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Atrial fibrillation and diabetes: time to reconsider duration of the disease to evaluate the bleeding risk? Impact of diabetes status in patients suffering of non-valvular atrial fibrillation requiring anticoagulation have been analysed previously and risk/benefit balance of NOACs have been confirmed in these patients. The implication of that pathology in the evaluation of the thrombotic risk is discussed but more importantly bleeding risk in this growing population is analysed, perhaps neglected until now.

Aortic valve stenosis (AS) is the third most common cardiovascular disease. The prevalence of both AS and arterial hypertension increases with age, and the conditions therefore often co-exist. Co-existence of AS and arterial hypertension is associated with higher global left ventricular (LV) pressure overload, more abnormal LV geometry and function, and more adverse cardiovascular outcome. Arterial hypertension may also influence grading of AS, leading to underestimation of the true AS severity. Current guidelines suggest re-assessing patients once arterial hypertension is controlled. Management of arterial hypertension in AS has historically been associated with prudence and concerns, mainly related to potential adverse consequences of drug-induced peripheral vasodilatation combined with reduced stroke volume due to the fixed LV outflow obstruction. Current evidence suggests that patients should be treated with antihypertensive drugs blocking the renin-angiotensin-aldosterone system, adding further drug classes when required, to achieve similar target blood pressure (BP) values as in hypertensive patients without AS. The introduction of transcatheter aortic valve implantation has revolutionized the management of patients with AS, but requires proper BP management during and following valve replacement. The purpose of this document is to review the recent evidence and provide practical expert advice on management of hypertension in patients with AS., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Objective: Hypoalbuminemia is common in heart failure (HF), especially in elderly patients. It is associated with an increased risk of death. The present study sought to examine the prognostic significance of serum albumin level in the prediction of long-term mortality in patients admitted for acute HF. Methods and results: We examined the association between albumin and hospital mortality in a cohort of 509 patients admitted for acute HF. None of the patients had infectious disease, severe arrhythmias (atrial fibrillation, ventricular tachycardia, ventricular fibrillation), required invasive ventilation or presented with acute coronary syndrome or primary valvular disease. Sixty-nine patients (14%) died during the 1-year follow-up. With multivariable analysis, haemoglobin level ( p  = .003), systolic blood pressure ( p  = .004) and serum albumin level ( p  = .003) emerged as independent predictors of long-term mortality. Hypoalbuminemia (<35.7 g/L) had a hazard ratio of 2.01 (95% CI 1.24-3.25) and haemoglobin of 2.6 (95% CI 1.29-5.22) for predicting long-term mortality. Conclusions: Serum albumin level measured at admission, especially if combined with anaemia, can serve as a simple prognostic factor in acute HF for predicting long-term outcome.

Importance: The natural history and the management of patients with asymptomatic aortic stenosis (AS) have not been fully examined in the current era., Objective: To determine the clinical outcomes of patients with asymptomatic AS using data from the Heart Valve Clinic International Database., Design, Setting, and Participants: This registry was assembled by merging data from prospectively gathered institutional databases from 10 heart valve clinics in Europe, Canada, and the United States. Asymptomatic patients with an aortic valve area of 1.5 cm2 or less and preserved left ventricular ejection fraction (LVEF) greater than 50% at entry were considered for the present analysis. Data were collected from January 2001 to December 2014, and data were analyzed from January 2017 to July 2018., Main Outcomes and Measures: Natural history, need for aortic valve replacement (AVR), and survival of asymptomatic patients with moderate or severe AS at entry followed up in a heart valve clinic. Indications for AVR were based on current guideline recommendations., Results: Of the 1375 patients included in this analysis, 834 (60.7%) were male, and the mean (SD) age was 71 (13) years. A total of 861 patients (62.6%) had severe AS (aortic valve area less than 1.0 cm2). The mean (SD) overall survival during medical management (mean [SD] follow up, 27 [24] months) was 93% (1%), 86% (2%), and 75% (4%) at 2, 4, and 8 years, respectively. A total of 104 patients (7.6%) died under observation, including 57 patients (54.8%) from cardiovascular causes. The crude rate of sudden death was 0.65% over the duration of the study. A total of 542 patients (39.4%) underwent AVR, including 388 patients (71.6%) with severe AS at study entry and 154 (28.4%) with moderate AS at entry who progressed to severe AS. Those with severe AS at entry who underwent AVR did so at a mean (SD) of 14.4 (16.6) months and a median of 8.7 months. The mean (SD) 2-year and 4-year AVR-free survival rates for asymptomatic patients with severe AS at baseline were 54% (2%) and 32% (3%), respectively. In those undergoing AVR, the 30-day postprocedural mortality was 0.9%. In patients with severe AS at entry, peak aortic jet velocity (greater than 5 m/s) and LVEF (less than 60%) were associated with all-cause and cardiovascular mortality without AVR; these factors were also associated with postprocedural mortality in those patients with severe AS at baseline who underwent AVR (surgical AVR in 310 patients; transcatheter AVR in 78 patients)., Conclusions and Relevance: In patients with asymptomatic AS followed up in heart valve centers, the risk of sudden death is low, and rates of overall survival are similar to those reported from previous series. Patients with severe AS at baseline and peak aortic jet velocity of 5.0 m/s or greater or LVEF less than 60% have increased risks of all-cause and cardiovascular mortality even after AVR. The potential benefit of early intervention should be considered in these high-risk patients.

Opinion Statement: Aortic valve disease and especially aortic stenosis (AS) is a growing cardiac pathology. Aortic valve replacement (AVR) is still the only treatment with proven benefit on survival in symptomatic patients and in patients with a left ventricular ejection fraction (LVEF) <50%. The benefit of prophylactic AVR in asymptomatic patients is still unproven. Once symptoms develop, the prognosis worsens. Exercise testing has emerged as a tool to unmask the "pseudo-asymptomatic" patients with AS (those without self-reporting symptoms), to link "exercise induced dyspnea" more confidently and more objectively to aortic valve disease and to allow for a safe "watchful waiting strategy" in "pseudo-symptomatic" patients (those with dyspnea unrelated to aortic valve disease). In cases in which exercise testing is unable to link dyspnea to aortic valve disease, exercise stress echocardiography and cardiopulmonary exercise testing may be helpful. Whatever the results of exercise testing with regard to symptom development, an increase in mean aortic valve pressure gradient >18-20 mmHg was associated with an increased risk of cardiac related events in severe AS patients (class IIb indication for AVR in the ESC guidelines). The decrease in LVEF during exercise as well as the development of exercise induced pulmonary hypertension, as revealed by exercise stress echocardiography, may be also useful in the risk stratification of these asymptomatic patients with severe AS. Data on the role of exercise echocardiography in asymptomatic severe aortic regurgitation patients is still scarce and further studies are needed. It seems that an exercise induced decrease in LVEF by 5% may be a better predictor of LV systolic dysfunction after AVR in asymptomatic patients or in patients with minimal symptoms. Exercise testing and exercise echocardiography are safe in the asymptomatic patients with aortic disease, provide useful clinical information that may help in risk assessment of these complicated patients and their use should be encouraged especially in heart valve clinics.

Heart valve disease is common and a major indication for imaging. Echocardiography is the first-line imaging technique for diagnosis, assessment, and serial surveillance. However, other modalities, notably cardiac magnetic resonance imaging and computerized tomography, are used if echocardiographic imaging is suboptimal or to obtain complementary information, particularly to aid risk assessment in individual patients. This review is a summary of current evidence for state-of-the-art clinical practice to inform appropriateness criteria for heart valve disease. It is divided according to common clinical scenarios: detection of valve disease, assessment of the valve and other cardiac structures, risk assessment, screening, and intervention., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.)

Background: Early detection of pulmonary arterial hypertension (PH) is crucial in systemic scleroderma. However, predictors of new onset of resting PH during follow-up (FUPH) have been poorly explored., Aim: To determine whether nailfold videocapillaroscopy (NVC) grade and exercise echocardiographic variables are predictors of FUPH., Methods: We prospectively enrolled 40 patients with systemic sclerosis (age 54±13 years; 68% women). All patients underwent graded semisupine exercise echocardiography and NVC. Baseline resting PH and FUPH were defined as systolic pulmonary arterial pressure (sPAP)>35 mmHg, and exercise-induced PH (EIPH) as exercise sPAP>50 mmHg., Results: Seventeen patients developed EIPH (43%). During follow-up (FU) (25±15 months), 11 patients without baseline PH developed FUPH (28%), all from the EIPH group. Patients with FUPH were significantly older (60±14 vs 50±12 years; P=0.04), had higher resting and exercise sPAP (30±4 vs 22±5 and 60±12 vs 40±11 mmHg, respectively; P<0.0001) and a higher exercise E/e' ratio (9.4±0.7 vs 5.8±0.4; P=0.0003) and presented more frequently NVC grade>2 (90% vs 35%; P=0.0009). After adjustment for age, resting sPAP, exercise sPAP and NVC grade>2 were associated with maximal resting sPAP during follow-up and FUPH (P<0.05). Patients with both EIPH and NVC grade>2 had a very high incidence of FUPH (82%), and both variables remained strongly associated with FUPH after adjustment for age (hazard ratio 11.6, 95% confidence interval 2.4-55.3; P=0.002)., Conclusion: Exercise echocardiography and NVC can identify a subgroup of patients with systemic sclerosis who are at risk of developing FUPH., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Aims: The objective assessment of maximal exercise capacity (MEC) using peak oxygen consumption (VO2) measurement may be helpful in the management of asymptomatic aortic stenosis (AS) patients. However, the relationship between left ventricular (LV) function and MEC has been relatively unexplored. We aimed to identify which echocardiographic parameters of LV systolic function can predict MEC in asymptomatic AS., Methods and Results: Asymptomatic patients with moderate to severe AS (n = 44, aortic valve area <1.5 cm(2), 66 ± 13 years, 75% of men) and preserved LV ejection fraction (LVEF > 50%) were prospectively referred for resting echocardiography and cardiopulmonary exercise test. LV longitudinal strain (LS) of each myocardial segment was measured by speckle tracking echocardiography (STE) from the apical (aLS) 4-, 2-, and 3-chamber views. An average value of the LS of the analysable segments was provided for each myocardial region: basal (bLS), mid (mLS), and aLS. LV circumferential and radial strains were measured from short-axis views. Peak VO2 was 20.1 ± 5.8 mL/kg/min (median 20.7 mL/kg/min; range 7.2-32.3 mL/kg/min). According to the median of peak VO2, patients with reduced MEC were significantly older (P < 0.001) and more frequently females (P = 0.05). There were significant correlations between peak VO2 and age (r = -0.44), LV end-diastolic volume (r = 0.35), LV stroke volume (r = 0.37), indexed stroke volume (r = 0.32), and E/e' ratio (r = -0.37, all P < 0.04). Parameters of AS severity and LVEF did not correlate with peak VO2 (P = NS for all). Among LV deformation parameters, bLS and mLS were significantly associated with peakVO2 (r = 0.43, P = 0.005, and r = 0.32, P = 0.04, respectively). With multivariable analysis, female gender (β = 4.9; P = 0.008) and bLS (β = 0.50; P = 0.03) were the only independent determinants (r(2) = 0.423) of peak VO2., Conclusion: In asymptomatic AS, impaired LV myocardial longitudinal function determines reduced MEC. Basal LS was the only parameter of LV regional function independently associated with MEC., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)