Echocardiographic assessment of the right ventricle in COVID -related acute respiratory syndrome.

In patients with the novel coronavirus (COVID-19) infection, the echocardiographic assessment of the right ventricle (RV) represents a pivotal element in the understanding of current disease status and in monitoring disease progression. The present manuscript is aimed at specifically describing the echocardiographic assessment of the right ventricle, mainly focusing on the most useful parameters and the time of examination. The RV direct involvement happens quite often due to preferential lung tropism of COVID-19 infection, which is responsible for an interstitial pneumonia characterized also by pulmonary hypoxic vasoconstriction (and thus an RV afterload increase), often evolving in acute respiratory distress syndrome (ARDS). The indirect RV involvement may be due to the systemic inflammatory activation, caused by COVID-19, which may affect the overall cardiovascular system mainly by inducing an increase in troponin values and in the sympathetic tone and altering the volemic status (mainly by affecting renal function). Echocardiographic parameters, specifically focused on RV (dimensions and function) and pulmonary circulation (systolic pulmonary arterial pressures, RV wall thickness), are to be measured in a COVID-19 patient with respiratory failure and ARDS. They have been selected on the basis of their feasibility (that is easy to be measured, even in short time) and usefulness for clinical monitoring. It is advisable to measure the same parameters in the single patient (based also on the availability of valid acoustic windows) which are identified in the first examination and repeated in the following ones, to guarantee a reliable monitoring. Information gained from a clinically-guided echocardiographic assessment holds a clinical utility in the single patients when integrated with biohumoral data (indicating systemic activation), blood gas analysis (reflecting COVID-19-induced lung damage) and data on ongoing therapies (in primis ventilatory settings).

Acute insulin resistance assessed by the homeostatic model assessment in acute coronary syndromes without previously known diabetes.

We assessed the incidence and the prognostic role for early death of acute insulin resistance (by means of homeostatic model assessment [HOMA] index) in 1350 patients with acute coronary syndrome (ACS) consecutively admitted to our intensive cardiac care unit (ICCU). The incidence of HOMA positivity was 5% (68 of 1350), with the highest percentage of HOMA positivity among ST-segment elevation myocardial infarction (STEMI). Patients with HOMA positivity showed a higher body mass index (P = .003), lower values of admission and discharge left-ventricular ejection fraction (LVEF; P < .001 and P = .003, respectively), and higher levels of peak troponin I (Tn I; P < .001). The HOMA index was an independent predictor of early death (odds ratio 1.724, 95% confidence interval 1.252-2.375, P = .001). In patients with ACS and without previously known diabetes, acute insulin resistance (HOMA index) is associated with a larger myocardial damage (ie, higher values of peak Tn I and lower LVEF) and a greater inflammatory activation (indicated by correlation with leukocyte count). The HOMA positivity was an independent predictor of in-ICCU mortality.

Intraaortic balloon pump: incidence and predictors of complications in the Florence registry.

BACKGROUND: The intraaortic balloon pump (IABP) is the most commonly used mechanical circulatory support for patients with acute coronary syndromes and cardiogenic shock. Nevertheless, IABP-related complications are still frequent and associated with a poor prognosis. HYPOTHESIS: To prospectively assess the incidence and predictors of complications in patients treated with IABP. METHODS: A total of 481 patients treated with IABP were prospectively enrolled in our registry (the Florence Registry). At multivariable logistic regression analysis the following variables were independent predictors for complications (when adjusted for age >75 years, eGFR and time length of IABP support): use of inotropes (OR 2.450, P < 0.017), nadir platelet count (1000/µL step; OR 0.990, P < 0.001), admission lactate (OR 1.175, P = 0.003). Nadir platelet count showed a negative correlation with length of time of IABP implantation (r-0.31; P < 0.001). A nadir platelet count cutoff value of less than 120,000 was identified using a receiver operating characteristic (ROC) curve for the development of complications (area under the curve [AUC] 0.70; P < 0.001). RESULTS: Complications were observed in the 13.1%, among whom 33 of 63 showed major bleeding. The incidence of complications was higher in patients aged >75 years (P = 0.015) and in those who had an IABP implanted for more than 24 hours (P = 0.001). Patients with complications showed an in Intensive Cardiac Care Unit (ICCU) mortality higher than patients who did not (44.4% vs 17.2%, P < 0.001). CONCLUSIONS: In consecutive patients treated with IABP support, the degree of hemodynamic impairment and the decrease in platelet count were independent predictors of complications, whose development was associated with higher in-ICCU mortality.

[Dealing with error in cardiology]. / L'errore in cardiologia.

A commonly used definition describes an error as a harmful or potentially harmful occurrence for the patient. Although over the last years the evolution of medicine has been characterized by remarkable technological advances, the percentage of errors in clinical practice has not changed since the '40s. In this setting, the aim of our review is to assess how errors develop in real life in modern cardiology and how they can be identified early, corrected, and possibly prevented. In our opinion, the more a healthcare system (i.e., a cardiology ward or a hospital) is capable of facing its error, the safer it is. In our daily practice, errors can be distinguished in "clinical errors" (mainly related to knowledge) and "system errors" (mainly referring to healthcare organization; i.e., the integrated cardiac network). Bearing in mind the high frequency and consequences, cardiologists should consider errors as among the main determinants of quality of care, which the whole team has to deal with. Time and resources should be spent to identify the best approaches to cope with errors, tailored for each cardiology team. Ultimately, the care of a patient with heart disease should be viewed holistically and not as the afinalistic sum of procedures, no matter how technically developed.

Prognostic role of insulin resistance as assessed by homeostatic model assessment index in the acute phase of myocardial infarction in nondiabetic patients submitted to percutaneous coronary intervention.

BACKGROUND AND OBJECTIVES: Little information is available on the relation between insulin resistance and acute myocardial infarction. METHODS: In 253 consecutive nondiabetic patients with ST elevation myocardial infarction (STEMI) submitted to percutaneous coronary intervention, we assessed the prevalence of insulin resistance by homeostatic model assessment (HOMA) index and its prognostic role in early and late mortality. RESULTS: Insulin resistance was detectable in 52.9% of patients. Anterior STEMI was more frequent in insulin-resistant patients (P = 0.040), who showed higher values of probrain natriuretic peptide (P = 0.010), creatinine (P < 0.001), creatinine phosphokinase and creatinine phosphokinase-MB (MB, isoenzyme present in the myocardium; P = 0.016 and P = 0.003, respectively). At backward stepwise logistic regression analysis, the following variables were independent predictors for intra-intensive cardiac care unit mortality: HOMA index [hazard ratio 1.40; 95% confidence interval (CI) 1.02-1.95; P = 0.049]; C-peptide (hazard ratio 3.14; 95% CI 1.40-24.80; P = 0.001) and lactic acid (hazard ratio 2.50; 95% CI 1.41-4.44; P = 0.002). At long-term follow-up (Cox regression analysis), neither fasting glycaemia nor HOMA index resulted in predictors for mortality. CONCLUSION: In nondiabetic STEMI patients submitted to percutaneous coronary intervention, insulin resistance, as assessed by HOMA index, is quite common and helps in the early prognostic stratification, as it represents an independent predictor of in-hospital mortality.

Simultaneous assessment of electrocardiographic parameters for risk stratification: validation in healthy subjects.

BACKGROUND: Sudden cardiac death represents a major public health problem, but in the general population the identification of those subjects at very high risk remains poor. Simultaneous multiparametric ECG analysis can improve the identification of high-risk patients. METHODS: Five-min ECG recordings at a 5 MHz sampling rate (extended length-XL-ECG, Mortara Instruments, Milwaukee, WI, USA) were acquired in 105 healthy subjects (age range 21 to 80 years), equally distributed for age decades and sex, and three additional recordings, 30 min apart, were repeated in 30 subjects on the second day. The following parameters were recorded and analyzed: the RR interval, QRS duration, QT interval corrected according to the Bazett and Fridericia formulae, QT dispersion, T wave complexity, activation-recovery interval dispersion, standard deviation of the RR intervals, filtered QRS duration, the square root of the mean voltage of the last 40 ms of the filtered QRS, and the length of time that the terminal vector magnitude complex remains < 40 microV. RESULTS: QRS duration, activation-recovery interval dispersion, and filtered QRS differed in the two sexes. The standard deviation of the RR intervals, T wave complexity and QT dispersion were significantly correlated with age. The reproducibility was good for each parameter. CONCLUSIONS: The XL-ECG allows the simultaneous calculation of eight adequately reproducible different parameters the values of which are in agreement with those of the literature. Thus, XL-ECG is a reliable time- and cost-saving tool.