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To describe prevalence, risk factors, and clinical impact of coronary artery disease (CAD) in patients with asymptomatic bilateral carotid stenosis.We conducted a single-center retrospective cohort study on consecutive patients referred for bilateral carotid stenosis70% (2014-2021). All patients underwent systematic coronary angiography. Depending on anatomic and clinical characteristics, patients were addressed to combined carotid endarterectomy (CEA)+coronary artery bypass grafting, coronary percutaneous intervention followed by CEA or stenting (CAS), or staged bilateral CEA under cardiac best medical therapy. Cumulative 30-days stroke/myocardial infarction (MI) rate after cardiac and bilateral carotid interventions and long-term survival and freedom from cardiovascular mortality were assessed.One-hundred-sixty-seven patients with bilateral carotid stenosis70% received preoperative coronary angiography, identifying a severe CAD in 108 cases (65.1%). Echocardiography abnormalities (OR 2.07, 95%CI 1.03-5.78; P=.04) or prior coronary intervention (OR 11.94, 95%CI 2.99-63.81; P=.001) were significantly associated with severe CAD. CAD was treatable in 91 patients (84%) and untreatable in 17 (16%). The cumulative MI rate was 4.8%; 5.6% in patients with severe CAD and 1.7% in those without severe CAD (P=.262). The cumulative stroke rate was 1.8%, 1.8% in cases with severe CAD and 1.7% in cases without severe CAD (P=1.00). The overall stroke/MI rate was 6.6%; 8.3% for those with severe CAD and 3.3% in patients without severe CAD (P=.33). Patients with severe CAD deemed untreatable for coronary bypass or percutaneous intervention were at higher risk of perioperative stroke/MI (OR 1.24, 95%CI 1.00-2.83; P=.04). At 10 years, overall survival was 67.1% (95%CI 57-79) and freedom from cardiovascular mortality was 78.5% (95%CI 69-89). Patients with untreatable CAD maintained a higher risk of 10-years mortality (HR 5.5, 95%CI 1.6-19.9; P.01).The prevalence of CAD in patients with bilateral carotid stenosis is high, especially in those with abnormal echocardiography findings. CAD is potentially treatable in 80% of cases, and a staged or simultaneous CAD treatment was performed with an acceptable stroke/MI complication rate in these patients. The presence of an untreatable CAD was associated with worsened early and long-term outcomes, questioning the benefit of carotid interventions in this subset of patients.

The aim was to determine the clinical impact of routine cardiology consultation before carotid endarterectomy (CEA) in neurologically asymptomatic patients, in terms of early and long term cardiovascular events.A single centre retrospective review of consecutive patients receiving CEA from 2007 to 2017 for asymptomatic carotid stenosis was performed. Two groups were compared: patients operated on from 2007 to 2012 received a pre-operative cardiology consultation only in selected cases (group A); from 2012 to 2017 patients received a routine pre-operative cardiology consultation (group B). In hospital death, myocardial infarction (MI), heart failure, dysrhythmias, and stroke were compared. A multiple logistic regression was performed to identify predictors of peri-operative complications. Long term overall survival and freedom from fatal cardiovascular events were compared.In total, 878 CEAs were performed in group A and 1094 in group B. Patients in group B were more likely to have had a previous coronary intervention (0.5% vs. 5.1%; p .001), and to be on dual antiplatelet (4.6% vs. 9.5%; p = .001), statin therapy (60.3% vs. 72.4%; p .001), and a higher number of cardiac drugs (1.77 ± 1.22 vs. 1.92 ± 1.23; p = .01) at the time of CEA. In hospital mortality was 0.1% for both groups (p = 1.0), and there were no significant differences regarding neurological complications (0.8% vs. 0.3%; p = .20); group B had a significant reduction in overall cardiac complications (3.4% vs. 1.9%; p = .05) and MI (1.6% vs. 0.6%; p = .05). Multivariable analysis confirmed that routine cardiology consultation was an independent predictor of MI (odds [OR] ratio 0.61; p = .04) and overall reduction in cardiac complications (OR 0.28; p = .01). At five years, overall survival was similar (84.2% vs. 82.4%; p = .72), but patients in group B had a significantly lower mortality from cardiovascular events (92.0% vs. 95.8%; p = .04).Routine cardiology consultation before elective CEA in patients with asymptomatic carotid stenosis reduced peri-operative cardiac complications and long term fatal cardiovascular events. This approach may be considered to maximise the risk/benefit ratio of CEA in asymptomatic patients.

Cardiovascular disease (CVD) is the leading cause of excess mortality in chronic kidney disease (CKD) and dialysis patients (DP) who have higher prevalence of left ventricular hypertrophy (LVH), the strongest predictor of CV events. Rho kinase (ROCK) activation is linked in hypertensive patients to cardiac remodeling while ROCK inhibition suppresses cardiomyocyte hypertrophy and, in a human clinical condition opposite to hypertension, its downregulation associates with lack of CV remodeling. Information on ROCK activation-LVH link in CKD and DP is lacking.Mononuclear cells (PBMCs) MYPT-1 phosphorylation, a marker of ROCK activity, and the effect of fasudil, a ROCK inhibitor, on MYPT-1 phosphorylation were assessed in 23 DPs, 13 stage 3-4 CKD and 36 healthy subjects (HS) by Western blot. LV mass was assessed by M-mode echocardiography.DP and CKD had higher MYPT-1 phosphorylation compared to HS (p0.001 and p=0.003). Fasudil (500 and 1000μM) dose dependently reduced MYPT-1 phosphorylation in DP (p0.01). DP had higher LV mass than CKD (p0.001). MYPT-1 phosphorylation was higher in patients with LVH (p=0.009) and correlated with LV mass both in DP and CKD with LVH (p0.001 and p=0.006).In DP and CKD, ROCK activity tracks with LVH. This ROCK activation-LVH link provided in these CVD high-risk patients along with similar findings in hypertensive patients and added to opposite findings in a human model opposite to hypertension and in type 2 diabetic patients, identify ROCK activation as a potential LVH marker and provide further rationale for ROCK activation inhibition as target of therapy in CVD high-risk patients.

Background. Chest ultrasound (US) is a non-invasive wellvalidated technique for estimating extravascular lung water (LW) in patients with heart diseases and in end-stage renal disease. We systematically applied this technique to the whole peritoneal dialysis (PD) population of five dialysis units. Methods. We studied the cross-sectional association between LW, echocardiographic parameters, clinical [pedal oedema, New York Heart Association (NYHA) class] and bioelectrical impedance analysis (BIA) markers of volume status in 88 PD patients. Results. Moderate to severe lung congestion was evident in 41 (46%) patients. Ejection fraction was the echocardiographic parameter with the strongest independent association with LW (r ¼� 0.40 P ¼ 0.002). Oedema did not associate with LW on univariate and multivariate analysis. NYHA class was slightly associated with LW (r ¼ 0.21 P ¼ 0.05). Among patients with severe lung congestion, only 27% had pedal oedema and the majority (57%) had no dyspnoea (NYHA Class I). Similarly, the prevalence of patients with BIA, evidence of volume excess was small (11%) and not significantly different (P ¼ 0.79) from that observed in patients with mild or no congestion (9%). Conclusions. In PD patients, LW by chest US reveals moderate to severe lung congestion in a significant proportion of asymptomatic patients. Intervention studies are necessary to prove the usefulness of chest US for optimizing the control of fluid excess in PD patients.

Objectives This study was designed to evaluate left ventricular (LV) anatomy and function in patients with Cushing’s syndrome. Background A high prevalence of LV hypertrophy and concentric remodeling has been reported in Cushing’s syndrome, although no data have been reported on LV systolic and diastolic function. Methods Forty-two consecutive patients with Cushing’s syndrome and 42 control subjects, matched for age, gender, and blood pressure, were studied. Left ventricular mass index (LVMI) and relative wall thickness (RWT) were measured by echocardiography, endocardial and midwall fractional shortening (FS) were assessed, and diastolic filling was measured by Doppler transmitral flow. Results The RWT was significantly greater in Cushing patients than in controls. Left ventricular hypertrophy and concentric remodeling were observed in 10 and 26 patients with Cushing’s syndrome, respectively. In Cushing patients, midwall FS was significantly reduced compared with controls (16.2 ± 3% vs. 21 ± 4.5%, p = 0.01). The ratio of transmitral E and A flow velocities was reduced and E deceleration time was prolonged in Cushing patients compared with controls (p = 0.03 and p Conclusions In patients with Cushing’s syndrome, cardiac structural changes are associated with reduced midwall systolic performance and with diastolic dysfunction that may contribute to the high risk of cardiovascular events observed in these patients.

The technique is demonstrated in a 78-year-old man; the preoperative CT angiogram showed a descending thoracic aorta ulcer of 5.9 cm in maximum diameter and 3.8 cm longitudinal extension. A ZTEG-2P-36-127-PF (Cook Medical) single tubular endograft was planned to be deployed. From the preoperative CT angiogram we planned to land 4.7 cm above the midline of the descending thoracic aorta ulcer and 8.0 cm below. In the operating room, under radioscopic vision the centre of the transesophageal echography probe was used as marker to identify the correspondent midline of the descending thoracic aorta ulcer and a centimeter-sized pigtail catheter in the aorta was used to calculate the desired length above and below the ulcer midline. The endograft was introduced and placed in the desired position compared to the transesophageal echography probe and the catheter; under transesophageal echography vision the graft was finally deployed. The CT angiogram at 1 month showed the correct endograft position, descending thoracic aorta ulcer exclusion with no signs of endoleak. In selected cases, this method allows planning in advance safe stent graft positioning and deployment totally assisted by transesophageal echography, with no risk of periprocedural contrast-related renal failure and reduced radiation exposure for the patient and operators.

Summary Background & aims Cardiovascular disease, the most common cause for morbidity and mortality in end-stage renal disease (ESRD), has prompted the exploration of multiple approaches to improve outcomes. Cardiovascular risk factors such as oxidative stress (OxSt) and cardiac remodelling are common in ESRD and dialysis patients. Green tea (GT) is well recognized as reducing OxSt. This 6 months study evaluated in 20 ESRD patients under chronic dialysis, the effect of GT treatment (1 g/day as commercially available capsule) on cellular and plasma OxSt and proliferation related markers using a molecular biology approach. Methods Mononuclear cell p22 phox , Haeme Oxygenase (HO)-1 protein expression, and phosphorylated ERK1/2 status were evaluated in dialysis patients at baseline, after 3 and 6 months of GT treatment by Western blot analysis and plasma oxLDL by ELISA. Cardiac remodelling was assessed by echocardiographic left ventricular (LV) mass determination at baseline and at the end of the study. Results GT treatment reduced p22 phox and pERK1/2 from baseline while HO-1 increased. At baseline, LV mass correlated with both p22 phox and oxLDL. GT treatment decreased LV mass from baseline, which correlated with oxLDL. 9 patients had LV hypertrophy at baseline, which, at 6 months, was normalized in 5 and reduced in 3, showing a parallel decrease of p22 phox , pERK1/2, oxLDL and increase of HO-1. Conclusions Treatment with GT decreased the expression of OxSt-related proteins tightly associated with cardiovascular disease and decreased LV mass. It appears highly likely that the addition of GT can provide a benefit in terms of cardiovascular protection in dialysis patients.

Low serum 25-hydroxyvitamin D [25(OH)D] levels may have an important role in predisposing to hypertension and myocardial disease. We investigated the relationship between 25(OH)D and left ventricular (LV) structure and function, assessed by echocardiography, in a series of patients with essential hypertension (EH).Sixty-two newly diagnosed never-treated patients (32 male/30 female), aged 18-65 years, with grade 1-2 hypertension, no diabetes, no obesity, no hyperlipidemia, and no cardiopulmonary, renal, or hepatic disease, were studied. Twenty-four healthy normotensive sex-, age-, BMI-matched subjects served as controls. Hypertensive patients with 25(OH)D deficiency, defined as serum 25(OH)D levels50 nmol/L, had higher prevalence of LV hypertrophy (LVH) than their 25(OH)D-sufficient counterparts (57.1 vs 17.6%, P = 0.02); no differences between the two groups were found in blood pressure levels as well as in other biochemical and hormone parameters. There was an inverse correlation between LV mass index and 25(OH)D levels (r = -0.366, P0.003) and a direct correlation between LV mass index and BMI (r = 0.333, P0.006) in the entire hypertensive population. The two variables remained independently associated with LVH at multivariable logistic regression analysis (OR 1.05, P0.005 and OR 1.25, P = 0.03, respectively). Prevalence of 25(OH)D deficiency was similar in EH patients and controls (45.1 vs 41.6%, P = 0.89), whereas no correlation between echocardiographic parameters and hormone levels was found.In the absence of major cardiovascular risk factors, 25(OH)D deficiency is a frequent finding in EH patients and is independently associated with LVH.

Cardiac autonomic dysfunction is associated with increased cardiovascular mortality. No data on sympathovagal balance are available in patients with Cushing's syndrome, in whom cardiovascular risk is high. We studied 10 patients with newly diagnosed Cushing's syndrome (1 male/9 females; age mean+/-SD, 47+/-10 yr) and 10 control subjects matched for age, sex, body mass index, and cardiovascular risk factors. In both groups there were 7 patients with arterial hypertension, 3 with diabetes mellitus, and 2 with obesity. Cardiac autonomic function was evaluated by analysis of short time heart rate variability (HRV) measures in frequency domain over 24-h, daytime, and nighttime. The 24-h ambulatory blood pressure monitoring and echocardiography were also performed. In comparison with controls, patients with Cushing's syndrome had lower 24-h (1.3+/-0.6 vs 3.7+/-1.5, mean+/-SD, p0.01), daytime (2.0+/-1.4 vs 4.5+/-1.6, p0.01), and night-time (1.0+/-0.4 vs 3.5+/-2.3, p0.01) low-frequency/ high frequency (LF/HF) power ratio. In the presence of similar LF power, the difference was due to elevation in HF power in Cushing's syndrome compared to controls: 24-h, 12.7+/-6.7 vs 5.8+/-2.8, p0.01; daytime, 10.2+/-7.3 vs 4.5+/-2.1, p0.05; nighttime, 14.2+/-7.0 vs 7.8+/-4.7, p0.05. Eight Cushing patients vs 4 controls had a non-dipping blood pressure profile. At echocardiography, Cushing patients had a greater left ventricular mass index and/or relative wall thickness, and impaired diastolic function, compared with controls. Compared to controls, patients with Cushing's syndrome showed a sympathovagal imbalance, characterized by a relatively increased parasympathetic activity. Whether this autonomic alteration is meant to counterbalance cortisol-induced effects on blood pressure and cardiac structure/function or has a different pathophysiological significance is still unknown.

BACKGROUND AND AIM: Insulin resistance is recognized as the pathophysiological hallmark of non-alcoholic fatty liver disease (NAFLD). A relation between insulin sensitivity and left ventricular morphology and function has been reported in essential hypertension, where a high prevalence of NAFLD has been recently found. We investigated the inter-relationship between left ventricular morphology/function, metabolic parameters and NAFLD in 86 never-treated essential hypertensive patients subdivided in two subgroups according to the presence (n = 48) or absence (n = 38) of NAFLD at ultrasonography. METHODS AND RESULTS: The two groups were similar as to sex, age and blood pressure levels. No patient had diabetes mellitus, obesity, hyperlipidemia, or other risk factors for liver disease. Body mass index, waist circumference, triglycerides, glucose, insulin, homeostasis model of assessment index for insulin resistance (HOMA-IR), aspartate aminotransferase and alanine aminotransferase were higher and adiponectin levels were lower in patients with NAFLD than in patients without NAFLD, and were associated with NAFLD at univariate analysis. Patients with NAFLD had similar prevalence of left ventricular hypertrophy compared to patients without NAFLD, but a higher prevalence of diastolic dysfunction (62.5 vs 21.1%, P < 0.001), as defined by E/A ratio 220 ms. Diastolic dysfunction (P = 0.040) and HOMA-IR (P = 0.012) remained independently associated with NAFLD at backward multivariate analysis. CONCLUSIONS: Non-alcoholic fatty liver disease was associated with insulin resistance and abnormalities of left ventricular diastolic function in a cohort of patients with essential hypertension, suggesting a concomitant increase of metabolic and cardiac risk in this condition.

Adiponectin is an adipocyte-derived protein with insulin-sensitizing and antiatherogenic properties. Failure to decrease blood pressure (BP) normally during night in hypertensive patients has been independently associated with left ventricular hypertrophy.We examined the relationship between adiponectin levels, insulin sensitivity, and left ventricular structure in 40 newly diagnosed never-treated patients with essential hypertension, including 20 patients with a normal night-time pressure decrease (ie, dippers) and 20 patients with BP persistently elevated throughout the 24-h period (ie, nondippers). All subjects had grade 1-2 hypertension, aged 18 to 65 years, no diabetes mellitus, no obesity, no hyperlipidemia, and no cardiopulmonary, renal, or hepatic disease.The two groups of patients were similar for age, sex, body mass index, and had no differences for clinic, 24-h, and diurnal BP, and 24-h, diurnal, and nocturnal heart rate, as well as glucose, total cholesterol, and triglyceride levels. Plasma insulin and homeostasis model assessment (HOMA index) were higher (P.01), and adiponectin levels were lower (P.005) in nondippers than in dippers. Adiponectin correlated inversely with HOMA index and insulin levels (r = -0.58, and r = -0.62, respectively, P.001) in the entire population. Nondippers showed left ventricular mass, relative wall thickness, and measure of early and late diastolic peak flow velocity ratio similar to those of dippers.In the absence of major cardiovascular risk factors, nondipper essential hypertensive patients show more prominent insulin resistance and lower adiponectin compared to dippers. Therapeutic modulation of adiponectin or insulin resistance might provide additional benefit to the conventional antihypertensive treatment.

Hypertrophic response of the left ventricle to systolic overload in aortic stenosis appears to be gender-dependent.To examine gender-related differences in left ventricular (LV) function in patients with isolated severe aortic stenosis, 145 patients (65 women, 80 men; mean age 66 +/- 8 years; range: 50 to 89 years) with aortic valve area0.8 cm2 who underwent cardiac catheterization were studied. No patient had associated myocardial, coronary or other valve disease; patients with diabetes mellitus and systemic hypertension were excluded.No significant differences were seen in aortic valve area between men and women. Neither were there any significant gender-related differences in LV end-systolic and end-diastolic volumes, LV end-diastolic pressure, LV mass indexed by body surface area, LV mass:volume ratio, LV mass:height ratio, elastic stiffness constant, ejection fraction, pulmonary wedge pressure, pulmonary arteriolar resistance and preload. Women showed significantly higher mean transaortic gradient, LV peak systolic pressure and peak systolic stress, end-systolic stress:end-systolic volume ratio, heart rate and cardiac index. In the subgroup of patients with LV pressure199 mmHg, the mass:volume ratio was increased in men compared with women; of note, the mass:volume ratio in women was not increased in this subgroup compared with the general population. LV pump function in this subgroup was normal and did not differ between men and women.Although no clear-cut difference in hemodynamic parameters was seen, there was a trend towards a less compensatory increase in LV mass in females.

Hypertension and left ventricular hypertrophy (LVH) are commonly associated in patients with CRF starting RDT. We report a case of eccentric LVH with marked dilatation and subsequent mitral incompetence of +3/4 that disappeared after three months of standard hemodialysis. Mrs SN, 62 years old, starting HD, had an echocardiography because of dyspnoea; the echo showed: dilated left atrium (78 ml/m2), moderately dilated left ventricle with normal systolic function (TDV 81 ml/m2, EF 66%), an increased ventricular mass (120 gr/m2) and a high grade mitral incompetence +3/4. After three months standard RDT and a dry weight only 2 kg less, the patients was normotensive without therapy, a cardiac angiogram with a hemodynamic study was performed as a pre-transplant workout: a normal left ventricle was found with normal systolic function (TDV 66, TSV 17, GS 49, EF 75%), and a perfectly competent mitral valve (reflux disappeared). The coronary angiography did not reveal critical stenosis. A new echocardiography confinned the data of the hemodynamic study: hypertensive cardiomiopathy with normal systolic function. After one year the patient has been transplanted, with a good renal function and the cardiac echo unchanged. Relieving uremic toxicity ameliorated the cardiac performance in this particular patient.

OBJECTIVE: To evaluate by echocardiography the cardiac structure and function in patients with primary adrenocortical insufficiency. DESIGN AND METHODS: Two-dimensionally guided M-mode echocardiograms and spectral Doppler studies were performed in seven consecutive patients with newly diagnosed autoimmune primary adrenal failure before and 4-8 months after an adequate regimen of steroid substitution. Echocardiographic parameters were also studied in ten healthy controls. RESULTS: In the cases with untreated Addison's disease, both left ventricular end-systolic and end-diastolic dimensions were significantly reduced in comparison with those in controls (P