Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review.

BACKGROUND: Acute myocarditis represents a challenging diagnosis as there is no pathognomonic clinical presentation. In patients with myocarditis, electrocardiogram (ECG) can display a variety of non-specific abnormalities. Nevertheless, ECG is widely used as an initial screening tool for myocarditis. METHODS: We researched all possible ECG alterations during acute myocarditis evaluating prevalence, physiopathology, correlation with clinical presentation patterns, role in differential diagnosis, and prognostic yield. RESULTS: The most common ECG abnormality in myocarditis is sinus tachycardia associated with nonspecific ST/T-wave changes. The presence of PR segment depression both in precordial and limb leads, a PR segment depression in leads with ST segment elevation, a PR segment elevation in aVR lead or a ST elevation with pericarditis pattern favor generally diagnosis of perimyocarditis rather than myocardial infarction. In patients with acute myocarditis, features associated with a poorer prognosis are: pathological Q wave, wide QRS complex, QRS/T angle ≥ 100°, prolonged QT interval, high-degree atrioventricular block and malignant ventricular tachyarrhythmia. On the contrary, ST elevation with a typical early repolarization pattern is associated with a better prognosis. CONCLUSIONS: ECG alterations in acute myocarditis could be very useful in clinical practice for a patient-tailored approach in order to decide appropriate therapy, length of hospitalization, and frequency of followup.

Relationship between HRV measurements and demographic and clinical variables in a population of patients with atrial fibrillation.

Little is known about the role of HRV in atrial fibrillation (AF) patients. Aim of our study was to assess the relationship between HRV measurements and demographic and clinical variables in a population of 274 AF patients. We selected all consecutive patients with persistent/permanent AF among whom had performed a Holter ECG in our Department from April 2010 to April 2015. Time-domain analysis of HRV was evaluated. Demographic and clinical variables were collected for each patient. At multivariable logistic regression, a higher pNN50 was associated with ACE inhibitors/ARBs (p = 0.016) and a lower pNN50 with obesity (p = 0.037) and higher heart rate (HR) (p < 0.0005). A higher RMSSD was associated with ACE inhibitors/ARBs (p = 0.001), digitalis (p < 0.0005) and beta-blockers (p = 0.002) and a lower RMSSD with a higher HR (p < 0.0005). A higher SDNNi was associated with ACE inhibitors/ARBs (p < 0.0005), digitalis (p < 0.0005) and beta-blockers (p = 0.002) and a lower SDNNi with dysthyroidism (p = 0.048) and higher HR (p < 0.0005). A higher SDANN was associated with non-dihydropyiridine calcium-channel-blockers (p = 0.002) and ACE inhibitors/ARBs (p = 0.002) and a lower SDANN with hypertension (p = 0.034), obesity (p = 0.011), stroke (p = 0.031), pneumonia (p = 0.005) and higher HR (p < 0.0005). A higher SDNN was associated with ACE inhibitors/ARBs (p < 0.0005), digitalis (p < 0.0005) and beta-blockers (p = 0.022) and a lower SDNN with obesity (p = 0.012), pneumonia (p = 0.049) and higher HR (p < 0.0005). Our study showed that, in AF patients, there is a direct relationship between some clinical variables and HRV measurements; as for patients with sinus rhythm, even in AF patients this relationship seemed to reflect the autonomic nervous system activity.

Electrocardiographic diagnosis of atrial tachycardia: classification, P-wave morphology, and differential diagnosis with other supraventricular tachycardias.

Atrial tachycardia is defined as a regular atrial activation from atrial areas with centrifugal spread, caused by enhanced automaticity, triggered activity or microreentry. New ECG classification differentiates between focal and macroreentrant atrial tachycardia. Macroreentrant atrial tachycardias include typical atrial flutter and other well characterized macroreentrant circuits in right and left atrium. Typical atrial flutter has been described as counterclockwise reentry within right atrial and it presents a characteristic ECG "sawtooth" pattern on the inferior leads. The foci responsible for focal atrial tachycardia do not occur randomly throughout the atria but tend to cluster at characteristic anatomical locations. The surface ECG is a very helpful tool in directing mapping to particular areas of interest. Atrial tachycardia should be differentiated from other supraventricular tachycardias. We propose a diagnostic algorithm in order to help the physician to discriminate among those. Holter analysis could offer further details to differentiate between atrial tachycardia and another supraventricular tachycardia. However, if the diagnosis is uncertain, it is possible to utilize vagal maneuvers or adenosine administration. In conclusion, in spite of well-known limits, a good interpretation of ECG is very important and it could help the physician to manage and to treat correctly patients with atrial tachycardia.

Autonomic dysfunction in a group of lower extremities arterial disease outpatients.

BACKGROUND: The understanding of the specific role of sympathetic neural control and dysregulation in lower extremities arterial disease (LEAD) is still very limited. Aim of our study was to investigate the autonomic profile in LEAD patients and to evaluate if the eventual autonomic alterations were more severe in patients with advanced disease. METHODS: We enrolled all consecutive outpatients with LEAD referred to our Departments between July 2012 and September 2014. They were compared to a group of matched outpatients without LEAD. All patients underwent Holter ECG monitoring. Time-domain analysis of heart rate variability (HRV) was evaluated. RESULTS: Compared to controls, patients with LEAD had a lower SDNN (P=0.007) and SDANN (P=0.003). Patients with clinically advanced LEAD had a lower SDNN (P=0.006) and SDANN (P=0.004) compared to LEAD patients with less severe disease and to those without disease. CONCLUSIONS: LEAD patients had a reduced SDNN and SDANN than patients without LEAD. Autonomic dysfunction was more significant in clinically advanced stages of disease. This association did not relate to ABI value but to clinical stage of disease.

Dual antiplatelet therapy is under-prescribed in patients with surgically treated acute myocardial infarction.

OBJECTIVES: Despite guideline recommendations, previous reports, coming mainly from outside Europe, showed low rates of prescriptions for dual antiplatelet therapy (DAPT) in patients with acute myocardial infarction (AMI) undergoing surgical revascularization. The present study assesses this issue in the era of potent P2Y12 inhibitors in Switzerland. METHODS: All patients with a diagnosis of AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry from January 2014 to December 2019 were screened; 9050 patients undergoing either percutaneous (8727, 96.5%) or surgical (323, 3.5%) revascularization were included in the analysis. RESULTS: Surgically treated patients were significantly less likely to receive DAPT at discharge (56.3% vs 96.7%; P < 0.001). Even when discharged with a prescription for DAPT, those patients were significantly less likely to receive a regimen containing a new P2Y12 inhibitor (67/182 [36.8%] vs 6945/8440 [83.2%]; P < 0.001). At multivariate analysis, surgical revascularization was independently associated with a lower likelihood of receiving a prescription for DAPT at discharge (odds ratio 0.03, 95% confidence interval 0.02-0.06). CONCLUSIONS: DAPT prescriptions for patients with AMI undergoing surgical revascularization are not in line with current guideline recommendations. Efforts are necessary to clarify the role of DAPT for secondary prevention in these patients and increase the confidence of treating physicians in guideline recommendations. CLINICAL TRIAL REGISTRATION: Acute Myocardial Infarction in Switzerland Plus Registry; registration number at ClinicalTrials.gov: NCT01305785.

Old and New Drugs for Treatment of Advanced Heart Failure.

BACKGROUND: Advanced heart failure (HF) is a progressive disease with high mortality and limited medical therapeutic options. Long-term mechanical circulatory support and heart transplantation remain goldstandard treatments for these patients; however, access to these therapies is limited by the advanced age and multiple comorbidities of affected patients, as well as by the limited number of organs available. METHODS: Traditional and new drugs available for the treatment of advanced HF have been researched. RESULTS: To date, the cornerstone for the treatment of patients with advanced HF remains water restriction, intravenous loop diuretic therapy and inotropic support. However, many patients with advanced HF experience loop diuretics resistance and alternative therapeutic strategies to overcome this problem have been developed, including sequential nephron blockade or use of the hypertonic saline solution in combination with high-doses of furosemide. As classic inotropes augment myocardial oxygen consumption, new promising drugs have been introduced, including levosimendan, istaroxime and omecamtiv mecarbil. However, pharmacological agents still remain mainly short-term or palliative options in patients with acute decompensation or excluded from mechanical therapy. CONCLUSION: Traditional drugs, especially when administered in combination, and new medicaments represent important therapeutic options in advanced HF. However, their impact on prognosis remains unclear. Large trials are necessary to clarify their therapeutic potential and prognostic role in these fragile patients.

Heart rate variability in sick sinus syndrome: does it have a diagnostic role?

BACKGROUND: Hypothesis of our study was that the irregular rhythm of sick sinus syndrome (SSS) was characterized by an augmented HRV. Objective was to assess whether SSS patients had a typical HRV profile. METHODS: We screened all 1947 consecutive Holter ECGs performed in our Units of Vascular Medicine and Internal Medicine and Cardioangiology at the University of Palermo (Italy) from April 2010 to September 2014. Among these, we selected 30 patients with ECG criteria of SSS. They were compared to 30 patients without SSS matched for age, sex and comorbidities. RESULTS: The SSS group had a lower mean heart rate (HR) (P=0.003), and a longer mean NN max-min longer (P<0.0005) compared to control group. SSS group had higher mean pNN50 (P=0.043), mean RMSSD (P=0.006), mean SDNN (P=0.021), and mean SDNNi (P=0.005) as compared with control group. Moreover, HR ≤64.5 bpm, NN max-min>1355 msec, pNN50>16.08, RMSSD>50.2, SDNN>151.94, and SDNNi>71.1 showed a predictive value for diagnosis of SSS. The positivity of all 6 variables according to the aforementioned cut-offs ensured a positive predictive value of 100% and the negativity of all 6 variables had a negative predictive value of 94% for diagnosis of SSS. Among SSS patients, we did not observe any correlation between HR and HRV variables. CONCLUSIONS: SSS patients have a HRV profile characterized by: low HR, long NN max-min interval, and elevated pNN50, RMSSD, SDNN and SDNNi values with specific diagnostic cut-offs for diagnosis of SSS. Moreover, we found the absence of correlation between HR and all time-domain HRV variables in SSS patients.

Does sympathetic overactivation feature all hypertensives? Differences of sympathovagal balance according to night/day blood pressure ratio in patients with essential hypertension.

When evaluating the 'night/day BP ratio', both hypertensives and normotensives can be arbitrarily classified into four groups: extreme dippers (ratio ⩽0.8), dippers (0.8

A re-entry tachycardia triggered by the spontaneous interruption of an atrial tachycardia.

The common atrioventricular nodal re-entry tachycardia is the most common form of paroxysmal supraventricular tachycardia. It starts frequently with a supraventricular ectopic beat that, on finding the fast pathway in refractory period, travels in the slow pathway as to appear as a prolongation of the PR interval on the ECG. In this study, we show a singular case of a common atrioventricular nodal re-entry tachycardia triggered by the spontaneous interruption of an atrial tachycardia.

QT Indexes in Cirrhotic Patients: Relationship with Clinical Variables and Potential Diagnostic Predictive Value.

BACKGROUND AND AIMS: A wide spectrum of cardiovascular changes characterizes cirrhosis, ranging from subclinical alterations to hyperkinetic syndrome. We looked for ECG markers of ventricular repolarization in a population of patients with cirrhosis in comparison to patients without cirrhosis and we investigated the relationship between these and other clinical and laboratory variables. METHODS: In 149 patients with cirrhosis and 152 controls, we measured QT maximum interval (QTmax), QT corrected interval (QTc), QT minimum interval (QTmin), QT dispersion (QTdisp), QT peak and T peak-to-end (TpTe). RESULTS: In subjects with cirrhosis, in comparison with controls, we observed a higher mean QTmax, mean QTc, mean QTmin, mean QTdisp and mean TpTe. At Cox regression analysis, diastolic blood pressure and beta-blocker treatment were significantly associated with mean QTmax, hypertension with mean QTmin and mean QTc, diastolic blood pressure, beta-blockers and ACE-inhibitors/ARBs with QT disp, and beta-blockers with TpTe. Analysis of ROC curves showed a significant area under curve towards cirrhosis diagnosis, respectively, for a cut-off value of > 400 msec of QTmax, > 360 msec of QTmin, > 450 msec of QTc, > 105 msec of TpTe and > 55 msec of QTdisp. CONCLUSIONS: Our study shows that QT indexes are altered in cirrhotic patients and have a potential diagnostic predictive value.

Peripheral frequency of CD4+ CD28- cells in acute ischemic stroke: relationship with stroke subtype and severity markers.

CD4+ CD28- T cells also called CD28 null cells have been reported as increased in the clinical setting of acute coronary syndrome. Only 2 studies previously analyzed peripheral frequency of CD28 null cells in subjects with acute ischemic stroke but, to our knowledge, peripheral frequency of CD28 null cells in each TOAST subtype of ischemic stroke has never been evaluated. We hypothesized that CD4+ cells and, in particular, the CD28 null cell subset could show a different degree of peripheral percentage in subjects with acute ischemic stroke in relation to clinical subtype and severity of ischemic stroke.The aim of our study was to analyze peripheral frequency of CD28 null cells in subjects with acute ischemic stroke in relation to TOAST diagnostic subtype, and to evaluate their relationship with scores of clinical severity of acute ischemic stroke, and their predictive role in the diagnosis of acute ischemic stroke and diagnostic subtypeWe enrolled 98 consecutive subjects admitted to our recruitment wards with a diagnosis of ischemic stroke. As controls we enrolled 66 hospitalized patients without a diagnosis of acute ischemic stroke. Peripheral frequency of CD4+ and CD28 null cells has been evaluated with a FACS Calibur flow cytometer.Subjects with acute ischemic stroke had a significantly higher peripheral frequency of CD4+ cells and CD28 null cells compared to control subjects without acute ischemic stroke. Subjects with cardioembolic stroke had a significantly higher peripheral frequency of CD4+ cells and CD28 null cells compared to subjects with other TOAST subtypes. We observed a significant relationship between CD28 null cells peripheral percentage and Scandinavian Stroke Scale and NIHSS scores. ROC curve analysis showed that CD28 null cell percentage may be useful to differentiate between stroke subtypes.These findings seem suggest a possible role for a T-cell component also in acute ischemic stroke clinical setting showing a different peripheral frequency of CD28 null cells in relation of each TOAST subtype of stroke.

Mediterranean Diet in patients with acute ischemic stroke: Relationships between Mediterranean Diet score, diagnostic subtype, and stroke severity index.

BACKGROUND: Adherence to a Mediterranean Diet appears to reduce the risk of cardiovascular disease, cancer, Alzheimer's disease, and Parkinson's disease, as well as the risk of death due to cardiovascular disease. No study has addressed the association between diagnostic subtype of stroke and its severity and adherence to a Mediterranean Diet in subjects with acute ischemic stroke. AIM: To evaluate the association between Mediterranean Diet adherence, TOAST subtype, and stroke severity by means of a retrospective study. METHODS: The type of acute ischemic stroke was classified according to the TOAST criteria. All patients admitted to our ward with acute ischemic stroke completed a 137-item validated food-frequency questionnaire adapted to the Sicilian population. A scale indicating the degree of adherence to the traditional Mediterranean Diet was used (Me-Di score: range 0-9). RESULTS: 198 subjects with acute ischemic stroke and 100 control subjects without stroke. Stroke subjects had a lower mean Mediterranean Diet score compared to 100 controls without stroke. We observed a significant positive correlation between Me-Di score and SSS score, whereas we observed a negative relationship between Me-Di score and NIHSS and Rankin scores. Subjects with atherosclerotic (LAAS) stroke subtype had a lower mean Me-Di score compared to subjects with other subtypes. Multinomial logistic regression analysis in a simple model showed a negative relationship between MeDi score and LAAS subtype vs. lacunar subtype (and LAAS vs. cardio-embolic subtype). CONCLUSIONS: Patients with lower adherence to a Mediterranean Diet are more likely to have an atherosclerotic (LAAS) stroke, a worse clinical presentation of ischemic stroke at admission and a higher Rankin score at discharge.

Immune-inflammatory markers and arterial stiffness indexes in subjects with acute ischemic stroke with and without metabolic syndrome.

OBJECTIVE: The aim of our study was to evaluate the associations between arterial stiffness indexes and immune-inflammatory markers in subjects with acute ischemic stroke with and without metabolic syndrome. MATERIALS/METHODS: We enrolled 130 patients with acute ischemic stroke and metabolic syndrome, 127 patients with acute ischemic stroke without metabolic syndrome and 120 control subjects without acute stroke. Applanation tonometry was used to record the augmentation index (Aix) and pulse wave velocity (PWV). We also evaluated plasma levels of C-reactive protein (CRP), Interleukin-1beta (IL-1ß), tumor necrosis factor-alpha (TNF-α), Interleukin-6 (IL-6) and Interleukin-10 (IL-10), E-selectin, P-selectin, intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), von Willebrand Factor (vWF) plasma levels, tissue plasminogen activator (TPA) and plasminogen activator inhibitor-1 (PAI-1). RESULTS: In subjects with acute ischemic stroke and metabolic syndrome we observed higher median plasma values of immuno-inflammatory markers. In acute ischemic stroke patients and metabolic syndrome in relation of each TOAST subtype we observed a more significant positive correlation between PWV and immuno-inflammatory markers. CONCLUSIONS: Stroke subjects with acute ischemic stroke and metabolic syndrome showed a higher degree of immuno-inflammatory and arterial stiffness indexes possibly due to metabolic background of these types of patients that trigger a more intense immune-inflammatory activation irrespective of stroke subtype, whereas being related to stroke subtype in subjects without metabolic syndrome.

Medication prescription and adherence disparities in non valvular atrial fibrillation patients: an Italian portrait from the ARAPACIS study.

Non-valvular atrial fibrillation (NVAF) represents a major health-care problem, needing an extensive and strict thrombosis prevention for stroke and cardiovascular (CV) disease risks. NVAF management guidelines recommend adequate antithrombotic and anti-atherosclerotic therapies. Medication adherence has been recognized as a pivotal element in health quality promotion and in the achievement of better clinical outcomes. We conducted a post-hoc analysis of the "Atrial fibrillation Registry for Ankle-brachial index Prevalence Assessment-Collaborative Italian Study (ARAPACIS)" with the aim of discerning differences in pharmacological management and medication adherence among NVAF Italian patients. Furthermore, data were analysed according to Italian geographical macro-regions (North, Center, South) to evaluate whether socioeconomic conditions might also influence medication adherence. Thus, we selected 1,366 NVAF patients that fulfilled the Morisky Medication Adherence Scale-4 items. Regional disparities in drug prescriptions were observed. In particular, in high-risk patients (CHA2DS2-VASc ≥2) oral anticoagulants were more prescribed in Northern and Center patients (61 and 60 %, respectively) compared to 53 % of high-risk Southern patients. Also, medication adherence showed a progressive decrease from North to South (78 vs. 60 %, p < 0.001). This disparity was independent of the number of drugs consumed for any reason, since prevalence of poly-therapy among the three macro-regions was similar. Our results show regional differences in NVAF patients' antithrombotic management and medication adherence, potentially reflecting well-known disparities in socioeconomic status among Italian regions. Future interventions promoting campaigns to global health-care education may be desirable to improve clinical outcomes in NVAF patients.

Antiplatelets in stroke prevention.

Stroke is the second cause of death worldwide and one of the leading cause of disability. Due to the high rate of recurrence, in high risk-patients (eg patients affected by atherosclerotic vascular disease), long-term antiplatelet therapy reduces the risk of vascular events such as non-fatal myocardial infarction, non-fatal stroke, or vascular death. The percentage of reduction of the events can be estimated in approximately 25%. These data justify the directions that are given to us by the current guidelines for prevention of secondary stroke, which recommend the broad use of antiplatelet therapy both for the secondary prevention of stroke in patients with a history of non-cardioembolic stroke or TIA. As for the primary prevention indications are less accurate because the absolute benefi ts of aspirin in reducing the happening of vascular events, are generally much lower than in secondary prevention. Although several trials have been investigated use of antiplatelet drugs in ischemic stroke patients, ascertaining the sure benefit, especially in secondary prevention in non-cardioembolic stroke, various issues remains unclarified, and new questions raises with the analysis of the results of available trials.

Antivitamin K drugs in stroke prevention.

Among the different subtypes of ischaemic strokes, almost 20 % are of cardiac origin. Different are the causes of cardioembolic stroke, but the most common is the atrial fibrillation, a supraventricular arrhythmia. Appropriate use of antiplatelet drugs and anticoagulants after transient ischaemic attack (TIA) or ischaemic stroke depends on whether the underlying cause is cardioembolic or of presumed arterial origin. Adequate antiplatelet therapy is recommended for secondary prevention after cerebral ischaemia of presumed arterial origin, whether for patients with TIA and ischaemic stroke of cardiac origin, mainly due to atrial fibrillation. Vitamin K antagonists (VKAs) are highly effective in preventing recurrent ischaemic stroke but have important limitations and are thus underused. Current guidelines still regard Vitamin K Antagonists at INR 2·0-3·0 to be the standard treatment after cerebral ischaemia of cardiac origin for patients who can tolerate them. In this setting antiplatelet therapy provides an alternative when oral anticoagulation is contraindicated or when patient choice or compliance limits choice of therapy, but is much less effective than VKAs. Recent trial data performed with new anticogulants such as the factor Xa and thrombin inhibitors will need to be taken into account, in order to prevent several of the clinical problems actually related to VKAs use.

Supraventricular tachycardias: proposal of a diagnostic algorithm for the narrow complex tachycardias.

The narrow complex tachycardias (NCTs) are defined by the presence in a 12-lead electrocardiogram (ECG) of a QRS complex duration less than 120ms and a heart rate greater than 100 beats per minute; those are typically of supraventricular origin, although rarely narrow complex ventricular tachycardias have been reported in the literature. As some studies document, to diagnose correctly the NCTs is an arduous exercise because sometimes those have similar presentation on the ECG. In this paper, we have reviewed the physiopathological, clinical, and ECG findings of all known supraventricular tachycardias and, in order to reduce the possible diagnostic errors on the ECG, we have proposed a quick and accurate diagnostic algorithm for the differential diagnosis of NCTs.

Arterial stiffness and ischemic stroke in subjects with and without metabolic syndrome.

We conducted a study to evaluate arterial stiffness markers in subjects with acute ischemic stroke and metabolic syndrome and in relation to TOAST subtype of stroke. We enrolled 130 patients with acute ischemic stroke and metabolic syndrome, 127 patients with acute ischemic stroke without metabolic syndrome and 120 control subjects without acute stroke. Applanation tonometry to record pulse wave velocity (PWV). Stroke patients with metabolic syndrome, compared control subjects without stroke showed higher PWV. In subjects with ischemic stroke and metabolic syndrome, PWV was more significantly and positively correlated with body mass index, systolic blood pressure, hypertension, diabetes, glucose blood levels, LDL cholesterol levels, total cholesterol levels, micro-albuminuria, carotid plaque, previous brain infarct at neuro-imaging. Our findings underline important role of both small vessel disease and atherosclerosis on arterial stiffness pathogenesis in the clinical setting of metabolic syndrome.