Cardiac calcification by transthoracic echocardiography in patients with known or suspected coronary artery disease

OBJECTIVES: To estimate the correlation between the total heart calcification score index (CSI), assessed by echocardiography, left ventricle mass index (LVMI), Framingham risk score (FRS), and angiographically assessed coronary artery disease (CAD). BACKGROUND: Aortic valve and root sclerosis (AVS, ARS) and mitral annular calcium (MAC) detected by echocardiography have been associated with atherosclerosis. FRS is recommended for estimation of total coronary heart disease risk over the course of 10 years. The anatomic extent of CAD can be assessed with coronary angiography. Total and cardiovascular mortality risk increases with increasing LVMI. METHODS: 167 consecutive in-hospital patients (mean age 66.6+/-9.7 yrs, 119 men) underwent: 1) complete transthoracic echocardiography (TTE), with CSI assessment (from 0=normal to 10=diffuse calcification of aortic valve, mitral annulus and aortic root), 2) the FRS evaluation (FRS</=10=low, FRS>/=11 and </=20=average risk, and a FRS>/=21=high risk), and 3) coronary angiography (with Duke score evaluation, from 0=normal to 100=severe left main disease). RESULTS: The mean CSI of the entire population was 3.94+/-2.1, with a mean of 2.75+/-2 in patients at low risk, with a progressive increase in patients at average risk (4.11+/-2.2), at high risk (4.7+/-1.7), respectively. CSI was associated with the presence of CAD (p=0.003) and the presence of abnormal LVMI (p=0.002). CONCLUSIONS: Echocardiographically assessed CSI is correlated to FRS, Duke score and LVMI and can provide a simple, radiation-free index of cardiovascular risk

Aortic valve sclerosis is associatedwith systemic endothelial dysfunction

AbstractObjectivesWe sought to examine the association between aortic valve sclerosis (AVS) and systemic endothelial manifestations of the atherosclerotic process.BackgroundClinical and experimental studies suggest that AVS is a manifestation of the atherosclerotic process. Systemic endothelial dysfunction is an early sign of the atherosclerotic process and can be assessed by ultrasonography of the brachial artery.MethodsA total of 102 in-hospital patients (76 men; mean age 63.5 ± 9.7 years) referred to the stress echocardiography laboratory underwent: 1) transthoracic echocardiography, with specific assessment of AVS (thickened valve leaflets with a transaortic flow velocity <2.5 m/s); 2) stress echocardiography; 3) coronary angiography, with evaluation of the Duke score (from 0 [normal] to 100 [most severe disease]); and 4) an endothelial function study, with assessment of endothelium-dependent, post-ischemic, flow-mediated dilation (FMD).ResultsAortic valve sclerosis was present in 35 patients (group I) and absent in 67 (group II). Groups I and II were similar in terms of the frequency of stress-induced wall motion abnormalities (35.3% vs. 19.4%, p = NS) and the angiographic Duke score (33.8 ± 28.6 vs. 35.2 ± 29.1, p = NS). Patients with AVS showed a markedly lower FMD than those without AVS (2.2 ± 3.5% vs. 5.3 ± 5.3%, p < 0.01). On multivariate analysis, only FMD was highly predictive of AVS, with an odds ratio of 1.18 for each percent decrease in FMD (95% confidence interval 1.05 to 1.32; p = 0.01).ConclusionsAortic valve stenosis is associated with systemic endothelial dysfunction. This observation may provide a mechanistic insight into the emerging association between AVS and cardiovascular events

The prognostic value of ultrasound lung comets in patients with pulmonary hypertension

Background: Ultrasound Lung Comets (ULCs) consist of multiple comet tails originating from thickened interlobular septa, due to water or connective tissue accumulation. Therefore they are detectable in patients with several lung diseases. Aim: To assess the prognostic value of ULCs in patients with pulmonary hypertension. Materials and methods: 33 in-hospital patients (age 67?13 years, 16 females) admitted to the Pneumology Division of Clinical Physiology in Pisa with diagnosis of idiopathic or secondary pulmonary hypertension were evaluated upon admission with a comprehensive 2D and Doppler echocardiography, and chest sonography with ULCs assessment. A patient ULC score was obtained by summing the number of comets from each of the scanning spaces in the anterior right and left hemithorax, from second to fifth intercostal spaces. By echocardiography, we measured Tricuspid Annular Plane Systolic Excursion (TAPSE) as an index of right ventricular function, and Pulmonary Artery Systolic Pressure (PASP) from tricuspid regurgitant jet velocity. Results: During the follow-up, 16 events occurred: 4 deaths, 12 new admission for the worsening of symptoms or respiratory function. A ROC analysis identified 14 ULCs as the best diagnostic cut-off to predict events with 94 % sensitivity and 71 % specificity. The 9-months event-free survival was higher in patients with no ULCs and lower in patients with ULCs (see Figure). There was a weak significant correlation between ULCs and PAPs (r=.541, p<.001) and no correlation between ULCs and TAPSE (r=.088, p=ns). Conclusion: ULCs are a simple, user-friendly, radiation-free bedside sign of thickened lung interlobular septa, adding a useful information for straightforward prognostic stratification of patients with pulmonary hypertension

Valve disease in cardiac amyloidosis: an echocardiographic score

Cardiac amyloidosis (CA) may affect all cardiac structures, including the valves. From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR-) or light-chain (AL-) CA, and age- and sex-matched controls. We chose 31 echocardiographic items related to the mitral, aortic and tricuspid valves, giving a value of 1 to each abnormal item. Patients with ATTR-CA displayed more often a shortened/hidden and restricted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL-CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (13.6-17.4) in ATTR-CA, 11.0 (9.3-14.9) in AL-CA, 12.8 (11.1-14.4) in ATTR-CA controls, and 11.0 (9.1-13.0) in AL-CA controls (p = 0.004 for ATTR- vs. AL-CA, 0.009 for ATTR-CA vs. their controls, and 0.461 for AL-CA vs. controls). Area under the curve values to diagnose ATTR-CA were 0.782 in patients with ATTR-CA or matched controls, and 0.773 in patients with LV hypertrophy. Patients with ATTR-CA have a prominent impairment of mitral valve structure and function, and higher score values. The valve score may help identify patients with ATTR-CA among patients with CA or unexplained hypertrophy

Spectroscopic characterization of the protocluster of galaxies around 7C 1756+6520 at z - 1.4

The aim of this paper is the spectroscopic study of 13 galaxies belonging to the field of the protocluster associated with the radio galaxy (RG) 7C 1756+6520 at z = 1.4156. In particular, we focus on the characterization of the nuclear activity. This analysis has been performed on rest-frame optical spectra taken with LBT-LUCI. The spectral coverage allowed us to observe emission lines such as Halpha, Hbeta, [Oiii]5007 A, and [Nii]6583 A at the z of the central RG. We observed the central part of the protocluster, which is suitable to include the radio galaxy, several spectroscopically confirmed AGN belonging to the protocluster, and other objects that might be members of the protocluster. For four previously identified protocluster members, we derived the redshift by detecting emission lines that have never detected before for these galaxies. The stacked spectrum of the galaxies in which we detected the [Oiii]5007 A emission line revealed the presence of the second line of the [Oiii] doublet at 4959 A and of Hbeta, which confirms that they belong to the protocluster. By collecting all members identified so far in this work and other members from the literature, we defined 31 galaxies, including the central RG, around z = 1.4152 +/- 0.056, corresponding to peculiar velocities <~5000 km/s with respect to the RG. The PV phase-space diagram suggests that 3 protocluster AGN and the central RG might be a virialized population that has been coexisting for a long time in the densest core region of this forming structure. This protocluster is characterized by a high fraction of AGN (23%). For one of them, AGN1317, we produced 2 BPT diagrams. The high fraction of AGN and their distribution within the protocluster seem to be consistent with predictions of some theoretical models on AGN growth and feedback.Comment: Accepted for publication in A&A, 17 pages, 8 Figures, 2 Tables. Revised versio

Prognostic value of lung ultrasound in patients hospitalized for heart disease irrespective of symptoms and ejection fraction

Aims: Lung ultrasound B-lines are the sonographic sign of pulmonary congestion and can be used in the differential diagnosis of dyspnoea to rule in or rule out acute heart failure (AHF). Our aim was to assess the prognostic value of B-lines, integrated with echocardiography, in patients admitted to a cardiology department, independently of the initial clinical presentation, thus in patients with and without AHF, and in AHF with reduced and preserved ejection fraction (HFrEF and HFpEF). Methods and results: We enrolled consecutive patients admitted for various cardiac conditions. Patients were classified into three groups: (i) acute HFrEF; (ii) acute HFpEF; and (iii) non-AHF. All patients underwent an echocardiogram coupled with lung ultrasound at admission, according to standardized protocols. We followed up 1021 consecutive inpatients (69 ± 12 years) for a median of 14.4 months (interquartile range 4.6-24.3) for death and rehospitalization for AHF. During the follow-up, 126 events occurred. Admission B-lines > 30, ejection fraction 2.8 m/s, and tricuspid annular plane systolic excursion 30 had a strong predictive value in HFpEF and non-AHF, but not in HFrEF. Conclusions: Ultrasound B-lines can detect subclinical pulmonary interstitial oedema in patients thought to be free of congestion and provide useful information not only for the diagnosis but also for the prognosis in different cardiac conditions. Their added prognostic value among standard echocardiographic parameters is more robust in patients with HFpEF compared with HFrEF

Echocardiography-Derived Forward Left Ventricular Output Improves Risk Prediction in Systolic Heart Failure

Background and aims: Though widely used to classify heart failure (HF) patients, the prognostic role of left ventricular ejection fraction (LVEF) is debated. We hypothesized that the echocardiographic measures of forward LV output, being more representative of cardiac hemodynamics, may improve risk prediction in a large cohort of HF patients with systolic dysfunction. Methods: Consecutive stable HF patients with LVEF &lt;50% on guideline-recommended therapies undergoing an echocardiography including the evaluation of forward LV output (i.e., LV outflow tract velocity-time integral [LVOT-VTI], stroke volume index [SVi], and cardiac index [CI]) over a 6-year period, were selected and followed-up for the endpoint of cardiac and all-cause death. Results: Among the 1,509 patients analyzed (71±12 years, 75% males, LVEF 35±9%), 328 (22%) died during a median 28-month (14-40) follow-up, 165 (11%) of which for cardiac causes. At multivariable regression analysis, LVOT-VTI (&lt;0.001), SVi (p&lt;0.001), and CI (p&lt;0.001), but not LVEF (p&gt;0.05), predicted cardiac and all-cause death. The optimal prognostic cut-offs for LVOT-VTI, SVi, and CI were 15 cm, 38 mL/m2, and 2 L/min/m2, respectively. Adding each of these measures to a multivariable risk model (including clinical, biohumoral, and echocardiographic markers) improved risk prediction (p&lt;0.001). Among the different measures of forward LV output, CI was less accurate than LVOT-VTI and SVi. Conclusion: The echocardiographic evaluation of forward LV output improves risk prediction in HF patients across a wide LVEF spectrum over other well-established clinical, biohumoral, and echocardiographic prognostic markers

Left ventricular outflow tract velocity-time integral improves outcome prediction in patients with secondary mitral regurgitation.

peer reviewedAIMS: Left ventricular outflow velocity-time integral (LVOT-VTI) has been shown to improve outcome prediction in different patients' subsets, with or without heart failure (HF). Nevertheless, the prognostic value of LVOT-VTI in patients with HF and secondary mitral regurgitation (MR) has never been investigated so far. Therefore, in the present study, we aimed to assess the prognostic value different metrics of LV forward output, including LVOT-VTI, in HF patients with secondary MR. METHODS AND RESULTS: Consecutive patients with HF and moderate-to-severe/severe secondary MR and systolic dysfunction (i.e., left ventricular ejection fraction [LVEF] <50%) were retrospectively selected and followed-up for the primary endpoint of cardiac death. Out of the 287 patients analyzed (aged 74 ± 11 years, 70% men, 46% ischemic etiology, mean LVEF 30 ± 9%, mean LVOT-VTI 20 ± 5 cm), 71 met the primary endpoint over a 33-month median follow-up (16-47 months). Patients with an LVOT-VTI ≤17 cm (n = 96, 32%) showed the greatest risk of cardiac death (Log Rank 44.3, p < 0.001) and all-cause mortality (Log rank 8.6, p = 0.003). At multivariable regression analysis, all the measures of LV forward volume (namely LVOT-VTI, stroke volume index, cardiac output, and cardiac index) were predictors of poor outcomes. Among these, LVOT-VTI was the most accurate in risk prediction (univariable C-statistics 0.70 [95%CI 0.64-0.77]). CONCLUSION: Left ventricular forward output, noninvasively estimated through LVOT-VTI, improves outcome prediction in HF patients with low LVEF and secondary MR

Valve disease in cardiac amyloidosis: an echocardiographic score

: Cardiac amyloidosis (CA) may affect all cardiac structures, including the valves. From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR-) or light-chain (AL-) CA, and age- and sex-matched controls. We chose 31 echocardiographic items related to the mitral, aortic and tricuspid valves, giving a value of 1 to each abnormal item. Patients with ATTR-CA displayed more often a shortened/hidden and restricted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL-CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (13.6-17.4) in ATTR-CA, 11.0 (9.3-14.9) in AL-CA, 12.8 (11.1-14.4) in ATTR-CA controls, and 11.0 (9.1-13.0) in AL-CA controls (p = 0.004 for ATTR- vs. AL-CA, 0.009 for ATTR-CA vs. their controls, and 0.461 for AL-CA vs. controls). Area under the curve values to diagnose ATTR-CA were 0.782 in patients with ATTR-CA or matched controls, and 0.773 in patients with LV hypertrophy. Patients with ATTR-CA have a prominent impairment of mitral valve structure and function, and higher score values. The valve score may help identify patients with ATTR-CA among patients with CA or unexplained hypertrophy