Prognostic Assessment of HLM Score in Heart Failure Due to Ischemic Heart Disease: A Pilot Study.

Background: Ischemic heart disease (IHD) represents the main cause of heart failure (HF). A prognostic stratification of HF patients with ischemic etiology, particularly those with acute coronary syndrome (ACS), may be challenging due the variability in clinical and hemodynamic status. The aim of this study is to assess the prognostic power of the HLM score in a population of patients with ischemic HF and in a subgroup who developed HF following ACS. Methods: This is an observational, prospective, single-center study, enrolling consecutive patients with a diagnosis of ischemic HF. Patients were stratified according to the four different HLM stages of severity, and the occurrence of CV death, HFH, and worsening HF events were evaluated at 6-month follow-up. A sub-analysis was performed on patients who developed HF following ACS at admission. Results: The study included 146 patients. HLM stage predicts the occurrence of CV death (p = 0.01) and CV death/HFH (p = 0.003). Cox regression analysis confirmed HLM stage as an independent predictor of CV death (OR: 3.07; 95% IC: 1.54-6.12; p = 0.001) and CV death/HFH (OR: 2.45; 95% IC: 1.43-4.21; p = 0.001) in the total population of patients with HF due to IHD. HLM stage potentially predicts the occurrence of CV death (p < 0.001) and CV death/HFH (p < 0.001) in patients with HF following ACS at admission. Conclusions: Pathophysiological-based prognostic assessment through HLM score is a potentially promising tool for the prediction of the occurrence of CV death and CV death/HFH in ischemic HF patients and in subgroups of patients with HF following ACS at admission.

Telemedicine: an Effective and Low-Cost Lesson From the COVID-19 Pandemic for the Management of Heart Failure Patients.

PURPOSE: The purpose of this review is to explore the benefits and controversies that telemedicine (TM), applied to patients with heart failure (HF), can provide in terms of diagnosis, therapeutic management, and prognosis improvement. During the coronavirus disease 19 (COVID-19) outbreak, TM emerged as the most effective and feasible method available to ensure continuous care for chronic diseases. Among these, HF, characterized by high mortality, morbidity, and the need for frequent visits, may benefit of the TM role. HF patients are affected by frequent exacerbations undergoing a progressive prognosis impoverishment, strongly depending on the disease's management. A precise clinical handling is always required, with a constant optimization of the therapy, a continuous control of risk factors, and a sensitive attention to any change in symptoms, clinical signs, and laboratory tests. In this context, TM has shown to improve therapy adherence and HF: patients' self-care, impacting the prognosis even if specific results are controversial. Major evidence shows that TM may allow an adequate primary prevention, reducing the impact of the main cardiovascular risk factors. TM can also be useful for the secondary prevention, early detecting a likely HF exacerbation before it becomes clinically manifest, thereby lowering the need for hospitalization. Moreover, an optimal up-titration of the therapy and an increase in treatment adherence are feasible by using TM. However, some studies did not show unambiguous results, and uncertainties still remain.

The evolving role of echocardiography in the assessment of patent foramen ovale in patients with left-side thromboembolism.

Patent foramen ovale (PFO) is the most common congenital cardiac abnormality found approximately in 25% of the adult population The pathophysiological role of paradoxical embolization through the PFO in ischemic stroke is well established. "Self-expanding double disk" and, more recently, suture-based "deviceless" systems are used for PFO closure in the setting of secondary prevention after ischemic stroke likely related to paradoxical embolization. Ultrasound plays a significant role in PFO assessment, indication to treatment, intra-procedural guidance, and follow-up for those undergoing PFO closure. Three different techniques are frequently used for these purposes: transesophageal echocardiography, transthoracic echocardiogram, and transcranial Doppler. In this review, advantages and limits of these techniques are discussed in detail to improve our skills in detection and treatment of this important condition by using ultrasound.

How to perform a cardio-thoracic magnetic resonance imaging in COVID-19: comprehensive assessment of heart, pulmonary arteries, and lung parenchyma.

We proposed a combined cardiothoracic-MRI (CaTh-MRI) protocol for the comprehensive assessment of cardiovascular structures, lung parenchyma, and pulmonary arterial tree, in COVID-19 patients with progressive worsening of clinical conditions and/or suspicion of acute-onset myocardial inflammation. A 25-minutes fast protocol was also conceived for unstable or uncooperative patients by restricting the number of sequences to those necessary to rule out myocardial and to assess pulmonary involvement. In patients requiring CMR characterization of myocardial damage, the addition of lung and thoracic vessel evaluation is of clinical benefit at a minimal time expense.

Mortality Risk Assessment Using CHA(2)DS(2)-VASc Scores in Patients Hospitalized With Coronavirus Disease 2019 Infection.

Early risk stratification for complications and death related to Coronavirus disease 2019 (COVID-19) infection is needed. Because many patients with COVID-19 who developed acute respiratory distress syndrome have diffuse alveolar inflammatory damage associated with microvessel thrombosis, we aimed to investigate a common clinical tool, the CHA(2)DS(2)-VASc, to aid in the prognostication of outcomes for COVID-19 patients. We analyzed consecutive patients from the multicenter observational CORACLE registry, which contains data of patients hospitalized for COVID-19 infection in 4 regions of Italy, according to data-driven tertiles of CHA(2)DS(2)-VASc score. The primary outcomes were inpatient death and a composite of inpatient death or invasive ventilation. Of 1045 patients in the registry, 864 (82.7%) had data available to calculate CHA(2)DS(2)-VASc score and were included in the analysis. Of these, 167 (19.3%) died, 123 (14.2%) received invasive ventilation, and 249 (28.8%) had the composite outcome. Stratification by CHA(2)DS(2)-VASc tertiles (T1: ≤1; T2: 2 to 3; T3: ≥4) revealed increases in both death (8.1%, 24.3%, 33.3%, respectively; p <0.001) and the composite end point (18.6%, 31.9%, 43.5%, respectively; p <0.001). The odds ratios for mortality and the composite end point for T2 patients versus T1 CHA(2)DS(2)-VASc score were 3.62 (95% CI:2.29 to 5.73,p <0.001) and 2.04 (95% CI:1.42 to 2.93, p <0.001), respectively. Similarly, the odds ratios for mortality and the composite end point for T3 patients versus T1 were 5.65 (95% CI:3.54 to 9.01, p <0.001) and 3.36 (95% CI:2.30 to 4.90,p <0.001), respectively. In conclusion, among Italian patients hospitalized for COVID-19 infection, the CHA(2)DS(2)-VASc risk score for thromboembolic events enhanced the ability to achieve risk stratification for complications and death.

C1-C2 X-Ray assessment of misalignment parameters in patients with Chronic Cerebra-spinal Venous Insufficiency and Multiple Sclerosis versus patients with other pathologies.

PURPOSE: The complete compression of the internal jugular veins, in front position, shows a prevalence of 48% and it is equally distributed in the various segments of these veins in patients with Chronic Cerebro-Spinal Venous Insufficiency (CCSVI) and Multiple Sclerosis (MS). The aim of this search is to identify radiological dislocation of C1-C2 as specific markers in patients with CCSVI and Multiple Sclerosis (MS). METHOD: We investigated 386 patients suffering from CCSVI and Multiple Sclerosis and a control group of 156 patients without MS. RESULTS: The assessment of Anterior Intrusion shows the following average values: in the group with CCSVI and MS: 4.29 ±1.48 mm while in the control group: 3.78 ±1.45 mm (p = 0.0008).The evaluation of the Right Laterality shows the following average values: in group with CCSVI and MS: 2.31±1.41 mm, in control group: 1.97 ±1.28 mm (p = 0.0426). We found also that a longer duration of the disease corresponds to a higher severity of the pathological condition (p <0.0001). CONCLUSION: Data analysis of C1-C2 X-Ray parameters shows statistical significance of severe anterior intrusion and right laterality misalignment in the people with CCSVI and MS, that are two to three times more frequent as compared to controls. Considering the novelty of this work and the total absence of scientific similar works able to confirm this data, it is necessary to continue these studies in order to improve the clinical management of these patients and to perform therapeutic strategies based on venous decompressive treatments both surgical that manipulatives.

Economic evaluation of levosimendan versus dobutamine for the treatment of acute heart failure in Italy.

INTRODUCTION: Inodilators are the first-choice class of drugs for the treatment of acute heart failure (AHF). Levosimendan is a relatively recent inodilatory agent, presenting superior outcomes in comparison with traditional inotropes. METHODS: An economic evaluation of levosimendan for the treatment of AHF in Italy was performed. In a retrospective study conducted on patients with AHF admitted to a teaching hospital in Rome, two groups were derived from an observational registry: 147 patients treated with levosimendan and 145 treated with dobutamine. Follow-up was at 1 year after treatment. In the reference study looked at in this paper, treatment with levosimendan reduced mean length of stay (LOS) by 1.5 days (P<0.05). Reduction in the rehospitalization rate was 6.7% (P<0.05). Mortality rate at 1 month was reduced by 4.8% (P<0.05). RESULTS: Based on the reference study, a cost analysis from the hospital perspective was carried out. The incremental cost of treatment with levosimendan (€697) was equivalent to the incremental savings (€694), the latter being obtained from the reduction in LOS (€508) and rehospitalization rate (€186). CONCLUSION: Despite the limitations of this study, and even neglecting all nonmonetary health gains as additional outcomes, levosimendan appears to be a competitive alternative compared with dobutamine for the treatment of AHF in the Italian hospital setting.

Cost-effectiveness of levosimendan in patients with acute heart failure.

Heart failure is a major public health problem because of its high prevalence and impact on mortality, morbidity, quality of life, and social costs. The aim of this analysis was to estimate the effects of the novel inodilator levosimendan versus standard inotropic therapy (ST) of dobutamine in acute heart failure. A study population of 292 patients with acute heart failure was derived from an observational registry of patients referred to our department. Of these, 147 patients received iv levosimendan (0.05-0.1 µg·kg·min for 24 hours), and 145 patients were treated with ST. Duration of hospitalization, survival at 1 month, and the rehospitalization rate during the year after the index hospitalization were evaluated. Cost-effectiveness analysis was performed. The mean length of hospitalization was 12.08 and 13.57 days in the levosimendan and ST groups, respectively (P < 0.05). Rehospitalization rates were lower in the levosimendan group at 6 months (1.44% vs. 2.3%; P < 0.05) and 12 months (7.6% vs. 14.3%; P < 0.05). Mortality rate at 1 month was 2.1% versus 6.9% in the levosimendan and ST groups, respectively (P < 0.05). The per-capita cost of treatment with levosimendan was €78.86 higher than that with ST during the first hospitalization but €280.22 lower when the rehospitalization rate was considered.

Pulmonary hypertension: echocardiographic assessment.

Pulmonary arterial hypertension (PAH) is a clinical condition characterized by elevated vascular resistance, associated with a poor prognosis and usually diagnosed in late stage. Echocardiographic assessment of PAH includes early disease detection and functional heart evaluation, in order to introduce a more accurate surveillance at an early stage of the disease and to contribute to prognostic stratification of advanced disease. Detection involves pulmonary artery systolic pressure (PASP) estimation. There is no clear consensus on defining normal distribution, but a PASP of 36 mmHg has been widely assumed as a cut-off value for mild PAH, requiring a more aggressive surveillance to detect further progression. Functional heart evaluation requires an accurate characterization of morphologic and hemodynamic changes, secondary to PAH development, which involves description of dimensional parameters, ventricular interdependency, intracardiac flow patterns, and right ventricular systolic performance. A valid assessment of these issues results in a useful evaluation of cardiac function, supporting clinical context in defining heart failure condition.

Assessment of left atrial appendage wall velocities by transesophageal tissue Doppler echocardiography: a clinical study in patients with sinus rhythm.

To assess left atrial appendage (LAA) wall velocities, 42 patients in sinus rhythm underwent tissue Doppler interrogation during a clinically indicated transesophageal echocardiography. Color Doppler (B-mode and M-mode) and pulsed Doppler of LAA walls were obtained and analyzed in all patients. Color-coded tissue Doppler rendered a qualitative assessment of LAA wall, depicting both the timing and the sequence of LAA contraction. With pulsed Doppler interrogation, a triphasic signal was recorded in all patients, consisting of a positive wave (D1), followed by a biphasic wave (positive D2 and negative D3). Peak velocities of D1, D2, and D3 were 6.1 +/- 2, 20.1 +/- 7, and 16.1 +/- 5 cm/s, respectively. Mean coefficient of variation of LAA wall velocities was 6%, significantly lower than that of LAA percentage area change (29%). Compared with patients with abnormal relaxation, patients with normal mitral inflow had higher D1 peak velocities (7.3 +/- 1.2 vs 4.3 +/- 1 cm/s, respectively; P <.0001). Time sequence of ECG, LAA flow, and mitral inflow indicates that D1 component of LAA wall occurs in early diastole and is likely due to the upward movement of the mitral ring toward the base of the LAA wall. In conclusion, evaluation of LAA wall using tissue Doppler is feasible and reproducible. Although color tissue Doppler analysis allows a qualitative assessment, pulsed Doppler gives new quantitative insights for the comprehensive assessment of LAA wall dynamics, which complements the information obtained with flow interrogation.