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Background: Cardiac resynchronization therapy (CRT) is a standard treatment for patients with heart failure and electrical dyssynchrony. Cardiac magnetic resonance (CMR) is the gold standard for assessing left ventricular (LV) function. However, the feasibility of using CMR with active CRT is still uncertain. Purpose: To assess the feasibility of a CRT "off‐on" protocol during CMR and measure the acute effects of CRT interruption on LV function. Methods: Patients underwent CMR before (pre‐CRT) and 6 months after (post‐CRT) an MR‐conditional CRT defibrillator implantation. The post‐CRT scan included two complete sets of cine images, one with inactive (post‐CRTOFF) and one with active CRT (post‐CRTON), maintaining a continuous connection between device and programmer. Results: Out of 29 enrolled patients, 8 (28%) had complete and analyzable post‐CRT data. Unsuccessful procedures were attributed to connection problems between the CRT device and the programmer (n = 10), poor image quality (n = 7), and lack of patient cooperation (n = 4). LV ejection fraction significantly increased between pre‐CRT scan (28.1%) and both post‐CRTOFF (37.9%; p = 0.046) and post‐CRTON CMR (35.0%; p = 0.037), with a nonstatistically significant trend toward decreased LV volumes. No adverse events or significant changes in device electrical parameters (including battery level) were detected during the post‐CMR scan period. Conclusion: A CRT "off‐on" protocol during CMR studies can be safely executed in patients with an MR‐conditional CRT defibrillator. However, technical improvements are needed to facilitate high‐quality scans during active CRT. Favorable changes in LV function induced by CRT remodeling were not acutely reversed with the interruption of electrical therapy. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To evaluate whether the peak systolic velocities of the displacement of the lateral mitral anulus (S a) and of the mid-portion of the interventricular septal wall (S m) correlate with measures of left ventricular load, left ventricular mass, and Doppler stroke volume in normotensive and hypertensive subjects without clinically overt cardiovascular disease. Methods and results: Tissue Doppler imaging was used to evaluate S a and S m in apical 4-chamber view; standard echocardiographic procedures were used to assess left ventricular structure and traditional parameters of systolic function (ejection fraction, stress-corrected midwall shortening, meridional and circumferential end-systolic stress); pulsed Doppler was employed to evaluate stroke volume. In 87 subjects meeting inclusion criteria, S a and S m were not significantly correlated either with left ventricular end-diastolic volume and end-systolic stress, or with stroke volume; in contrast, endocardial and midwall fractional shortening were lower with higher afterload, as expected. Fractional shortening at endocardium and midwall, and S m were lower with higher left ventricular mass. Mean S a and S m values were lower in subjects with low vs. those with normal stress-corrected midwall shortening, but low S a was not associated with lower stress-corrected midwall shortening in our study sample. Conclusions: While S a and S m might be indices of longitudinal left ventricular systolic mechanics, they should not be considered as measures of left ventricular contractility alternative to well-established parameters of systolic function, such as stress-corrected midwall shortening, in subjects at rest without overt heart disease. [Copyright &y& Elsevier]

Aims: To assess inter- and intra-study reproducibility of myocardial contrast echocardiography (MCE) imaging for quantitative measurement of myocardial perfusion rate in humans in ambulatory setting.Methods and results: In 20 subjects, we performed 2 MCE tests 20–40 min apart on the same day under the same standardized protocol, and evaluated single-reader between-study and between-reading reproducibility of assessment of indicators of myocardial perfusion rate, such as the slope of video-intensity change k, and the factors A (peak video-intensity) and B (background video-intensity after bubble destruction) and the product k×A. The region of interest was placed at the mid-posterior interventricular septal wall visualized in apical 4-chamber view. In a sub-analysis, we evaluated indicators of myocardial perfusion rate comparing subjects with normal vs. those with subnormal ejection fraction (EF). Inter-study reproducibility of assessment of k was relatively low (intraclass correlation coefficient = 0.36), whereas intra-study reproducibility was fair (intraclass correlation coefficient = 0.61). The parameters k×A and B showed higher reproducibility than the k (inter- and intra-study intraclass correlation coefficients 0.64 and 0.75, 0.74 and 0.91, respectively). For reference, reproducibility data of the depth of the region of interest, of EF and CO were excellent. k and k×A were lower in subjects with low vs. those with normal EF. Only k and k×A were lower in subjects with subnormal than in those with normal EF.Conclusions: The MCE-derived indicator of myocardial perfusion rate k×A showed fairly good between-study and between-reading reproducibility. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate whether the benefit of cardiac resynchronization therapy with an implantable defibrillator (CRT-D) may differ among classes of indications to device therapy., Methods: All-cause mortality, first hospitalization for non-fatal heart failure, stable improvement of NYHA functional class (responders), and implant-related complications were evaluated retrospectively in 103 patients selected among those (n = 133) who received consecutively CRT-D between 2006 and 2009. Patients were divided into three groups: group IA (n = 65) included patients receiving CRT-D for a class IA indication; group IIa (n = 26) included patients with atrial fibrillation and QRS ≥ 130 ms receiving CRT-D for a class IA indication; nonconventional group (NC) (n = 12) included patients with an indication to defibrillator implantation extended to CRT-D because of NYHA class III-IV and echocardiographic evidence of electromechanical dyssynchrony. Echocardiographic examination was performed in all patients to identify wall target for left-side lead placement., Results: Group IIa patients were slightly older than group IA patients (p<0.05); gender distribution, left ventricular ejection fraction at implantation, ischemic etiology, and heart failure treatment were comparable among groups (all p>0.5), except for a higher digitalis use in group IIa patients (p<0.05). In a mean observation period of 3 years (up to December 2010), the rates of fatal events (IA: 22%, IIa: 23%, NC: 20%), rehospitalization for worsening heart failure (IA: 30%, IIa: 33%, NC: 22%), clinical responders (IA: 78%, IIa: 78%, NC: 78%), implant-related complications requiring reintervention (IA: 15%, IIa: 19%, NC: 25%), including pocket or catheter infections (IA: 5%, IIa: 11%, NC: 8%) were comparable among groups (all p>0.5)., Conclusions: In the "real world", the benefit of CRT-D in advanced heart failure patients might be comparable among class IA, IIa or NC indication.

Background: Whether home telemonitoring after acute episodes of heart failure (HF) may reduce de-novo cardiac decompensation is disputed. We tested home telemonitoring of blood pressure (BP), heart rate (HR), and blood oxygen saturation (SO2) to reduce rehospitalization in patients with recent admission for acute HF. METHODS; We screened patients hospitalized in Cardiology due to prominent cardiac cause of acute dyspnea, and pulmonary/peripheral congestion, and with one admission or more for similar symptoms/signs in the previous year. Patients with acute coronary syndrome, poor prognosis due to extracardiac causes, and reduced self-sufficiency and cognitive ability were excluded. Of the selected patients, 63% accepted and received a device for BP, HR and SO2 measurement connected to an analogical modem for data transmission to a hospital server. Patients were educated to measure vital signs 3 times/week. A dedicated doctor-nurse unit monitored the patients' data twice weekly to manage therapeutic adjustments of diuretic dosage or in-hospital visits if necessary. HF treatment was standardized based on current guidelines. Unplanned hospitalizations for HF or all-cause death were primary endpoints; unplanned hospitalizations (total) for any cause, and all-cause death were the composite endpoints., Results: Twenty-three patients (mean age 70 years, range 44-80 years) were recruited: 26% were women, 61% had coronary heart disease, 52% chronic lung disease, 57% renal insufficiency, 30% anemia; 17% had moderate or severe mitral regurgitation. At a mean follow-up of 302 days (range 55-622 days), 12 patients experienced the composite endpoints (52%, p=0.1), with the primary endpoint occurring in 8 patients (35%, 1 sudden death, p=0.058), the secondary endpoints occurring in 2 patients, and hospitalization not for HF occurring in 2 patients. The total number of hospitalizations/patient/year decreased from 2.2 ± 1.3 in the previous year to 0.9 ± 1.2 during the study period (p<0.01). On average, systolic BP tended to decrease, but BP, HR and SO 2 values prior to the index event (1-7 days) did not significantly differ from those recorded at the beginning of telemonitoring., Conclusions: In HF, home telemonitoring of simple variables had no significant impact on all-cause hospitalization/mortality, but was associated with a higher patient compliance and achievement of therapeutic targets, which may translate into a reduction in hospitalization rates for HF.

Background: Diagnostic reliability of indexations of peak exercise ST-segment depression (deltaST) for heart rate reserve (HRi) or chronotropic reserve (CR) to identify significant coronary artery disease (CAD) by bicycle exercise testing has not been evaluated previously., Methods: Upright bicycle exercise testing (25 W increment every 3 min) was performed in consecutive patients in primary prevention with at least one of the following criteria: history of exercise-induced chest discomfort and cardiovascular risk factors; overt peripheral arterial disease; type 2 diabetes associated with two or more additional cardiovascular risk factors. Coronary angiography was performed to define significant CAD (stenosis > or = 70% of the main coronary arteries or of their major branches, or isolated left main stenosis > or = 50%, or two or more stenoses 50-69%). Duke angina index was used to grade exercise-induced chest pain; deltaST, ST/HRi and ST/CR were calculated at peak exercise; three different criteria for the definition of inducible myocardial ischemia were tested versus significant CAD: peak deltaST > or =100 microV, ST/HRi > 1.69 microV/b/min or ST/CR > 1.76 microV/%., Results: Of the study sample (n = 46), 40% had typical angina; during stress test 80% showed deltaST > or = 100 microV; 76% had ST/HRi > 1.69 microV/b/min; 62% had ST/CR >1.76 microV/%. Diagnostic accuracy of deltaST > or = 100 microV, of ST/HRi > 1.69 micro5V/b/min, and of ST/CR > 1.76 microV/% were 78%, 72%, and 89% respectively (p < 0.001 for the difference in diagnostic performance). ST/CR > 1.76 microV/% showed the highest diagnostic accuracy both in patients with submaximal exercise (96%) and in women (92%). Similarly, ST/CR >1.76 microV/% was associated with the highest diagnostic accuracy both in patients with maximal exercise (78%) and in men (88%). Analyses of the ROC curve revealed that ST/CR was associated with the greatest area under the curve, and a population-specific cut-off of 1.77 microV/% was associated with a sensitivity of 88% and a specificity of 90%., Conclusions: Our pilot study suggests that in patients undergoing bicycle stress testing for differential diagnosis or screening of significant CAD, and with moderate-to-high pre-test probability, the use of ST/CR > 1.76 microV/% may provide elevated sensitivity and specificity, and the best diagnostic accuracy, which was consistent in patients with submaximal exercise test and in women.

Background: Whether the practice of family doctors of assessing individuals' cardiovascular risk profile improves individuals' knowledge of risk factors in primary prevention has not been established. Accordingly, we evaluated patients' knowledge of cardiovascular risk factors and lifestyle in healthy subjects whose family doctors provided individual cardiovascular risk score., Methods: Subjects who visited their family doctor in a time frame of 3 months, who accepted to fill-in a simple questionnaire measuring their knowledge of cardiovascular risk factors and of non-pharmacological interventions able to reduce cardiovascular risk were evaluated., Results: Fifty-one family doctors were involved. The study sample comprised 4239 subjects (mean age 56 +/- 9 years, 62% women) in primary prevention. They were classified by their family doctors, based on the Framingham algorithm, as being at low (< 10%; 45.7% of subjects), medium (10-20%; 38.7% of subjects) or moderate-to-high (> 20%; 15.6% of subjects) cardiovascular risk. The prevalence of obese subjects (40, 48, and 49%, respectively) and of heavy smokers (> or = 20 cigarettes/day; 26, 30, and 34%) increased from the low to the moderate-to-high risk group (both p < 0.05). The proportion of subjects unaware of personal history of arterial hypertension (5, 6, and 9%) and that of subjects who were unaware of history of elevated cholesterol levels (10, 11, and 12%, both p < 0.01) increased with higher cardiovascular risk score. The proportion of subjects self-reporting blood pressure > 135/85 mmHg, but self-reporting being normotensive (30, 50, and 52%), and the proportion of subjects who referred cholesterol levels > 200 mg/dl among those who self-referred not to have elevated cholesterol levels (13, 25, and 31%) increased both with cardiovascular risk category (p < 0.001). The proportion of subjects who were unaware of their personal history of diabetes was similar in the cardiovascular risk groups. The prevalence of low educational level was higher (56, 58, and 62%, p < 0.01) and the level of knowledge of non-pharmacological remedies to cardiovascular risk factors (63, 61, and 59%, p < 0.01) was lower in higher cardiovascular risk score group. Subjects aged < 55 years showed similar lack of knowledge about cardiovascular risk factors and the proportion of heavy smoking was as high as in the group of older participants., Conclusions: In cardiovascular primary prevention, the projection of higher individuals' risk profile by family doctors was not paralleled by an increase in individual's knowledge of major cardiovascular risk factors and of lifestyle interventions able to reduce the cardiovascular risk.

Background: Whether the practice of family doctors of assessing the global cardiovascular risk profile improves the knowledge of cardiovascular risk factors and the attitude to lifestyle change in patients' secondary cardiovascular prevention is unknown., Methods: We evaluated subjects who visited their family doctors and those with self-reported cardiovascular disease in the urban area of Naples, Italy. Patients self-administered a simple standard questionnaire to evaluate their knowledge of cardiovascular risk factors and of simple lifestyle modifications to reduce the cardiovascular risk burden. For each participant, family doctors, blinded to the information provided by patients, had to provide a global coronary risk based on the risk factors recorded in their electronic database, or report the missing information., Results: The study sample comprised 560 subjects, 61% male, with mean age 60 +/- 9 years. Angina pectoris (49%) and myocardial infarction (40.9%) were the most frequently self-reported cardiovascular diseases in the study sample. The self-reported data revealed that 46% of the sample was overweight and an additional 20% overtly obese. Among those who self-reported arterial hypertension, approximately 11% admitted that they were unaware of their blood pressure, and 26% believed that they were normotensive but reported a recently detected blood pressure > 140/90 mmHg. Approximately 8% were not aware of whether they had high cholesterol levels, and among those who declared having normal cholesterol levels, 9% referred levels > 200 mg/dl. Of the sample, 22% self-reported diabetes, but 7% did not know whether they were diabetic or not. Thirty percent of the sample were smokers and among these, 40% smoked > 20 cigarettes/day. A low level of education was reported in 66% of the study sample. Women were more frequently obese, more often reported high cholesterol levels, had a low level of education and achieved a lower score from the questionnaire on knowledge of cardiovascular risk factors than men. Patients > 55 years more often reported an elevated blood pressure among those who defined themselves as normotensive, and achieved a lower score from the questionnaire on knowledge of cardiovascular risk factors than younger patients., Conclusions: With regard to secondary cardiovascular prevention, the study population was found to have insufficient knowledge of cardiovascular risk factors and of the correct approach to reduce their global risk despite the fact that the attitude of their family doctors in detecting and recording risk factors was above average.