary epicardial AV and ventricular LV pacing at the LV apical (outside the ischemic region) or lateral wall. LV hemodynamic data were recorded (ejection fraction, stroke volume, dP/dtmax, systolic pressure, cardiac output and e/e΄ ratio) and torsional (twist, rotation), as well as deformation (radial and circumferential strain), indices of LV function were assessed using two-dimensional speckle tracking imaging. Results: The LV function was highly dependent on the pacing mode and site. LV dP/dtmax, systolic pressure and twist decreased significantly during LV pacing in comparison to sinus rhythm (p = 0.004, p

Environmental factors constitute an important but underappreciated risk factor towards the development and progression of cardiovascular disease (CVD). Environmental exposure to variable pollutants is implicated in the derangement or propagation of adverse pathophysiological processes linked with atherosclerosis, including genetic, hemodynamic, metabolic, oxidative and inflammation parameters. However, no data exist on environmental pollution in rural or semi-rural areas. Therefore, the purpose of the “Corinthia” study is to examine the impact of environmental pollution in indices of cardiovascular morbidity and mortality in a cross-sectional and longitudinal design. The Corinthia study began in October 2015 and is planned to recruit 1,500 individuals from different regions of Corinthia country with different environmental exposures to pollutants and different patterns of soil/ground and/or air pollution until December 2016. Baseline measurements will include lifestyle measurements, anthropometric characteristics and a comprehensive cardiovascular examination. The follow-up is planned to extend prospectively up to 10 years and this study is anticipated to provide valuable data on the distinct impact of soil and air pollution on early markers of atherosclerosis and cardiovascular disease and on the overall impact of environment pollution to cardiovascular morbidity and mortality.

Introduction Omega-3 polyunsaturated fatty acids (omega 3-PUFAs) seem to favorably affect cardiac hemodynamics and may benefit the clinical course of heart failure patients. The role of omega 3-PUFAs supplementation on the left and right ventricular function of patients with chronic compensated systolic heart failure, under optimal treatment, was studied. Methods 205 consecutive patients with chronic compensated heart failure, due to ischemic (IHF) or dilated cardiomyopathy (DCM)-NYHA classification I–III, under optimal medical treatment, were enrolled. Participants were 1-to-1 randomized on 1000 mg omega 3-PUFA supplementation or no supplementation, in a non-blinded fashion. Echocardiographic assessment was performed at first visit and 6 months after. Plasma BNP and serum creatinine levels were also measured. Results As compared with the control group, BNP levels in omega 3-PUFA intervention group were 34.6% lower (p = 0.001); end-diastolic and end-systolic left ventricle dimensions were decreased by 2.5% (p = 0.047) and 3.7% (p = 0.01), maximum diameter of left atrium was decreased by 8.4% (p = 0.004), left atrium ejection fraction was ameliorated by 6.03% (p = 0.021) and as regards tissue Doppler parameters, TDI_Etv/Atv was decreased in omega 3-PUFA intervention group by 6.3% (p = 0.038). Moreover, improvement in diastolic indices was more prominent in subjects with DCM as compared to IHF patients. Conclusion Omega 3-PUFA supplementation was associated with improved left diastolic function and decreased BNP levels in patients with chronic heart failure. These findings suggest a beneficial role of omega 3-PUFAs on the hemodynamic course of patients with systolic heart failure.

The metabolic syndrome (MS) is widespread among hypertensive patients. However, the net impact of MS on major atherosclerotic events beyond the cardiovascular risk imposed by its individual components remains controversial in this group. We sought to assess both the independent and incremental prognostic role of MS for unfavorable cardiovascular events in a cohort of essential hypertensives.We followed up 2176 essential hypertensives free of cardiovascular disease for a median period of 40 months. All subjects had at least one annual visit. MS was defined according to the updated NCEP III criteria. Endpoint of interest was the incidence of stroke, coronary artery disease (CAD) and their composite.MS was present at baseline in 819 hypertensives (37.6%). MS group presented increased prevalence of resistant hypertension in comparison to MS free group (18.4% versus 10.6%, p0.001). The incidence of the composite end-point was 3.1% (69 events) across the follow-up period. Patients with MS were more likely to experience major adverse cardiovascular events (MACE) in comparison to reference category (3.7% versus 1.9%, log rank p = 0.024). While MS was an independent predictor for MACE, none of the individual components of the syndrome was associated independently with the endpoint. MS provided incremental discriminative value (Harrell's c, p0.05 for all) over individual risk factors for the incidence of MACE.MS predicts adverse cardiovascular events in hypertensives incrementally of its individual components. Early identification of MS in this population may enable more accurate prediction of future cardiovascular risk and could implement more efficient strategies in terms of primary prevention.

Bacterial pericarditis caused by Streptococcus Milleri Group (SMG) strains is a particularly exceptional pathology. All the eight previous reported cases were under the care of medical teams and the seven existed reports in medical journals were more or less from this perspective. Herein, we reported a unique case of a pericardial-cutaneous fistula resulting from a recurrent purulent pericardial effusion caused by SMG strains, which had been treated with open surgical drainage two months before. A thorough review of the surgical treatment options and the results has also been presented.

Hypertension consists a major risk factor for cardiovascular events. Despite the proven effectiveness of antihypertensive treatment, approximately half of hypertensive patients have inadequate blood pressure control. Non-adherence to medication has been shown to be an important barrier to achieving adequate blood pressure control and nurse interventions can substantially improve therapeutic compliance. We sought to evaluate the role of nurse interventions in alleviating non-adherence to medication in patients with hypertension by performing a systematic review of the literature for all relevant articles. Ten clinical studies were identified. The majority of studies reported beneficial effect of nursing intervention on treatment adherence in hypertensive patients. Telephone contacts and home visits were found to be the most effective educational approaches. Although comorbidities are considered to be an important barrier to adherence, there was not enough evidence to elucidate this aspect. Identifying specific factors that affect behavioral change in the setting of a successful intervention was difficult due to high heterogeneity among studies regarding materials and methods. Nursing interventions were shown to alleviate non-adherence to medication in patients with hypertension. Large well designed clinical trials are needed to evaluate specific factors that are associated with effective interventions.

Purpose Menopause-related changes may affect regional but also morphological characteristics of adipose tissue. We sought to assess the clinical value of echogenicity of subcutaneous adipose tissue (SAT) and preperitoneal adipose tissue (pPAT) in postmenopausal women without cardiovascular disease. Methods In 244 consecutively recruited postmenopausal women, subclinical atherosclerosis was assessed in the femoral and carotid arteries by intima-media thickness (IMT) and atheromatous plaques using high-resolution ultrasonography. In 41 women with a second visit (median follow-up 41.5 months), carotid atherosclerosis was re-evaluated. Images of SAT and pPAT were ultrasonographically acquired, and their echogenicity was evaluated by grayscale mean (GSMn) using a dedicated software. A control group of 20 healthy premenopausal women was used for comparisons in fat echogenicity. Results SAT GSMn but not pPAT was higher in postmenopausal as compared with healthy premenopausal women and was independently associated with metabolic markers of adiposity including body mass index (BMI) and waist circumference (WC). SAT GSMn was associated with carotid IMT and the presence and number of atheromatous plaques [adjusted OR 2.44 and 2.32 per 1-SD increase in GSMn (95% CIs 1.55 to 3.93 and 1.55 to 3.45), respectively]. SAT GSMn conferred incremental value over traditional risk factors, insulin resistance, BMI, and WC for the detection of subclinical atherosclerosis. Increased baseline SAT GSMn was associated with increased rate of progression in carotid IMT. Conclusions SAT echogenicity may serve as a qualitative marker of adiposity, conferring incremental clinical value over BMI and WC in postmenopausal women. Further investigation is warranted to assess the utility of ultrasonography-derived fat echogenicity as a screening method for morbid obesity.