Liver involvement in presence of heart disease and heart involvement in presence of liver disease: a conundrum.

Data from literature show a cross-talk between the heart and liver during diseases which primarily involve one of the two organs, but data regarding this relationship are scant. Aim of this study was to investigate this relationship. In this narrative review we critically explored the most recent literature on this topic using PubMed and Medline and examining the most recent studies about liver involvement in heart failure and heart involvement in course of liver disease. Patients with acute and chronic heart failure and those who undergo heart transplatation (HT) manifest various signs of liver damage with a rate of incidence which is higher in candidates for left ventricular assist device. In presence of cardiogenic shock a very marked hepatocellular necrosis may occur while in the setting of chronic heart failure congestive hepatopathy and-or the so-called cardiac cirrhosis are observed. On the other side in presence of chronic liver disease and in case of liver transplantation (LT) heart functions may be altered and cirrhotic cardiomyopathy, which is a syndrome characterized by systolic, diastolic and electrophysiological abnormalities may occur. In this review we have analyzed the relationship between heart and liver disease, even in case of LT and HT. Furthermore we have underscored the effects of chronic alcoholism and of systemic disorders such as hemochromatosis and amyloidosis on both heart and liver.

Impaired Left Ventricular Global Longitudinal Strain among Patients with Chronic Kidney Disease and End-Stage Renal Disease and Renal Transplant Recipients.

BACKGROUND: Although heart failure is the most prevalent cardiovascular disease associated with adverse outcome in chronic kidney disease (CKD) and after kidney transplantation, left ventricular (LV) systolic function is often preserved in renal patients. The aim of this study was to evaluate global longitudinal strain (GLS), which is reportedly a more accurate tool for detecting subclinical LV systolic dysfunction, in patients with various degrees of renal function impairment, including kidney transplant recipients (KTRs). METHODS: This prospective study evaluated demographic, clinical, and ultrasound data, including the assessment of LV GLS and mitral E peak velocity and averaged ratio of mitral to myocardial early velocities (E/e'), of 70 consecutive renal patients (20 with stage 2-4 CKD, 25 with end-stage renal disease on hemodialysis [HD], and 25 KTRs). All patients had an LV ejection fraction ≥50% and no history of heart failure or coronary artery disease. We used multivariable logistic analysis to assess the risk of compromised GLS. One hundred and twenty control subjects with or without hypertension served as controls. RESULTS: A compromised GLS <-18% was shown in 55% of patients with stage 2-4 CKD, 60% of HD patients, and 28% of KTRs, while it was 32% in hypertensive controls and 12% in non-hypertensive controls (p < 0.0001). Patients with HD had higher systolic pressure and a significantly greater prevalence of increased LV mass and diastolic dysfunction. In renal patients, E/e' (p = 0.025), and LV mass index (p = 0.063) were independent predictors of compromised GLS at logistic regression analysis. E/e', systolic artery pressure, and LV mass also exhibited the greatest areas under the curve on receiver operating characteristic analysis to identify a compromised GLS. CONCLUSIONS: Renal disease proved to be associated with early and subclinical impairment of LV systolic function, which persists after starting dialysis and even in spite of successful kidney transplantation. An increased E/e' resulted to be the most powerful independent predictor of abnormal GLS.

Ranolazine for the treatment of atrial fibrillation.

INTRODUCTION: Atrial fibrillation (AF) is a frequent occurrence with advancing age and is associated with increased morbidity and mortality. Unfortunately, the currently available AF therapies have a great deal of side effects. AREAS COVERED: In this review, the authors discuss the evidence upon which the use of Ranolazine as an anti-arrhythmic drug is based. Specifically, the authors review the Phase I-III trials that studied ranolazine as potential treatment for AF. They also discuss the efficacy, safety, tolerability and side effects and compare the MERLIN TIMI 36, HARMONY and ROLE trials. EXPERT OPINION: Although ranolazine is considered an anti-angina drug, it may also be, according to the available data, used in patients with AF. Ranolazine has anti-AF efficacy, both alone or in combination with other drugs such as amiodarone and dronedarone. Indeed, its efficacy has been demonstrated in various settings such as the termination of paroxysmal AF, the facilitation of AF electrical cardioversion, and postoperative AF prevention. Although there is a great deal of evidence from pioneering experimental studies, the clinical evidence of the AF-suppressing effect of ranolazine is derived from studies with small sample size or from secondary analyses. A better understanding of the role of ranolazine as an anti-AF drug will be obtained through larger, prospective, placebo-controlled clinical trials in different populations.

[Polymyalgia rheumatica and aortic involvement]. / Polimialgia reumatica e coinvolgimento dell'aorta toracica.

Polymyalgia rheumatica (PMR) is an inflammatory disorder that affects people over 50 years of age, characterized by pain and stiffness in the neck and shoulder and pelvic girdles. PMR may occur as an isolated condition or concomitantly with giant cell arteritis. Similar to other inflammatory rheumatic disorders, PMR is associated with an increased cardiovascular risk due to inflammatory changes in large arterial vessels, which result in an increased chance of developing aneurysms and dissections. International guidelines do not provide specific indications about the management of PMR patients with aortic wall inflammation. In this review, we propose a diagnostic pathway for the management of PMR patients with aortic involvement based on literature data and personal experience.

Left atrial thrombosis in an anticoagulated patient after bioprosthetic valve replacement: Report of a case.

We present the case of a 74 year old woman suffering from severe mitral valve incompetence and rapid atrial fibrillation. After an appropriate vitamin K antagonist (VKA) therapy, the patient underwent mitral valve replacement by bioprosthesis. Then, the patient was re-hospitalized for jaundice. Suspecting hepatotoxicity, VKA was discontinued and fondaparinux was started. During this treatment, the patient developed a symptomatic atrial thrombus. After exclusion of a hepatic disease, VKA was re-established with hemodynamic and liver enzymes normalization and atrial thrombus resolution. Caution has to be used when considering fondaparinux as an alternative strategy to VKA in patients with multiple thrombotic risk factors.