[Pulmonary thromboembolism and multimodality imaging: diagnostic work-up]

Pulmonary thromboembolism and multimodality imaging: diagnostic work-u

Direct oral anticoagulants for the treatment of left ventricular thrombosis: an updated systematic review and meta-analysis

Aims This meta-analysis aims to compare direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in the setting of left ventricular thrombosis (LVT). Method and Results We systematically searched MEDLINE, Cochrane Library, Biomed Central and Web of Science for trials comparing DOACs versus VKAs in the setting of LVT and reporting outcome data on thrombosis resolution, stroke and bleeding. Fourteen studies were finally selected. The Mantel-Haenszel method with a random effect model was used for the pooled analysis. The primary outcome was the occurrence of LVT resolution. The secondary outcomes were the occurrence of stroke or bleeding during treatment. One thousand three hundred and thirty-two patients were included in the analysis for the primary outcome. Of these, 424 were treated with DOACs and 908 with VKAs. The pooled odds ratio (OR) for the primary outcome was 1.00 [95% confidence interval (95% CI) 0.77-1.31, I-2 0.0%], reflecting equal effect in terms of thrombus resolution. Overall, 2290 patients, 608 on DOACs and 1682 on VKAs were included in the analysis of stroke occurrence, showing reduced risk of events in patients treated with DOACs (pooled OR 0.58, 95% CI 0.36-0.93; I-2 0.0%) as well as for bleeding occurrence (number of patients included 2139; pooled OR 0.64, 95% CI 0.44-0.94; I-2 0.0%). Conclusion Compared with VKAs, we found DOACs to have similar efficacy on thrombus resolution and favorable effects on stroke reduction and bleedings. DOACs should be considered as an alternative treatment for LVT. Large prospective randomized clinical trials are needed to confirm this exploratory finding

Atrial Longitudinal Strain Predicts New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysis

Atrial Longitudinal Strain Predicts New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysi

Left ventricular output indices and sacubitril/valsartan titration: role of stroke volume index

Aims This study aims to investigate the role of echocardiographically determined left ventricular output indices on sacubitril/valsartan titration in a cohort of outpatients with heart failure and reduced ejection fraction (HFrEF).Methods and results We analysed 106 HFrEF patients who underwent echocardiography examination up to 1 week before starting treatment with sacubitril/valsartan. For each patient, a comprehensive list of clinical and laboratory parameters was collected, and stroke volume index (SVi), cardiac index, and flow rate were calculated. The primary endpoint was the occurrence of complete titration of sacubitril/valsartan. The secondary endpoint was the incidence of adverse events (hypotension and renal adverse events). Univariate and multivariate logistic regression were used to identify variables associated with the primary and secondary endpoints. Mean age of patients was 73.7 +/- 10.4 years, 72 patients (71.7%) had ischaemic aetiology of HF, and mean ejection fraction was 29.4 +/- 5.9%. At multivariate analysis, SVi [odds ratio (OR) 1.43 per 5 mL/m(2) increase, 95% confidence interval (CI) 1.03-1.97; P = 0.028], serum sodium (OR 1.18, 95% CI 1.02-1.37; P = 0.022), and haemoglobin (OR 1.73, 95% CI 1.25-2.40; P = 0.001) were found to be independent predictors of titration during follow-up. Multivariate analysis for the secondary endpoint showed SVi (OR 0.63 per 5 mL/m(2) increase, 95% CI 0.44-0.90; P = 0.012) and New York Heart Association Class III (OR 2.65, 95% CI 1.07-6.5; P = 0.034) to be associated with hypotension.Conclusions Stroke volume index is positively associated with complete titration of sacubitril/valsartan. Patients with low SVi are more prone to experience hypotension during titratio

Phenotypic heterogeneity of COVID-19 pneumonia: clinical and pathophysiological relevance of the vascular phenotype

Recent data support the existence of a distinctive 'vascular' phenotype with the involvement of both pulmonary parenchyma and its circulation in COVID-19 pneumonia. Its prompt identification is important for the accurate management of COVID-19 patients. The aim is to analyse the pro and contra of the different modalities to identify the 'vascular' phenotype. Chest computed tomography scan and angiogram may quantify both parenchyma and vascular damage, but the presence of thrombosis of pulmonary microcirculation may be missed. Increased D-dimer concentration confirms a thrombotic state, but it cannot localize the thrombus. An elevation of troponin concentration non-specifically reflects cardiac injury. Echocardiogram and electrocardiogram provide specific signs of right ventricular pressure overload. This is particularly relevant for the 'vascular' phenotype, which does not necessarily represent the result of thrombo-embolic venous complications, but more frequently, it is the result of pulmonary microcirculation thrombosis in situ and needs immediate therapeutic action.Condensed abstract Despite diagnosis of the 'vascular' phenotype of COVID-19 pneumonia may be subtle, the evidence indicates a reasonable possibility of identifying it already in the initial stage of the infection. Chest computed tomography scan and angiogram, increased D-dimer concentration, and elevation of troponin concentration may be not sufficient to identify 'vascular' phenotype. Echocardiogram and electrocardiogram provide specific signs of right ventricular pressure overload. This is particularly relevant for the 'vascular' phenotype, which does not necessarily represent the result of thrombo-embolic venous complications, but more frequently, it is the result of pulmonary microcirculation thrombosis in situ and needs immediate therapeutic action

Left atrial pressure in patients with respiratory failure due to SARS-CoV-2 infection and supraventricular arrythmias

No abstract availabl

Diagnostic accuracy of baseline troponin and troponin change for the diagnosis of myocardial infarction complicated with heart failure

Background The diagnosis of myocardial infarction (MI) in the presence of heart failure (HF) presents a clinical problem. While diagnostic algorithms using high-sensitivity cardiac troponin have been established for suspected MI, their accuracy in patients with HF remains uncertain. This study aims to assess the diagnostic accuracy of high-sensitivity troponin I (TnI) levels in identifying acute MI among patients with HF, focusing on baseline, absolute and relative TnI changes.Methods Data from 562 individuals admitted to the emergency department with suspected MI were retrospectively analysed. Two-point TnI and baseline brain natriuretic peptide (BNP) test results were available. HF status was determined based on clinical, laboratory and instrumental criteria.Results Among the 562 patients, 299 (53.2%) were confirmed having MI. Baseline TnI demonstrated predictive capability for MI in the overall population (area under the curve (AUC) 0.63), while TnI relative change exhibited superior performance (AUC 0.83). Baseline TnI accuracy varied significantly by group, notably decreasing in the third group (severe HF) (AUC 0.54) compared with the first and second groups (AUC 0.67 and AUC 0.71, respectively). TnI relative change demonstrated consistent accuracy across all groups, with AUCs of 0.79, 0.79 and 0.89 for the first, second and third groups, respectively, even after adjustment for age, sex and glomerular filtration rate.Discussion Troponin relative change is a reliable predictor of MI, even in patients with acute HF. Baseline TnI accuracy is influenced by HF severity. It is essential to consider HF status and BNP levels when employing high-sensitivity cardiac troponin testing to rule out suspected MIs

Over time relationship between platelet reactivity, myocardial injury and mortality in patients with SARS-CoV-2-associated respiratory failure

The aim of this study (NCT04343053) is to investigate the relationship between platelet activation, myocardial injury, and mortality in patients affected by Coronavirus disease 2019 (COVID-19). Fifty-four patients with respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were enrolled as cases. Eleven patients with the same clinical presentation, but negative for SARS-CoV-2 infection, were included as controls. Blood samples were collected at three different time points (inclusion [T1], after 7 ± 2 days [T2] and 14 ± 2 days [T3]). Platelet aggregation by light transmittance aggregometry and the circulating levels of soluble CD40 ligand (sCD40L) and P-selectin were measured. Platelet biomarkers did not differ between cases and controls, except for sCD40L which was higher in COVID-19 patients (p = .003). In COVID-19 patients, P-selectin and sCD40L levels decreased from T1 to T3 and were higher in cases requiring admission to intensive care unit (p = .004 and p = .008, respectively). Patients with myocardial injury (37%), as well as those who died (30%), had higher values of all biomarkers of platelet activation (p < .05 for all). Myocardial injury was an independent predictor of mortality. In COVID-19 patients admitted to hospital for respiratory failure, heightened platelet activation is associated with severity of illness, myocardial injury, and mortality. ClinicalTrials.gov number: NCT04343053

ECG/echo indexes in the diagnostic approach to amyloid cardiomyopathy: A head-to-head comparison from the AC-TIVE study

Background and aims: The discordance between QRS voltages on electrocardiogram (ECG) and left ventricle (LV) wall thickness (LVWT) on echocardiogram (echo) is a recognized red flag (RF) of amyloid cardiomyopathy (AC) and can be measured by specific indexes. No head-to-head comparison of different ECG/echo indexes among subjects with echocardiographic suspicion of AC has yet been undertaken. The study aimed at evaluating the performance and the incremental diagnostic value of different ECG/echo indexes in this subset of patients. Methods: Electrocardiograms of subjects with LV hypertrophy, preserved ejection fraction and ≥&nbsp;1 echocardiographic RF of AC participating in the AC-TIVE study, an Italian prospective multicenter study, were independently analyzed by two cardiologists. Low QRS voltages and 8 different ECG/echo indexes were evaluated. Cohort specific cut-offs were computed. Results: Among 170 patients, 55 (32&nbsp;%) were diagnosed with AC. Combination of low QRS voltages with interventricular septum ≥&nbsp;1,6&nbsp;cm was the most specific (specificity 100&nbsp;%, positive predictive value 100&nbsp;%) ECG/echo index, while the ratio between the sum of all QRS voltages and LVWT &lt;7,8 was the most sensitive and accurate (sensitivity 94&nbsp;%, negative predictive value 97&nbsp;%, accuracy 82&nbsp;%). When the latter index was added to a model using easily-accessible clinical variables, the diagnostic accuracy for AC greatly increased (AUC from 0,84 to 0,95; p&nbsp;=&nbsp;0,007). Conclusions: Among patients with non-dilated hypertrophic ventricles with normal ejection fraction and echocardiographic RF of AC, easily-measurable ECG/echo indexes, mainly when added to few clinical variables, can help the physician orient second level investigations. External validation of the results is warranted

A national survey on prevalence of possible echocardiographic red flags of amyloid cardiomyopathy in consecutive patients undergoing routine echocardiography: study design and patients characterization-the first insight from the AC-TIVE Study

none46National survey on prevalence of possible echocardiographic red flags of amyloid cardiomyopathy in consecutive patients undergoing routine echocardiography: study design and patients characterization-the first insight from the AC-TIVE StudynoneMarco Merlo, Aldostefano Porcari, Linda Pagura, Matteo Cameli, Giuseppe Vergaro, Beatrice Musumeci, Elena Biagini, Marco Canepa, Lia Crotti, Massimo Imazio, Cinzia Forleo, Francesco Cappelli, Stefano Favale, Gianluca Di Bella, Franca Dore, Carlo Mario Lombardi, Rita Pavasini, Valeria Rella, Giuseppe Palmiero, Martina Caiazza, Miriam Albanese, Andrea Igoren Guaricci, Giovanna Branzi, Angelo Giuseppe Caponetti, Giulia Saturi, Giovanni La Malfa, Andrea Carlo Merlo, Alessandro Andreis, Francesco Bruno, Francesca Longo, Enrico Sfriso, Luca Di Ienno, Giuseppe De Carli, Elisa Giacomin, Valentina Spini, Antonino Milidoni, Giuseppe Limongelli, Camillo Autore, Iacopo Olivotto, Luigi Badano, Gianfranco Parati, Stefano Perlini, Marco Metra, Michele Emdin, Claudio Rapezzi, Gianfranco SinagraMerlo, Marco; Porcari, Aldostefano; Pagura, Linda; Cameli, Matteo; Vergaro, Giuseppe; Musumeci, Beatrice; Biagini, Elena; Canepa, Marco; Crotti, Lia; Imazio, Massimo; Forleo, Cinzia; Cappelli, Francesco; Favale, Stefano; Di Bella, Gianluca; Dore, Franca; Mario Lombardi, Carlo; Pavasini, Rita; Rella, Valeria; Palmiero, Giuseppe; Caiazza, Martina; Albanese, Miriam; Igoren Guaricci, Andrea; Branzi, Giovanna; Giuseppe Caponetti, Angelo; Saturi, Giulia; La Malfa, Giovanni; Carlo Merlo, Andrea; Andreis, Alessandro; Bruno, Francesco; Longo, Francesca; Sfriso, Enrico; Di Ienno, Luca; De Carli, Giuseppe; Giacomin, Elisa; Spini, Valentina; Milidoni, Antonino; Limongelli, Giuseppe; Autore, Camillo; Olivotto, Iacopo; Badano, Luigi; Parati, Gianfranco; Perlini, Stefano; Metra, Marco; Emdin, Michele; Rapezzi, Claudio; Sinagra, Gianfranc