Echocardiography in the Diagnosis of Cardiomyopathies: Current Status and Future Directions.

Cardiomyopathies are a challenging pathology and echocardiography is essential for diagnosis and prognosis. The most frequent cardiomyopathies are the dilated cardiomyopathy (DCM) and the hypertrophic cardiomyopathy (HCM), followed by the less frequent restrictive (RCM) and arrhythmogenic right ventricle cardiomyopathies (ARVC). Echocardiography can identify diagnostic features, and guide further testing for a definitive diagnosis. Echographic parameters are involved in risk score computing and prognosis assessment. While the most prevalent hallmark of HCM is the asymmetric left ventricular hypertrophy and systolic anterior motion of the mitral valve with the obstructive phenotype, DCM shows dilated left ventricle with different degrees of systolic dysfunction, and RCM is usually characterized by undilated ventricles associated with atrial enlargement. The aim of this review is to display and compare the most frequent cardiomyopathies encountered in clinical practice and highlight their most characteristic features in a useful way for the practicing clinician.

Early Echocardiographic Predictors for Atrial Fibrillation Propensity: The Left Atrium Oracle.

Atrial fibrillation (AF) results from structural and electrical remodeling of the atria, primarily of the left atrium (LA); therefore, LA changes, both anatomical and functional are recognized as proarrhythmic markers with a powerful prognostic value. Being widely available and noninvasive, echocardiography is used to monitor LA form and function in clinical practice. Early functional (electrical) remodeling of the LA precedes anatomical alterations. Impaired LA functions and reduced atrial compliance due to atrial fibrosis may be evaluated using novel echocardiographic techniques, such as tissue Doppler analysis and speckle tracking. Functional evaluation of the LA conveys prognostic information about the risk of AF, as the severity of the impairment is an independent predictor of new-onset AF and AF recurrence. However, specific parameters are still investigated for incorporation into algorithms to predict future AF occurrence. The aim of the review is to summarize echocardiographic parameters, their predicting value and applicability in practice.

Inflammation as A Precursor of Atherothrombosis, Diabetes and Early Vascular Aging.

Vascular disease was for a long time considered a disease of the old age, but it is becoming increasingly clear that a cumulus of factors can cause early vascular aging (EVA). Inflammation plays a key role in vascular stiffening and also in other pathologies that induce vascular damage. There is a known and confirmed connection between inflammation and atherosclerosis. However, it has taken a long time to prove the beneficial effects of anti-inflammatory drugs on cardiovascular events. Diabetes can be both a product of inflammation and a cofactor implicated in the progression of vascular disease. When diabetes and inflammation are accompanied by obesity, this ominous trifecta leads to an increased incidence of atherothrombotic events. Research into earlier stages of vascular disease, and documentation of vulnerability to premature vascular disease, might be the key to success in preventing clinical events. Modulation of inflammation, combined with strict control of classical cardiovascular risk factors, seems to be the winning recipe. Identification of population subsets with a successful vascular aging (supernormal vascular aging-SUPERNOVA) pattern could also bring forth novel therapeutic interventions.

Phenotyping the Prediabetic Population-A Closer Look at Intermediate Glucose Status and Cardiovascular Disease.

Even though the new thresholds for defining prediabetes have been around for more than ten years, there is still controversy surrounding the precise characterization of this intermediate glucose metabolism status. The risk of developing diabetes and macro and microvascular disease linked to prediabetes is well known. Still, the prediabetic population is far from being homogenous, and phenotyping it into less heterogeneous groups might prove useful for long-term risk assessment, follow-up, and primary prevention. Unfortunately, the current definition of prediabetes is quite rigid and disregards the underlying pathophysiologic mechanisms and their potential metabolic progression towards overt disease. In addition, prediabetes is commonly associated with a cluster of risk factors that worsen the prognosis. These risk factors all revolve around a common denominator: inflammation. This review focuses on identifying the population that needs to be screened for prediabetes and the already declared prediabetic patients who are at a higher risk of cardiovascular disease and require closer monitoring.

The E/e' Ratio-Role in Risk Stratification of Acute Heart Failure with Preserved Ejection Fraction.

Background and Objectives: Heart failure with preserved ejection fraction (HFpEF) remains a worldwide management problem. Although there is a general effort for characterizing this population, few studies have assessed the predictive value of the echocardiographic E/e' ratio in patients with acute HFpEF. The aim of the study was to identify groups with different prognosis in patients hospitalized with a first acute episode of HFpEF. Materials and Methods: The primary endpoint of the study was heart failure readmissions (HFR) at 6 months, while the secondary outcome was six-month mortality. We consecutively enrolled 91 patients hospitalized for the first time with acute HFpEF. We examined the E/e' ratio as an independent predictor for HFR using univariate regression. Results: We identified and validated the E/e' ratio as an independent predictor for HFR. An E/e' ratio threshold value of 13.80 was calculated [(area under the receiver operating characteristic curve (AUROC) = 0.693, sensitivity = 78.60%, specificity = 55%, p < 0.004)] and validated as an inflection point for an increased number of HFR. Thus, we divided the study cohort into two groups: group 1 with an E/e' ratio < 13.80 (n = 39) and group 2 with an E/e' ratio > 13.80 (n = 49). Compared to group 1, group 2 had an increased number of HFR (p = 0.003) and a shorter time to first HFR (p = 0.002). However, this parameter did not influence all-cause mortality within six months (p = 0.84). Conclusions: The dimensionless E/e' ratio is a useful discriminator between patients with acute HFpEF. An E/e' value over 13.80 represents a simple, yet effective instrument for assessing the HFR risk. However, all-cause mortality at six months is not influenced by the E/e' ratio.

Value of ejection fraction/velocity ratio in the prognostic stratification of patients with asymptomatic aortic valve stenosis.

BACKGROUND: The ejection fraction/velocity ratio (EFVR) is a simple function-corrected index of aortic stenosis severity with a good correlation with aortic valve area measured using the Gorlin formula at cardiac catheterization. It is calculated by dividing left ventricular ejection fraction (LVEF) to 4 × (peak jet velocity)2 . OBJECTIVE: Our aim was to evaluate the value of EFVR in predicting adverse events in patients with asymptomatic aortic stenosis. METHODS: We analyzed the clinical and echocardiographic data of 216 asymptomatic patients with at least moderate aortic stenosis (AVA ≤ 1.5 cm2 ). The primary end-point was cardiovascular death or aortic valve replacement. RESULTS: There were 119 (55%) men and mean age was 68 ± 10 years. The mean follow-up time was 4.2 ± 1.6 years (median 4.3 years). During follow-up, the composite end-point of death or aortic valve replacement was reached in 105 patients (49%). Using multivariate Cox regression analysis, EFVR and valvulo-arterial impedance emerged as independent variables associated with outcome (P < 0.001 and P = 0.001, respectively). In the subgroup of patients with severe aortic stenosis (AVA < 1 cm2 ), EFVR ≤ 0.9 was associated with an increased hazard ratio for the composite end-point of mortality and aortic valve replacement (HR 2.14, 95% CI: 1.15-4.0, P = 0.017), even after adjusting for aortic valve area. CONCLUSIONS: In patients with asymptomatic moderate to severe aortic stenosis, EFVR is useful for risk stratification. Our results suggest that incorporating EFVR in the evaluation of patients with asymptomatic aortic stenosis might help identify those who are most likely to benefit from early elective aortic replacement.

Impact of associated significant aortic regurgitation on left ventricular remodeling and hemodynamic impairment in severe aortic valve stenosis.

OBJECTIVES: The left ventricular (LV) response to combined pressure and volume overload [aortic stenosis (AS) and aortic regurgitation (AR)] versus pressure overload (isolated AS)has not been systematically studied. We aimed to assess LV remodeling, functional and hemodynamic consequences inpatients with mixed aortic valve disease versus patients with isolated AS. METHODS: We enrolled 181 patients (67 ± 9 years,109 men) with severe AS (aortic valve area indexed to body surface area <0.6 cm 2 /m 2 ) who underwent preoperative cardiac catheterization and a complete echocardiogram. Pulmonary capillary wedge pressure (PCWP), LV end-diastolic pressure (LVEDP) and pulmonary artery pressure (PAP) were measured. RESULTS: One hundred and ten patients (group A)had isolated severe AS (AR 0­1) and 71 patients (group B)had mixed aortic valve disease (severe AS plus AR 2­3). Patients in group B were younger and in a higher New York Heart Association class (p < 0.01). Severity of AS was similar in both groups. Patients in group B had a higher indexed LV mass, a lower LV ejection fraction, and higher PCWP, LVED Pand PAP (all p ≤ 0.01). CONCLUSIONS: Patients with severe AS and significant AR are more symptomatic than patients with isolated severe AS. The increased burden due to the combined lesion induces pronounced LV remodeling and more severe hemodynamic consequences.

B-Type Natriuretic Peptide at Admission Is a Predictor of All-Cause Mortality at One Year after the First Acute Episode of New-Onset Heart Failure with Preserved Ejection Fraction.

Background: Heart failure with preserved ejection fraction (HFpEF) has been assessed extensively, but few studies analysed the predictive value of the NT-proBNP in patients with de novo and acute HFpEF. We sought to identify NT-proBNP at admission as a predictor for all-cause mortality and rehospitalisation at 12 months in patients with new-onset HFpEF. Methods: We analysed 91 patients (73 ± 11 years, 68% females) admitted for de novo and acute HFpEF, using the Cox proportional hazard risk model. Results: An admission NT-proBNP level above the threshold of 2910 pg/mL identified increased all-cause mortality at 12 months (AUC = 0.72, sensitivity = 92%, specificity = 53%, p < 0.001). All-cause mortality adjusted for age, gender, medical history, and medication in the augmented NT-proBNP group was 16-fold higher (p = 0.018), but with no difference in rehospitalisation rates (p = 0.391). The predictors of increased NT-proBNP ≥ 2910 pg/mL were: age (p = 0.016), estimated glomerular filtration rate (p = 0.006), left atrial volume index (p = 0.001), history of atrial fibrillation (p = 0.006), and TAPSE (p = 0.009). Conclusions: NT-proBNP above 2910 pg/mL at admission for de novo and acute HFpEF predicted a 16-fold increased mortality at 12 months, whereas values less than 2910 pg/mL forecast a high likelihood of survival (99.3%) in the next 12 months, and should be considered as a useful prognostic tool, in addition to its utility in diagnosing heart failure.

A Practical Risk Score for Prediction of Early Readmission after a First Episode of Acute Heart Failure with Preserved Ejection Fraction.

BACKGROUND: The first admission for acute heart failure with preserved ejection fraction (HFpEF) drastically influences the short-term prognosis. Baseline characteristics may predict repeat hospitalization or death in these patients. METHODS: A 103 patient-cohort, admitted for the first acute HFpEF episode, was monitored for six months. Baseline characteristics were recorded and their relation to the primary outcome of heart failure readmission (HFR) and secondary outcome of all-cause mortality was assessed. RESULTS: We identified six independent determinants for HFR: estimated glomerular filtration rate (eGFR) (p = 0.07), hemoglobin (p = 0.04), left ventricle end-diastolic diameter (LVEDD) (p = 0.07), E/e' ratio (p = 0.004), left ventricle outflow tract velocity-time integral (LVOT VTI) (p = 0.045), and diabetes mellitus (p = 0.06). Three of the variables were used to generate a risk score for HFR: LVEDD, E/e', LVOT VTI -DEI Score = - 28.763 + 4.558 × log (LVEDD (mm)) + 1.961 × log (E/e' ratio) + 1.759 × log (LVOT VTI (cm)). Our model predicts a relative amount of 20.50% of HFR during the first 6 months after the first acute hospitalization within the general population with HFpEF with a DEI Score over -0.747. CONCLUSIONS: We have identified three echocardiographic parameters (LVEDD, E/e', and LVOT VTI) that predict HFR following an initial acute HFpEF hospitalization. The prognostic DEI score demonstrated good accuracy.

Type I Kounis Syndrome after Protracted Anaphylaxis and Myocardial Bridge-Brief Literature Review and Case Report.

The term allergic angina, introduced for the first time by Nicholas Kounis in 1991, initially referred to the coexistence of acute coronary syndromes with allergy or hypersensitivity. At present, it is believed that Kounis syndrome is a particular case of systemic disease, with multiorgan arterial involvement generated during immediate hypersensitivity reactions. Myocardial bridging (MB), a condition that can induce coronary artery spasm, has long been regarded as a benign condition. Since both pathologies are associated with arterial spasm, Kounis syndrome and MB are considered to be confounding pathologies for acute coronary syndromes, and their association is quite a rare finding. To date, there are no precise data on the epidemiology, and the population affected by Kounis syndrome seems to be highly heterogeneous. Since this is a rare disease, even less is known about possible different phenotypes, including MB overlap. We report a case of type I variant Kounis syndrome associated with MB with no evidence of coronary artery disease, occurring as late presentation, following a severe systemic reaction (anaphylaxis) induced by a Hymenoptera sting. At present, only two other cases of type I and one case of type II Kounis syndrome occurring in patients with myocardial bridging have been described.

Obesity, Cardiac Remodeling, and Metabolic Profile: Validation of a New Simple Index beyond Body Mass Index.

AIM: The body mass index (BMI), the most used anthropometric index of obesity, has an important limitation, not taking into consideration the distribution of body fat. We developed a new simple index: the waist-corrected BMI (wBMI), calculated as waist circumference (WC) × BMI. The study aim was to assess the role of wBMI, compared to BMI, WC, and Waist-to-Height Ratio (WHtR) in predicting abnormal cardiac geometry, insulin resistance, increased arterial stiffness, and dyslipidemia. METHODS: This was a cross-sectional study that included 805 patients referred to our Department of Preventive Cardiology for risk factors evaluation and treatment. Eleven echographic and laboratory parameters were determined, and receiver operating characteristic (ROC) curves were derived. Areas under ROC curves (AUC) were used to assess the accuracy of the four indexes to identify unfavorable characteristics. RESULTS: There were 29% overweight, 59% obese, and 77% hypertensive patients. Of 11 echographic and laboratory parameters, wBMI, BMI, WHtR, and WC had the largest AUC for identifying 3, 1, 6, and 1 parameters, respectively, but with overlapping 95% confidence intervals. wBMI had the largest AUC for increased arterial stiffness and insulin resistance; also, it was superior to BMI for increased left atrial volume, relative wall thickness, and triglyceride level. CONCLUSIONS: In a large population with a high prevalence of obesity and hypertension, all four indexes were associated with unfavorable characteristics. wBMI has the theoretical advantage of taking into account simultaneously the global fat mass and distribution and might be useful for a better cardiovascular risk assessment.

Prognostic value of ventricular-arterial coupling and B-type natriuretic peptide in patients after myocardial infarction: a five-year follow-up study.

BACKGROUND: The aim of this study was to determine the prognostic role of ventricular-arterial coupling compared with B-type natriuretic peptide (BNP) in patients after myocardial infarctions. METHODS: Forty-one consecutive patients with history of myocardial infarctions were enrolled. Ventricular-arterial coupling was assessed as the ratio between arterial elastance (E(a)) and end-systolic ventricular elastance (E(es)). E(a) and E(es) were calculated using systolic and diastolic blood pressure, echocardiographically derived stroke volume, left ventricular ejection fraction, and the ratio between aortic preejection time and total systolic time. Cardiovascular mortality was the prespecified endpoint, with 5-year follow-up. RESULTS: BNP was significantly correlated with New York Heart Association class and known echocardiographic parameters of systolic and diastolic left ventricular function and also with the E(a)/E(es) ratio (P = .001), which emerged as an independent correlate of BNP in multivariate analysis. The E(a)/E(es) ratio demonstrated good accuracy in predicting long-term cardiovascular mortality (area under the receiver operating characteristic curve, 0.73; P = .019), comparable with that of BNP in patients after myocardial infarctions. CONCLUSION: Ventricular-arterial coupling assessed using the E(a)/E(es) ratio is an independent echocardiographic correlate of BNP levels in patients with previous myocardial infarctions and has a significant role in predicting long-term cardiovascular mortality in this setting.