New Evidence About Aortic Valve Stenosis and Cardiovascular Hemodynamics

Aortic stenosis (AS) is the most common degenerative valvular disease in western word. In patients with severe AS, small changes in aortic valve area can lead to large changes in hemodynamics. The correct understanding of cardiac hemodynamics and its interaction with vascular function is of paramount importance for correct identification of severe AS and to plan effective strategies for its treatment. In the current review with highlight the importance of pressure recovery phenomenon and valvular arterial impedance as novel tools in the evaluation of patients with aortic stenosis.publishedVersio

From Structural to Functional Hypertension Mediated Target Organ Damage—A Long Way to Heart Failure with Preserved Ejection Fraction

Arterial hypertension (AH) is a major risk factor for the development of heart failure (HF) which represents one of the leading causes of mortality and morbidity worldwide. The chronic hemodynamic overload induced by AH is responsible for different types of functional and morphological adaptation of the cardiovascular system, defined as hypertensive mediated target organ damage (HMOD), whose identification is of fundamental importance for diagnostic and prognostic purposes. Among HMODs, left ventricular hypertrophy (LVH), coronary microvascular dysfunction (CMVD), and subclinical systolic dysfunction have been shown to play a role in the pathogenesis of HF and represent promising therapeutic targets. Furthermore, LVH represents a strong predictor of cardiovascular events in hypertensive patients, influencing per se the development of CMVD and systolic dysfunction. Clinical evidence suggests considering LVH as a diagnostic marker for HF with preserved ejection fraction (HFpEF). Several studies have also shown that microalbuminuria, a parameter of abnormal renal function, is implicated in the development of HFpEF and in predicting the prognosis of patients with HF. The present review highlights recent evidence on the main HMOD, focusing in particular on LVH, CMD, subclinical systolic dysfunction, and microalbuminuria leading to HFpEF

Cardiac adaptation to hypertension in adult female Dahl salt-sensitive rats is dependent on ovarian function, but loss of ovarian function does not predict early maladaptation

Aim of study was to examine experimentally the adult female hypertensive heart in order to determine the role of ovary function in the response of the heart to salt-dependent hypertension. Dahl salt-sensitive rats, age 12 weeks, with/without ovariectomy were fed a standard (0.3% NaCl) or high-salt diet (8%) for 16 weeks. Mean arterial blood pressure monitored noninvasively in conscious state increased significantly by high salt. Echocardiography was performed at baseline and endpoint. Heart function and molecular changes were evaluated at endpoint by left ventricle catheterization, by sirius red staining for collagen and by gene expression using quantitative RT-PCR for selected genes. At endpoint, significant concentric hypertrophy was present with high salt. Increase in relative wall thickening with high salt compared to normal diet was more pronounced with intact ovaries (0.33 0.02 and 0.57 0.04 vs. 0.29 0.00 and 0.46 0.03) as was the reduction in midwall fractional shortening (20 0.6 and 14 2 vs. 19 0.9 and 18 1). Ovariectomy increased stroke volume and decreased the ratio of mitral peak velocity of early filling (E) to early diastolic mitral annular velocity (E0 ) (E/E’ ratio) when compared to hearts from intact rats. High salt increased expression of collagen I and III genes and perivascular collagen in the heart slightly, but % interstitial collagen by sirius red staining remained unchanged in intact rats and decreased significantly by ovariectomy. Added volume load but not deterioration of function or structure characterized the nonfailing hypertensive heart of salt-sensitive females ovariectomized at mature age when compared to corresponding intact females

Survey on arterial hypertension management: a report from the ESC Council for Cardiology Practice and the ESC Council on Hypertension

Aims: To explore the management of hypertensive patients by general cardiologists a few months after the European Society of Cardiology (ESC)-European Society of Hypertension (ESH) Guidelines publication. Methods and results: A survey based on a 26-point questionnaire was sent to ∼69 000 worldwide ESC members, a few months after the ESC-ESH Guidelines publication. A total of 1458 responses were collected via a web-based form. Among them, 68% were men, 48% were below 45 years old, and 60% were from Europe. Current guidelines have been read, at least partially, by 92.8%. Measurement of blood pressure (BP) is mostly done using the auscultatory method (58.8%) while unattended BP is rarely performed. Different bladder cuffs are not available for different arm circumferences for 27% of responders. Routine workup in hypertensive patients includes more often 12 leads ECG (97.7%) and echocardiography (79.6%). Only 30.9% of responders systematically assess the cardiovascular risk by the SCORE system and orthostatic hypotension is systematically researched by only 39.1%. Respondents consider that BP target of 140/90 mmHg is achievable in 60-80% of patients and 130/80 mmHg in 40-60%. Guidelines are considered too tight to be achievable by 15.6%, while 77.4% consider they are exactly right. Low patient's compliance, awareness of hypertension (HT) risk, and, at a lower degree, physician inertia, represent the main treatment challenges in reaching BP goals to most respondents, while treatment effectiveness is not in question. The present survey demonstrates specific gaps in HT management that need attention in clinical practice

Association of myocardial energetic efficiency with circumferential and longitudinal left ventricular myocardial function in subjects with increased body mass index (The FATCOR study)

Lower myocardial mechanic-energetic efficiency (MEEi), expressed as stroke volume/heart rate ratio (SV/HR) in mL/s/g of the left ventricular (LV) mass, is associated with the incidence of heart failure in subjects with cardiometabolic disorders. We explored the association of MEEi with LV systolic circumferential and longitudinal myocardial function in 480 subjects with increased body mass index (BMI) without known cardiovascular disease (mean age 47 ± 9 years, 61% women, 63% obese, 74% with hypertension) participating in the fat-associated cardiovascular dysfunction (FATCOR) study. Insulin resistance was assessed by the homeostasis model assessment insulin-resistance index (HOMA-IR). SV was calculated by Doppler echocardiography. The LV systolic circumferential myocardial function was evaluated by midwall fractional shortening (MFS) and longitudinal function by global longitudinal strain (GLS). Patients were grouped into MEEi quartiles. The lowest MEEi quartile (<0.41 mL/s per g) was considered low MEEi. The association of MEEi with MFS and GLS were tested in multivariable linear regression analyses. Patients with low MEEi were more frequently men, with obesity and hypertension, dyslipidemia and higher HOMA-IR index (all p for trend <0.05). In multivariable analyses, lower MEEi was associated with lower LV myocardial function by MFS and GLS independent of higher LV mass and clinical variables, including older age, male sex, presence of hypertension and a higher triglycerides level (all p < 0.05). In conclusion, in subjects with increased BMI without known cardiovascular disease participating in the FATCOR study, reduced MEEi was associated with lower LV myocardial function both in the circumferential and longitudinal direction, independent of cardiometabolic factors.publishedVersio

A case of pulmonary edema: The critical role of lung-heart integrated ultrasound examination.

Cardiogenic pulmonary edema is a common presentation of acute heart failure normally treated with continuous positive airway pressure (CPAP), diuretics and nitrates. This therapy is contraindicated in case of cardiac tamponade. We describe a case of pulmonary edema due to cardiac tamponade in which integrated lung-heart ultrasound examination allowed prompt diagnosis and pericardiocentesis before administration of CPAP thus avoiding circulatory collapse

Diagnostic performance of multi-organ ultrasound with pocket-sized device in the management of acute dyspnea

The availability of ultra-miniaturized pocket ultrasound devices (PUD) adds diagnostic power to the clinical examination. Information on accuracy of ultrasound with handheld units in immediate differential diagnosis in emergency department (ED) is poor. The aim of this study is to test the usefulness and accuracy of lung ultrasound (LUS) alone or combined with ultrasound of the heart and inferior vena cava (IVC) using a PUD for the differential diagnosis of acute dyspnea (AD)

Preexisting Oral Anticoagulant Therapy Ameliorates Prognosis in Hospitalized COVID-19 Patients

Objective: Altered coagulation parameters in COVID-19 patients is associated with a poor prognosis. We tested whether COVID-19 patients on chronic oral anticoagulants (cOACs) for thromboembolism prophylaxis could receive protection from developing more severe phenotypes of the disease. Approach and Results: We searched the database of the SARS-RAS study (Clinicaltrials.gov: NCT04331574), a cross-sectional observational multicenter nationwide survey in Italy designed by the Italian Society of Hypertension. The database counts 2,377 charts of Italian COVID-19 patients in 26 hospitals. We calculated the Charlson comorbidity index (CCI), which is associated with death in COVID-19 patients. In our population (n = 2,377, age 68.2 ± 0.4 years, CCI: 3.04 ± 0.04), we confirm that CCI is associated with increased mortality [OR: 1.756 (1.628-1.894)], admission to intensive care units [ICU; OR: 1.074 (1.017-1.134)], and combined hard events [CHE; OR: 1.277 (1.215-1.342)]. One hundred twenty-five patients were on cOACs (age: 79.3 ± 0.9 years, CCI: 4.35 ± 0.13); despite the higher CCI, cOACs patients presented with a lower risk of admissions to the ICU [OR 0.469 (0.250-0.880)] but not of death [OR: 1.306 (0.78-2.188)] or CHE [OR: 0.843 (0.541-1.312)]. In multivariable logistic regression, cOACs confirmed their protective effect on ICU admission and CHE. The CCI remains the most important risk factor for ICU admission, death, and CHE. Conclusions: Our data support a mechanism for the continuation of cOAC therapy after hospital admission for those patients who are on chronic treatment. Our preliminary results suggest the prophylactic use of direct cOACs in patients with elevated CCI score at the time of the COVID-19 pandemic even in absence of other risks of thromboembolism

Diagnostic accuracy of inferior vena cava evaluation in the diagnosis of acute heart failure among dyspneic patients.

Acute dyspnea is one of the main reasons for admission to the Emergency Department (ED). A rapid and accurate diagnosis can be lifesaving for these patients. Particularly, it is important to differentiate between dyspnea due to acute heart failure (AHF) and dyspnea of pulmonary origin. The aim of this study is to evaluate the real accuracy of the evaluation of diameter and collapsibility of IVC for the diagnosis of AHF among dyspneic patients. We analyzed 155 patients admitted for acute dyspnea to the ED of "Maurizio Bufalini" hospital in Cesena (Italy) and "Antonio Cardarelli" hospital in Naples (Italy) from November 2014 to April 2017. All patients underwent ultrasound of inferior vena cava (IVC) examination with a hand-held device in addition to the traditional pathway. Patients were classified into AHF group or non-AHF group according to the current guidelines. The final diagnosis was AHF in 64 patients and dyspnea of non-cardiac origin in 91 patients. Sensibility and specificity of IVC hypo-collapsibility was 75.81% (95% CI 63.26% to 85.78%) and 67.74% (95% CI 57.25% to 77.07%) for the diagnosis of AHF. Sensibility and specificity of IVC dilatation was 69.35% (95% CI 56.35% to 80.44%) and 74.19% (95%CI 64.08% to 82.71%) for the diagnosis of AHF. AUC was 0.718 (0.635-0.801) for IVC hypo-collapsibility, 0.718 (0.634-0.802) for IVC dilatation. Our study demonstrated that the sonographic assessment of IVC diameter and collapsibility is suboptimal to differentiate acute dyspnea due to AHF or other causes in the emergency setting