Considerations from the Epicenter of the Coronavirus Emergency

AbstractSince February 21, 2020, Lombardy region in northern Italy has experienced an outbreak of coronavirus disease 2019 (Covid-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This region, mainly a flat land with the highest density of population and industry of the country, has become the single deadliest hotspot for the coronavirus on the planet so far. More than 10,000 people have died here, with the national total across the country poised to top 18,000. The World Health Organization (WHO) first declared the Covid-19 respiratory illness unknown before the outbreak reported in Wuhan, China, last December. On January 30, 2020, the WHO denounced the Covid-19 outbreak a global health emergency. Some scientists declared the virus began circulating in Italy at least a month prior to the first case of infection recorded in February

Women's Cardiac Health in 2020: A Systematic Review

AbstractAlthough substantial progress has been made toward improving gender- and sex-specific cardiovascular disease (CVD) management and outcomes, contemporary reports indicate a persistent knowledge gap with regard to optimal risk-stratification and management in female cardiac heart disease (CHD) patients. Prominent patient and system delays in diagnosing CHD are, in part, due to the limited awareness for the latent CVD risk in women, a lack of sex-specific thresholds within clinical guidelines, and subsequent limited performance of contemporary diagnostic approaches in women. Several traditional risk factors for CHD affect both women and men. But other factors can play a bigger role in the development of heart disease in women. In addition, little is known about the influence of socioenvironmental and contextual factors on gender-specific disease manifestation and outcomes. It is imperative that we understand the mechanisms that contribute to worsening risk factors profiles in young women to reduce future atherosclerotic CVD morbidity and mortality. This comprehensive review focuses on the novel aspects of cardiovascular health in women and sex differences as they relate to clinical practice and prevention, diagnosis, and treatment of CVD. Increased recognition of the prevalence of traditional cardiovascular risk factors and their differential impact in women, as well as emerging nontraditional risk factors unique to or more common in women, contribute to new understanding mechanisms, leading to worsening outcome for women

Sub-clinical Detection of Left Ventricular Myocardial Dysfunction in Valvular Heart Diseases: A State-of-the-Art Review in a Speckle Tracking Echocardiography and Myocardial Performance

Purpose of the state-of-the-art review: Left ventricular (LV) global longitudinal strain (GLS) is recently recognized as a more sensitive measure of LV myocardial systolic function compared with LV ejection fraction (LVEF). In addition, left ventricular GLS , myocardial performance index (MPI) and maximum rate of LV pressure rise during isovolumetric contraction (LV dP/dtmax) are more reproducible than traditional assessment of LV systolic function by two dimensional echocardiography (2DE) LVEF. These underutilized techniques can detect preclinical myocardial dysfunction in patients who are at risk of LV failure in valvular-induced heart disease . Current guidelines for diagnosis and treatment of valvular heart disease (VHD) include LVEF as one of the parameters to take into consideration in the clinical decision-making. However, a large body of evidence has shown that left ventricular GLS, MPI and LV dP/dtmax have been classically considered as a sensitive marker of LV contractility and inotropic state. In turn GLS and myocardial performance may be a better prognosticator than LVEF in aortic and mitral valve heart diseases. This timely state-of-the-art review, appraised the evidence and role of GLS, MPI and dP/dT as clinical tools in patients with aortic and mitral valve disease. Recent findings: Left ventricular GLS has been shown to be prognostic in low-flow, low-gradient severe aortic stenosis with preserved LVEF. The role of left ventricular GLS, Tei index (MPI) and maximum rate of LV pressure rise (LV dP/dtmax) in patients with aortic regurgitation and mitral valve diseases (regurgitation and stenosis) is less well established. Summary: Echocardiography is considered the primary non-invasive imaging tool for valvular heart disease assessment and the cornerstone method in diagnosing and evaluating the morphology and severity of aortic and mitral valve diseases. Currently, diagnostic-cardiac catheterization is no more recommended except in very rare cases when echocardiographic image quality is suboptimal, non-diagnostic and when the results of 2DE are discrepant with clinical data. Once clinical decision-making is based on the 2DE and three dimensional echocardiographic in assessment of the severity of mitral and aortic valve diseases, it is crucial that standards should be adopted to maintain accuracy and consistency across echocardiographic laboratories. This illustrative review article assesses left ventricular systolic function (LVEF) employing two and/or three dimensional echocardiography in comparison to GLS, MPI and LV dP/dtmax, especially applied for aortic valve (AV) and mitral valve (MV) diseases. It is noteworthy that this document only provides echocardiographic standards rather than making recommendations for clinical management. Conclusion: It is concluded that GLS, MPI and maximum rate of LV pressure rise during isovolumetric contraction (LV dP/dtmax) are recommended and more so, they should be increasingly used to identify subclinical LV myocardial dysfunction in patients with mitral and aortic valve heart diseases, to identify optimal timing for surgery and prognosticate outcomes after surgery

Myocardial involvement during the early course of type 2 diabetes mellitus: usefulness of Myocardial Performance Index

To evaluate whether myocardial performance index detects a subclinical impairment of left ventricular systolic and diastolic function in patients with early stage of type 2 diabetes, without coronary artery disease, with or without hypertension. Furthermore, to evaluate whether some echocardiographic parameters relate to the metabolic control. Fourty-five consecutive male patients (mean age 52.5 years) with type 2 diabetes mellitus of recent onset (23 hypertensives and 22 normotensives) and 22 age matched healthy controls males were analysed. All participants had normal exercise ECG. All subjects underwent standard and Doppler echocardiography for the assessment of the isovolumic Doppler time interval and Doppler-derived myocardial performance index. In all diabetic patients a glycated haemoglobin test was also performed

Prediction of Preclinical Myocardial Dysfunction among Obese Diabetics with Preserved Ejection Fraction Using Tissue Doppler Imaging and Speckle Tracking Echocardiography

Background. Obesity and type 2 diabetes mellitus (T2DM) are two interrelated and preventable disorders. However, they are responsible for significant global mortality from cardiovascular diseases (CVDs). Clinical studies have demonstrated that global longitudinal strain (GLS) using speckle tracking echocardiography (STE), can assess myocardial function accurately in apparently, healthy patients with diabetes and obesity in the settings of acute and chronic ischemia and suspected cardiomyopathy without heart failure. No such studies have been published to date regarding subclinical detection of cardiac dysfunction among obese patients with T2DM. This study aims to investigate the role of STE in the early pre-clinical diagnosis of impairment of diastolic and systolic dysfunction in obese patients with T2DM. This study also investigated whether it is possible to detect early pre-clinical impairment of diastolic and systolic dysfunction in obese T2DM patients, via Tissue Doppler Imaging (TDI), maximum rate of left ventricular pressure development (peak dP/dt) and GLS using STE for comparison. Subjects and Methods. After clearance from the review board of Dibba- Hospital, Alfujairah, UAE, all the available records of patients with the diagnosis of obesity and diabetes were examined. The study included 214 patients presenting with obesity in conjunction with diabetes and 93 age-matched healthy control subjects. STE was performed among all the patients and subjects along with Tissue Doppler Imaging (TDI). This study assessed maximal rate of pressure rise during ventricular contraction (peak dP/dt) and global longitudinal strain (GLS) using STE methods. Transthoracic echocardiography, myocardial Doppler-derived systolic (sm), early diastolic velocity (em) and GLS were also obtained, among all the subjects. Results. The results show that cardiac functions via conventional echocardiography (CE) were similar in the 2 groups. Using TDI and conventional mitral Doppler flow, obese subjects with diabetes showed an evidence of diastolic function abnormalities in the form of lower Ea velocity (9.5 ± 2.9 vs. 18.4 ± 3.5 cm/s, p < 0.0001), an increased Aa velocity (16.5 ± 2.4 vs. 14.1 ± 2.2 cm/s p < 0.05), higher left ventricular filling pressure (E/Ea = 12 ± 4.4 vs 8±3.1), p 35) (n = 26) had reduced LV systolic and diastolic function compared with healthy controls. Regarding, systolic function indices, the findings revealed lower average longitudinal peak systolic strain, sm and reduced em, although, LV ejection fraction remained normal (56.48% ± 8.81). Among subjects with severe obesity (n = 26), the findings reveal that global longitudinal presystolic strain (GLPSS) is highly correlated with maximum rate of pressure development of LV (dp/dt), although the LVEF remained normal, in comparison to systolic strain and dp/dt. (.5% ±1.4 vs -19.54% ± 4.5; p < 0.001), in the age-matched healthy subjects. However, the frequency/grade of DCM detected by STE, among patients having obesity with T2DM, correlated closely with the degree of obesity, metabolic abnormalities and clustering of other major risk factors, especially high blood pressure. The findings also revealed that chest pain due to coronary heart disease (CAD), dyspnea and DCM were more common among female patients compared to men. Conclusion. The results indicate that patients having obesity with T2DM should be advised to undertake early TDI and STE for early diagnosis of decreased cardiac diastolic and systolic dysfunctions and cardiomyopathy, which is likely to be missed by conventional echocardiography. Significant differences in regional and global strain were also identified between the severely obese diabetic (BMI ≥ 35), (GLPSS (-13) patients compared to less obese subjects

Wartość diagnostyczna echokardiografii obciążeniowej z dobutaminą u chorych na cukrzycę

INTRODUCTION. The aim of this study was to assess the incremental value of dobutamine stress echocardiography (DSE) for the risk stratification of diabetic patients who are unable to perform an adequate exercise stress test. Exercise capacity is frequently impaired in patients with diabetes. The role of pharmacologic stress echocardiography in the risk stratification of diabetic patients has not been well defined. MATERIAL AND METHODS. We studied 396 diabetic patients (mean age 61 &plusmn; 11 years, 252 men [64%]) with limited exercise capacity who underwent DSE for evaluation of known or suspected coronary artery disease (CAD). End points were hard cardiac events (cardiac death and nonfatal myocardial infarction) and all causes of mortality. RESULTS. During a median follow-up of 3 years, 97 patients (24%) died (55 cardiac deaths), and 27 patients had nonfatal myocardial infarction. In an incremental multivariate analysis model, clinical predictors of hard cardiac events were history of congestive heart failure, previous myocardial infarction, hypercholesterolemia, and ejection fraction at rest. The percentage of ischemic segments was incremental to the clinical model in the prediction of hard cardiac events (c2 = 37 vs. 18, P < 0.05). Clinical predictors of all causes of mortality were history of congestive heart failure, age, hypercholesterolemia, and ejection fraction at rest. Wall motion score index at peak stress was incremental to the clinical model in the prediction of mortality (c2 = 52 vs. 43, P < 0.05). CONCLUSIONS. DSE provides incremental data for the prediction of mortality and hard cardiac events in patients with diabetes who are unable to perform an adequate exercise stress test.WSTĘP. Celem badania była ocena rosnącej wartości echokardiografii obciążeniowej z dobutaminą (DSE, dobutamine stress echocardiography) dla stratyfikacji ryzyka chorych na cukrzycę, którzy nie są w stanie wykonać odpowiedniego, wysiłkowego testu obciążeniowego. Wydolność fizyczna chorych na cukrzycę jest często zmniejszona. Dotychczas nie określono dobrze roli farmakologicznej echokardiografii obciążeniowej w stratyfikacji ryzyka u chorych na cukrzycę. MATERIAŁ I METODY. Przebadano 396 chorych na cukrzycę (średnia wieku 61 &plusmn; 11 lat, 252 mężczyzn &#8212; 64%) z ograniczoną wydolnością wysiłkową, u których wykonano DSE, by ocenić rozpoznaną lub podejrzewaną chorobę wieńcową (CAD, coronary artery disease). Kryteriami oceny badania były ciężkie epizody kardiologiczne (śmierć sercowa i zawał serca niezakończony zgonem) oraz zgon bez względu na przyczynę. WYNIKI. Podczas badania trwającego średnio 3 lata zmarło 97 pacjentów (24%) (55 zgonów z powodu śmierci sercowej), a u 27 chorych stwierdzono zawał serca niezakończony zgonem. W analizowanym, przyrostowym, wielozmiennym modelu, predyktorami klinicznymi ciężkich epizodów sercowych były: zastoinowa niewydolność serca w wywiadzie, wcześniejszy zawał serca, hipercholesterolemia oraz frakcja wyrzutowa w spoczynku. Odsetek niedokrwionych odcinków serca przyrastał w stosunku do modelu klinicznego w prognozowaniu ciężkich epizodów sercowych (c2 = 37 vs. 18, p < 0,05). Klinicznymi predyktorami zgonów bez względu na przyczynę były: zastoinowa niewydolność serca w przeszłości, wiek, hipercholesterolemia oraz frakcja wyrzutowa w spoczynku. Wskaźnik punktowy ruchomości ściany serca na szczycie obciążenia przyrastał w stosunku do modelu klinicznego w prognozowaniu umieralności (c2 = 52 vs. 43, p < 0,05). WNIOSKI. Echokardiografia obciążeniowa z dobutaminą dostarcza istotnych danych dotyczących prognozowania umieralności oraz ciężkich epizodów sercowych u chorych na cukrzycę, u których nie można przeprowadzić odpowiedniego testu stresowego

Prognostic value of dobutamine stress echocardiography in patients with diabetes

WSTĘP. Celem badania była ocena rosnącej wartości echokardiografii obciążeniowej z dobutaminą (DSE, dobutamine stress echocardiography) dla stratyfikacji ryzyka chorych na cukrzycę, którzy nie są w stanie wykonać odpowiedniego, wysiłkowego testu obciążeniowego. Wydolność fizyczna chorych na cukrzycę jest często zmniejszona. Dotychczas nie określono dobrze roli farmakologicznej echokardiografii obciążeniowej w stratyfikacji ryzyka u chorych na cukrzycę. MATERIAŁ I METODY. Przebadano 396 chorych na cukrzycę (średnia wieku 61 &plusmn; 11 lat, 252 mężczyzn &#8212; 64%) z ograniczoną wydolnością wysiłkową, u których wykonano DSE, by ocenić rozpoznaną lub podejrzewaną chorobę wieńcową (CAD, coronary artery disease). Kryteriami oceny badania były ciężkie epizody kardiologiczne (śmierć sercowa i zawał serca niezakończony zgonem) oraz zgon bez względu na przyczynę. WYNIKI. Podczas badania trwającego średnio 3 lata zmarło 97 pacjentów (24%) (55 zgonów z powodu śmierci sercowej), a u 27 chorych stwierdzono zawał serca niezakończony zgonem. W analizowanym, przyrostowym, wielozmiennym modelu, predyktorami klinicznymi ciężkich epizodów sercowych były: zastoinowa niewydolność serca w wywiadzie, wcześniejszy zawał serca, hipercholesterolemia oraz frakcja wyrzutowa w spoczynku. Odsetek niedokrwionych odcinków serca przyrastał w stosunku do modelu klinicznego w prognozowaniu ciężkich epizodów sercowych (c2 = 37 vs. 18, p < 0,05). Klinicznymi predyktorami zgonów bez względu na przyczynę były: zastoinowa niewydolność serca w przeszłości, wiek, hipercholesterolemia oraz frakcja wyrzutowa w spoczynku. Wskaźnik punktowy ruchomości ściany serca na szczycie obciążenia przyrastał w stosunku do modelu klinicznego w prognozowaniu umieralności (c2 = 52 vs. 43, p < 0,05). WNIOSKI. Echokardiografia obciążeniowa z dobutaminą dostarcza istotnych danych dotyczących prognozowania umieralności oraz ciężkich epizodów sercowych u chorych na cukrzycę, u których nie można przeprowadzić odpowiedniego testu stresowego.INTRODUCTION. The aim of this study was to assess the incremental value of dobutamine stress echocardiography (DSE) for the risk stratification of diabetic patients who are unable to perform an adequate exercise stress test. Exercise capacity is frequently impaired in patients with diabetes. The role of pharmacologic stress echocardiography in the risk stratification of diabetic patients has not been well defined. MATERIAL AND METHODS. We studied 396 diabetic patients (mean age 61 &plusmn; 11 years, 252 men [64%]) with limited exercise capacity who underwent DSE for evaluation of known or suspected coronary artery disease (CAD). End points were hard cardiac events (cardiac death and nonfatal myocardial infarction) and all causes of mortality. RESULTS. During a median follow-up of 3 years, 97 patients (24%) died (55 cardiac deaths), and 27 patients had nonfatal myocardial infarction. In an incremental multivariate analysis model, clinical predictors of hard cardiac events were history of congestive heart failure, previous myocardial infarction, hypercholesterolemia, and ejection fraction at rest. The percentage of ischemic segments was incremental to the clinical model in the prediction of hard cardiac events (c2 = 37 vs. 18, P < 0.05). Clinical predictors of all causes of mortality were history of congestive heart failure, age, hypercholesterolemia, and ejection fraction at rest. Wall motion score index at peak stress was incremental to the clinical model in the prediction of mortality (c2 = 52 vs. 43, P < 0.05). CONCLUSIONS. DSE provides incremental data for the prediction of mortality and hard cardiac events in patients with diabetes who are unable to perform an adequate exercise stress test