Guillain-Barré syndrome and SARS-CoV-2 infection: a systematic review and meta-analysis on a debated issue and evidence for the 'Italian factor'.

BACKGROUND AND PURPOSE: The association between Guillain-Barré syndrome (GBS) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is debated. This study reappraises, after three pandemic years, the epidemiological data and the features of GBS in SARS-CoV-2 patients. METHODS: A systematic review and meta-analysis of case reports/series and cohort studies published between 1 January 2020 and 19 April 2023 was performed. RESULTS: In all, 209 case reports/series (304 patients) and 26 cohort studies were included. The risk of GBS in northern Italy during the first pandemic wave was 2.85 times increased (95% confidence interval [CI] 1.54; 5.25) whereas in some countries the risk during the first pandemic year was 0.17 times reduced (risk ratio 0.83, 95% CI 0.75; 0.93). The incidence of GBS in SARS-CoV-2 Italian hospitalized cohorts was 8.55 per 1000 (95% CI 5.33; 12.49) with an estimated incidence of 0.13 GBS per 1000 in the SARS-CoV-2 infected population. In European cohorts the pooled rate of GBS with SARS-CoV-2 infection was 61.3% of the total. GBS patients with SARS-CoV-2 infection showed more frequently, but not differently from non-infected patients, the classical clinical presentation and the demyelinating subtype. Cranial nerves were more frequently involved in SARS-CoV-2 infected patients. CONCLUSIONS: An increased risk of GBS occurred in northern Italy during early COVID-19 pandemic. The recognition of the 'Italian factor' reconciles contrasting results of the epidemiological studies. The slightly reduced GBS risk in other countries and the relatively high frequency of GBS associated with SARS-CoV-2 infection can be explained by the adopted health measures that decreased the circulation of other GBS infective antecedents.

Moderate aortic stenosis: Navigating the uncharted.

Aortic stenosis (AS) stands as the most common valvular heart disease in developed countries and is characterized by progressive narrowing of the aortic valve orifice resulting in elevated transvalvular flow resistance, left ventricular hypertrophy, and progressive increased risk of heart failure and sudden death. This narrative review explores clinical challenges and evolving perspectives in moderate AS, where discrepancies between aortic valve area and pressure gradient measurements may pose diagnostic and therapeutic quandaries. Transthoracic echocardiography is the first-line imaging modality for AS evaluation, yet cases of discordance may require the application of ancillary noninvasive diagnostic modalities. This review underscores the importance of accurate grading of AS severity, especially in low-gradient phenotypes, emphasizing the need for vigilant follow-up. Current clinical guidelines primarily recommend aortic valve replacement for severe AS, potentially overlooking latent risks in moderate disease stages. The noninvasive multimodality imaging approach-including echocardiography, cardiac magnetic resonance, computed tomography, and nuclear techniques-provides unique insights into adaptive and maladaptive cardiac remodeling in AS and offers a promising avenue to deliver precise indications and exact timing for intervention in moderate AS phenotypes and asymptomatic patients, potentially improving long-term outcomes. Nevertheless, what we may have gleaned from a large amount of observational data is still insufficient to build a robust framework for clinical decision-making in moderate AS. Future research will prioritize randomized clinical trials designed to weigh the benefits and risks of preemptive aortic valve replacement in the management of moderate AS, as directed by specific imaging and nonimaging biomarkers.

Hallmarks for Thrombotic and Hemorrhagic Risks in Chronic Kidney Disease Patients.

Chronic kidney disease (CKD) is a global health issue causing a significant health burden. CKD patients develop thrombotic and hemorrhagic complications, and cardiovascular diseases are associated with increased hospitalization and mortality in this population. The hemostatic alterations are multifactorial in these patients; therefore, the results of different studies are varying and controversial. Endothelial and platelet dysfunction, coagulation abnormalities, comorbidities, and hemoincompatibility of the dialysis membranes are major contributors of hypo- and hypercoagulability in CKD patients. Due to the tendency of CKD patients to exhibit a prothrombotic state and bleeding risk, they require personalized clinical assessment to understand the impact of antithrombotic therapy. The evidence of efficacy and safety of antiplatelet and anticoagulant treatments is limited for end-stage renal disease patients due to their exclusion from major randomized clinical trials. Moreover, designing hemocompatible dialyzer membranes could be a suitable approach to reduce platelet activation, coagulopathy, and thrombus formation. This review discusses the molecular mechanisms underlying thrombotic and hemorrhagic risk in patients with CKD, leading to cardiovascular complications in these patients, as well as the evidence and guidance for promising approaches to optimal therapeutic management.

Gender Differences and Cardiometabolic Risk: The Importance of the Risk Factors.

Metabolic syndrome (Mets) is a clinical condition characterized by a cluster of major risk factors for cardiovascular disease (CVD) and type 2 diabetes: proatherogenic dyslipidemia, elevated blood pressure, dysglycemia, and abdominal obesity. Each risk factor has an independent effect, but, when aggregated, they become synergistic, doubling the risk of developing cardiovascular diseases and causing a 1.5-fold increase in all-cause mortality. We will highlight gender differences in the epidemiology, etiology, pathophysiology, and clinical expression of the aforementioned Mets components. Moreover, we will discuss gender differences in new biochemical markers of metabolic syndrome and cardiovascular risk.

Early cardiovascular prevention: the crucial role of nurse-led intervention.

The present comment on Qiu's work intends to emphasize two points: (1) Cardiovascular prevention must start early due to the progressive nature of atherosclerosis. (2) growing evidence that coaching performed by nurses leads to effective results. Nurses can intercept the young population who must be sensitized and educated about prevention.

Timing of mechanical circulatory support during primary angioplasty in acute myocardial infarction and cardiogenic shock: Systematic review and meta-analysis.

OBJECTIVES: We aim to define whether the timing of microaxial left ventricular assist device (IMLVAD) implantation might impact on mortality in acute myocardial infarction (AMI) cardiogenic shock (CS) patients who underwent primary percutaneous coronary intervention (PPCI). BACKGROUND: Despite the widespread use of PPCI, mortality in patients with AMI and CS remains high. Mechanical circulatory support is a promising bridge to recovery strategy, but evidence on its benefit is still inconclusive and the optimal timing of its utilization remains poorly explored. METHODS: We compared clinical outcomes of upstream IMLVAD use before PPCI versus bailout use after PPCI in patients with AMI CS. A systematic review and meta-analysis of studies comparing the two strategies were performed. Effect size was reported as odds ratio (OR) using bailout as reference group and a random effect model was used. Study-level risk estimates were pooled through the generic inverse variance method (random effect model). RESULTS: A total of 11 observational studies were identified, including a pooled population of 6759 AMI-CS patients. Compared with a bailout approach, upstream IMLVAD was associated with significant reduction of 30-day (OR = 0.65; 95% confidence interval [CI] = 0.51-0.82; I2 = 43%, adjusted OR = 0.54; 95% CI = 0.37-0.59; I2 = 3%, test for subgroup difference p = 0.30), 6-month (OR = 0.51; 95% CI = 0.27-0.96; I2 = 66%), and 1-year (OR = 0.56; 95% CI = 0.39-0.79; I2 = 0%) all-cause mortality. Incidence of access-related bleeding, acute limb ischemia and transfusion outcomes were similar between the two strategies. CONCLUSION: In patients with AMI-CS undergoing PPCI, upstream IMLVAD was associated with reduced early and midterm all-cause mortality when compared with a bailout strategy.

Clinical applications of heart rhythm monitoring tools in symptomatic patients and for screening in high-risk groups.

Recent technological advances have facilitated and diversified the options available for the diagnosis of cardiac arrhythmias. Ranging from simple resting or exercise electrocardiograms to more sophisticated and expensive smartphones and implantable cardiac monitors. These tests and devices may be used for varying periods of time depending on symptom frequency. The choice of the most appropriate heart rhythm test should be guided by clinical evaluation and optimized following accurate characterization of underlying symptoms, 'red flags', risk factors, and consideration of cost-effectiveness of the different tests. This review provides evidence-based guidance for assessing suspected arrhythmia in patients who present with symptoms or in the context of screening, such as atrial fibrillation or advanced conduction disturbances following transcatheter aortic valve implantation in high-risk groups. This is intended to help clinicians choose the most appropriate diagnostic tool to facilitate the management of patients with suspected arrhythmias.

Prognostic Significance of Chest Imaging by LUS and CT in COVID-19 Inpatients: The ECOVID Multicenter Study.

BACKGROUND: Point-of-care lung ultrasound (LUS) score is a semiquantitative score of lung damage severity. High-resolution computed tomography (HRCT) is the gold standard method to evaluate the severity of lung involvement from the novel coronavirus disease (COVID-19). Few studies have investigated the clinical significance of LUS and HRCT scores in patients with COVID-19. Therefore, the aim of this study was to evaluate the prognostic yield of LUS and of HRCT in COVID-19 patients. METHODS: We carried out a multicenter, retrospective study aimed at evaluating the prognostic yield of LUS and HRCT by exploring the survival curve of COVID-19 inpatients. LUS and chest CT scores were calculated retrospectively by 2 radiologists with >10 years of experience in chest imaging, and the decisions were reached in consensus. LUS score was calculated on the basis of the presence or not of pleural line abnormalities, B-lines, and lung consolidations. The total score (range 0-36) was obtained from the sum of the highest scores obtained in each region. CT score was calculated for each of the 5 lobes considering the anatomical extension according to the percentage parenchymal involvement. The resulting overall global semiquantitative CT score was the sum of each single lobar score and ranged from 0 (no involvement) to 25 (maximum involvement). RESULTS: One hundred fifty-three COVID-19 inpatients (mean age 65 ± 15 years; 65% M), including 23 (15%) in-hospital deaths for any cause over a mean follow-up of 14 days were included. Mean LUS and CT scores were 19 ± 12 and 10 ± 7, respectively. A strong positive linear correlation between LUS and CT scores (Pearson correlation r = 0.754; R2 = 0.568; p < 0.001) was observed. By ROC curve analysis, the optimal cut-point for mortality prediction was 20 for LUS score and 4.5 for chest CT score. According to Kaplan-Meier survival analysis, in-hospital mortality significantly increased among COVID-19 patients presenting with an LUS score ≥20 (log-rank 0.003; HR 9.87, 95% CI: 2.22-43.83) or a chest CT score ≥4.5 (HR 4.34, 95% CI: 0.97-19.41). At multivariate Cox regression analysis, LUS score was the sole independent predictor of in-hospital mortality yielding an adjusted HR of 7.42 (95% CI: 1.59-34.5). CONCLUSION: LUS score is useful to stratify the risk in COVID-19 patients, predicting those that are at high risk of mortality.

Classification of Drivers' Mental Workload Levels: Comparison of Machine Learning Methods Based on ECG and Infrared Thermal Signals.

Mental workload (MW) represents the amount of brain resources required to perform concurrent tasks. The evaluation of MW is of paramount importance for Advanced Driver-Assistance Systems, given its correlation with traffic accidents risk. In the present research, two cognitive tests (Digit Span Test-DST and Ray Auditory Verbal Learning Test-RAVLT) were administered to participants while driving in a simulated environment. The tests were chosen to investigate the drivers' response to predefined levels of cognitive load to categorize the classes of MW. Infrared (IR) thermal imaging concurrently with heart rate variability (HRV) were used to obtain features related to the psychophysiology of the subjects, in order to feed machine learning (ML) classifiers. Six categories of models have been compared basing on unimodal IR/unimodal HRV/multimodal IR + HRV features. The best classifier performances were reached by the multimodal IR + HRV features-based classifiers (DST: accuracy = 73.1%, sensitivity = 0.71, specificity = 0.69; RAVLT: accuracy = 75.0%, average sensitivity = 0.75, average specificity = 0.87). The unimodal IR features based classifiers revealed high performances as well (DST: accuracy = 73.1%, sensitivity = 0.73, specificity = 0.73; RAVLT: accuracy = 71.1%, average sensitivity = 0.71, average specificity = 0.85). These results demonstrated the possibility to assess drivers' MW levels with high accuracy, also using a completely non-contact and non-invasive technique alone, representing a key advancement with respect to the state of the art in traffic accident prevention.

Clinical outcome with different doses of low-molecular-weight heparin in patients hospitalized for COVID-19.

A pro-thrombotic milieu and a higher risk of thrombotic events were observed in patients with CoronaVirus disease-19 (COVID-19). Accordingly, recent data suggested a beneficial role of low molecular weight heparin (LMWH), but the optimal dosage of this treatment is unknown. We evaluated the association between prophylactic vs. intermediate-to-fully anticoagulant doses of enoxaparin and in-hospital adverse events in patients with COVID-19. We retrospectively included 436 consecutive patients admitted in three Italian hospitals. Outcome according to the use of prophylactic (4000 IU) vs. higher (> 4000 IU) daily dosage of enoxaparin was evaluated. The primary end-point was in-hospital death. Secondary outcome measures were in-hospital cardiovascular death, venous thromboembolism, new-onset acute respiratory distress syndrome (ARDS) and mechanical ventilation. A total of 287 patients (65.8%) were treated with the prophylactic enoxaparin regimen and 149 (34.2%) with a higher dosing regimen. The use of prophylactic enoxaparin dose was associated with a similar incidence of all-cause mortality (25.4% vs. 26.9% with the higher dose; OR at multivariable analysis, including the propensity score: 0.847, 95% CI 0.400-0.1.792; p = 0.664). In the prophylactic dose group, a significantly lower incidence of cardiovascular death (OR 0.165), venous thromboembolism (OR 0.067), new-onset ARDS (OR 0.454) and mechanical intubation (OR 0.150) was observed. In patients hospitalized for COVID-19, the use of a prophylactic dosage of enoxaparin appears to be associated with similar in-hospital overall mortality compared to higher doses. These findings require confirmation in a randomized, controlled study.

The 'dreaded PFO': anatomical and functional features of high risk for stroke.

Patent foramen ovale (PFO) has a high prevalence in general population and can be implicated in cryptogenic stroke among young people. Recent trials have shown that transcatheter PFO closure is superior to medical treatment in the secondary prevention of ischaemic stroke. The benefit in the reduction of stroke recurrence is particularly evident in patients who have documentation of a PFO with high-risk characteristics. Therefore, after the assessment of a clear causal relationship with the event, a thoughtful documentation of anatomic (height, length, presence of an aneurysmatic or a floppy atrial septum, a prominent Eustachian valve or Chiari's network, an acute angle with the inferior vena cava) and functional high-risk characteristics is mandatory.

Mitochondrial Dysfunction and Heart Disease: Critical Appraisal of an Overlooked Association.

The myocardium is among the most energy-consuming tissues in the body, burning from 6 to 30 kg of ATP per day within the mitochondria, the so-called powerhouse of the cardiomyocyte. Although mitochondrial genetic disorders account for a small portion of cardiomyopathies, mitochondrial dysfunction is commonly involved in a broad spectrum of heart diseases, and it has been implicated in the development of heart failure via maladaptive circuits producing and perpetuating mitochondrial stress and energy starvation. In this bench-to-bedside review, we aimed to (i) describe the key functions of the mitochondria within the myocardium, including their role in ischemia/reperfusion injury and intracellular calcium homeostasis; (ii) examine the contribution of mitochondrial dysfunction to multiple cardiac disease phenotypes and their transition to heart failure; and (iii) discuss the rationale and current evidence for targeting mitochondrial function for the treatment of heart failure, including via sodium-glucose cotransporter 2 inhibitors.

Cardiovascular magnetic resonance reference values of mitral and tricuspid annular dimensions: the UK Biobank cohort.

BACKGROUND: Mitral valve (MV) and tricuspid valve (TV) apparatus geometry are essential to define mechanisms and etiologies of regurgitation and to inform surgical or transcatheter interventions. Given the increasing use of cardiovascular magnetic resonance (CMR) for the evaluation of valvular heart disease, we aimed to establish CMR-derived age- and sex-specific reference values for mitral annular (MA) and tricuspid annular (TA) dimensions and tethering indices derived from truly healthy Caucasian adults. METHODS: 5065 consecutive UK Biobank participants underwent CMR using cine balanced steady-state free precession imaging at 1.5 T. Participants with non-Caucasian ethnicity, prevalent cardiovascular disease and other conditions known to affect cardiac chamber size and function were excluded. Absolute and indexed reference ranges for MA and TA diameters and tethering indices were stratified by gender and age (45-54, 55-64, 65-74 years). RESULTS: Overall, 721 (14.2%) truly healthy participants aged 45-74 years (54% women) formed the reference cohort. Absolute MA and TA diameters, MV tenting length and MV tenting area, were significantly larger in men. Mean ± standard deviation (SD) end-diastolic and end-systolic MA diameters in the 3-chamber view (anteroposterior diameter) were 2.9 ± 0.4 cm (1.5 ± 0.2 cm/m2) and 3.3 ± 0.4 cm (1.7 ± 0.2 cm/m2) in men, and 2.6 ± 0.4 cm (1.6 ± 0.2 cm/m2) and 3.0 ± 0.4 cm (1.8 ± 0.2 cm/m2) in women, respectively. Mean ± SD end-diastolic and end-systolic TA diameters in the 4-chamber view were 3.2 ± 0.5 cm (1.6 ± 0.3 cm/m2) and 3.2 ± 0.5 cm (1.7 ± 0.3 cm/m2) in men, and 2.9 ± 0.4 cm (1.7 ± 0.2 cm/m2) and 2.8 ± 0.4 cm (1.7 ± 0.3 cm/m2) in women, respectively. With advancing age, end-diastolic TA diameter became larger and posterior MV leaflet angle smaller in both sexes. Reproducibility of measurements was good to excellent with an inter-rater intraclass correlation coefficient (ICC) between 0.92 and 0.98 and an intra-rater ICC between 0.90 and 0.97. CONCLUSIONS: We described age- and sex-specific reference ranges of MA and TA dimensions and tethering indices in the largest validated healthy Caucasian population. Reference ranges presented in this study may help to improve the distinction between normal and pathological states, prompting the identification of subjects that may benefit from advanced cardiac imaging for annular sizing and planning of valvular interventions.

Quarantine during COVID-19 outbreak: Changes in diet and physical activity increase the risk of cardiovascular disease.

AIMS: CoV-19/SARS-CoV-2 is a highly pathogenic virus that is causing a global pandemic with a high number of deaths and infected people. To contain the diffusion of infection, several governments have enforced restrictions on outdoor activities or even collective quarantine on the population. The present commentary briefly analyzes the effects of quarantine on lifestyle, including nutrition and physical activity and the impact of new technologies in dealing with this situation. DATA SYNTHESIS: Quarantine is associated with stress and depression leading to unhealthy diet and reduced physical activity. A diet poor in fruit and vegetables is frequent during isolation, with a consequent low intake of antioxidants and vitamins. However, vitamins have recently been identified as a principal weapon in the fight against the Cov-19 virus. Some reports suggest that Vitamin D could exert a protective effect on such infection. During quarantine, strategies to further increase home-based physical activity and to encourage adherence to a healthy diet should be implemented. The WHO has just released guidance for people in self-quarantine, those without any symptoms or diagnosis of acute respiratory illness, which provides practical advice on how to stay active and reduce sedentary behavior while at home. CONCLUSION: Quarantine carries some long-term effects on cardiovascular disease, mainly related to unhealthy lifestyle and anxiety. Following quarantine, a global action supporting healthy diet and physical activity is mandatory to encourage people to return to a good lifestyle routine.

Late tricuspid regurgitation and right ventricular remodeling after tricuspid annuloplasty.

BACKGROUND: The aim of the present retrospective study was to evaluate the influence of preoperative right ventricular (RV) and tricuspid valve (TV) remodeling on the fate of tricuspid annuloplasty (TA) and right ventricle. METHODS: From May 2009 to December 2015, 423 patients who had undergone TA for functional tricuspid regurgitation (TR) were included in the study. Residual and recurrent TR were defined as moderate or more TR at discharge and follow-up, respectively. RV remodeling was defined as RV dysfunction and/or dilation. RESULTS: Residual TR after TA was recorded in 54 patients (13%). Five-year freedom from TR recurrence was 81% ± 3% in patients without residual TR and 41 ± 8 in patients with residual TR (P < .001). In patients without residual TR, the following risk factors for recurrent TR and late RV remodeling were identified: preoperative systolic pulmonary artery pressure, preoperative RV remodeling, severe preoperative TR or less than severe TR but with TV apparatus remodeling, and etiology of mitral regurgitation. Cox analysis with time-dependent variables confirmed TR recurrence (hazard ratio [HR]: 3.1) and late RV remodeling (HR: 6.5) as risk factors for lower survival. No protective effect of either flexible band or rigid ring TA compared with DeVega procedure was found. Similarly, preoperative atrial fibrillation and pacemaker dependency, late failure of mitral valve surgery did not affect the fate of TR. CONCLUSIONS: Prophylactic TA should be encouraged among surgeons. TA at the time of left-sided valve surgery should take into consideration not only annular size, but also tethering severity and RV remodeling.

Analysis of Risk Factors Independently Associated with Cognitive Impairment in Patients with Permanent Atrial Fibrillation: A Cross-sectional Observational Study.

BACKGROUND AND OBJECTIVE: Atrial Fibrillation (AF) is associated with an increased risk of stroke and development of cognitive impairment. Our cross-sectional study aims to identify risk factors for cognitive impairment in patients with permanent AF. MATERIALS AND METHODS: 212 consecutive outpatients with history of permanent AF lasting more than 1 year were enrolled and the Short Portable Mental Status Questionnaire (SPMSQ) was used to assess cognitive impairment (number of errors ≥5). The type of antithrombotic therapy, the time in therapeutic range (TTR) in case of treatment with warfarin and the degree of heart rate (HR) control (upon Holter ECG monitoring) were also assessed. RESULTS: ROC curve analysis indicated that TTR was associated with cognitive impairment (AUC 0.85 ± 0.03; 95% CI 0.77-0.88; p < 0.0001). Multivariate logistic regression analysis showed an independent association of previous cerebrovascular or cardiovascular events (OR 7.24, 95% CI 1.37-38.25; p = 0.020), aspirin therapy instead of anticoagulant therapy (OR 24.74, 95% CI 1.27-482.12; p = 0.034), warfarin use with TTR ≤60% (OR 21.71 , 95%CI 4.35-108; p < 0.001) and an average daily HR either <60 bpm or >100 bpm (OR 6.04, 95% 1.09-33.29; p = 0.039) with cognitive impairment. CONCLUSION: Among patients with permanent AF, cognitive impairment is more frequent in those with inadequate antithrombotic therapy (aspirin therapy instead of anticoagulant therapy) and with suboptimal oral anticoagulation (TTR ≤60%) or heart rate control. Efforts should be made to optimize therapies related to these parameters.

Multi-Site Photoplethysmographic and Electrocardiographic System for Arterial Stiffness and Cardiovascular Status Assessment.

The development and validation of a system for multi-site photoplethysmography (PPG) and electrocardiography (ECG) is presented. The system could acquire signals from 8 PPG probes and 10 ECG leads. Each PPG probe was constituted of a light-emitting diode (LED) source at a wavelength of 940 nm and a silicon photomultiplier (SiPM) detector, located in a back-reflection recording configuration. In order to ensure proper optode-to-skin coupling, the probe was equipped with insufflating cuffs. The high number of PPG probes allowed us to simultaneously acquire signals from multiple body locations. The ECG provided a reference for single-pulse PPG evaluation and averaging, allowing the extraction of indices of cardiovascular status with a high signal-to-noise ratio. Firstly, the system was characterized on optical phantoms. Furthermore, in vivo validation was performed by estimating the brachial-ankle pulse wave velocity (baPWV), a metric associated with cardiovascular status. The validation was performed on healthy volunteers to assess the baPWV intra- and extra-operator repeatability and its association with age. Finally, the baPWV, evaluated via the developed instrumentation, was compared to that estimated with a commercial system used in clinical practice (Enverdis Vascular Explorer). The validation demonstrated the system's reliability and its effectiveness in assessing the cardiovascular status in arterial ageing.

Prognostic significance of noncardiac syncope in the general population: A systematic review and meta-analysis.

INTRODUCTION: Cardiac syncope heralds significantly higher mortality compared with syncope due to noncardiac causes or unknown etiology, commonly considered a benign event. A few epidemiologic studies have examined the outcome of noncardiac/unexplained syncope comparing individuals with and without syncope, but with controversial results. We performed a systematic review and meta-analysis to clarify whether history of noncardiac/unexplained syncope is associated with increased all-cause mortality in the general population. METHODS AND RESULTS: Our systematic review of the literature published between January 1, 1966, and March 31, 2018 sought prospective, observational, cohort studies reporting summary-level outcome data about all-cause mortality in subjects with history of noncardiac/unexplained syncope compared with syncope-free participants. Adjusted hazard ratios were pooled through inverse variance random-effect meta-analysis to compute the summary effect size. Meta-regression models were performed to explore the effect of age, cardiovascular risk factors, or other potential confounders on the measured effect size. We identified four studies including 287 382 individuals (51.6% men; age, 64 ± 12 years): 38 843 with history of noncardiac/unexplained syncope and 248 539 without history of syncope. The average follow-up was 4.4 years. History of noncardiac/unexplained syncope was associated with higher all-cause mortality (pooled adjusted hazard ratio = 1.13; 95% confidence interval, 1.05 to 1.23). Meta-regression analysis showed a stronger positive relationship proportional to aging and increasing prevalence of diabetes and hypertension. CONCLUSIONS: This study-level meta-analysis showed that among older, diabetic and/or hypertensive individuals, history of noncardiac/unexplained syncope, even in the absence of an obvious cardiac etiology, is associated with higher all-cause mortality.

Walking training and cortisol to DHEA-S ratio in postmenopause: An intervention study.

The literature indicates that the plasma cortisol-to-dehydroepiandrosterone-sulfate (DHEA-S) ratio is a marker of health status after menopause, when a decline in both estrogen and DHEA-S and an increase in cortisol occur. An increase in the cortisol-to-DHEA-S ratio has been positively correlated with metabolic syndrome, all-cause mortality, cancer, and other diseases. The aim of this study was to investigate the effects of a walking program on the plasma cortisol-to-DHEA-S ratio in postmenopausal women. Fifty-one postmenopausal women participated in a 13-week supervised walking program, in the metropolitan area of Pescara (Italy), from June to September 2013. Participants were evaluated in April-May and September-October of the same year. The linear mixed model showed that the variation of the log10Cortisol-to-log10DHEA-S ratio was associated with the volume of exercise (p = .03). Participants having lower adherence to the walking program did not have a significantly modified log10Cortisol or log10DHEA-S, while those having the highest adherence had a significant reduction in log10Cortisol (p = .016) and a nearly significant increase in log10DHEA-S (p = .084). Walking training appeared to reduce the plasma log10Cortisol-to-log10DHEA-S ratio, although a minimum level of training was necessary to achieve this significant reduction.

Grading of aortic stenosis severity: a head-to-head comparison between cardiac magnetic resonance imaging and echocardiography.

AIM: To prospectively evaluate the accuracy of cardiac magnetic resonance (cMR) imaging for the assessment of aortic valve effective orifice area (EOA) by continuity equation and anatomical aortic valve area (AVA) by direct planimetry, as compared with transthoracic (TTE) and transesophageal (TEE) two-dimensional (2D) echocardiography, respectively. METHODS AND RESULTS: A total of 31 patients (21 men, 10 women, mean age 69 ± 10 years) with moderate-to-severe aortic stenosis (AS) diagnosed by TTE and scheduled for elective aortic valve replacement, underwent both cMR and TEE. AVA by cMR was obtained from balanced steady-state free-precession cine-images. EOA was computed from phase-contrast MR flow analysis. AVA at cMR (0.93 ± 0.42 cm2) was highly correlated with TEE-derived planimetry (0.92 ± 0.32 cm2) (concordance correlation coefficient, CCC = 0.85). By excluding 11 patients with extensively thickened and heavily calcified cusps, the CCC increased to 0.93. EOA at cMR (0.86 ± 0.30 cm2) showed a strong correlation with TTE-derived EOA (0.78 ± 0.25 cm2) (CCC = 0.82). CONCLUSIONS: cMR imaging is an accurate alternative for the grading of AS severity. Its use may be recommended especially in patients with poor transthoracic acoustic windows and/or in case of discordance between 2D echocardiographic parameters.