Assessment of Myocardial Contractility by SonR Sensor in Patients Undergoing Cardiac Resynchronization Therapy.

BACKGROUND: SonR sensor signal correlates well with myocardial contractility expressed in terms of left ventricular (LV) dP/dt max. The aim of our study was to evaluate the changes in myocardial contractility during isometric effort in heart failure patients undergoing cardiac resynchronization therapy (CRT) with right atrial SonR sensor. METHODS: Thirty-one patients (19 men, 65 ± 7 years, LV ejection fraction [LVEF] 28% ± 5%, in sinus rhythm) were implanted with a CRT-defibrillator (CRT-D) device equipped with SonR sensor, which was programmed in VVI mode at 40 beats/min. Twenty-four hours after implantation, each patient underwent a noninvasive hemodynamic evaluation at rest and during isometric effort, including: (1) measurement of beat-to-beat endocavitary SonR signal; (2) echocardiographic assessment; and (3) continuous measurement of blood pressure with Nexfin method (BMEYE, Amsterdam, the Netherlands). The following contractility parameters were considered: (1) mean value of beat-to-beat SonR signal; (2) mean value of LV dP/dt by Nexfin system; and (3) fractional shortening (FS) by echocardiography. RESULTS: At the third minute of the isometric effort, mean value of SonR signal significantly increased from baseline (P < 0.001). Similarly, mean value of both LV dP/dt by Nexfin and FS significantly increased compared to the resting condition (P < 0.001; P < 0.001). While in 27 (88%) patients SonR signal increased at the third minute of the isometric effort, in four (12%) patients SonR signal decreased. In these patients, both LV dP/dt by Nexfin and FS consensually decreased. CONCLUSIONS: In CRT patients, SonR sensor is able to detect changes in myocardial contractility in a consensual way like noninvasive methods such as Nexfin system and echocardiography.

Autoantibodies against ß1-Adrenergic Receptors: Response to Cardiac Resynchronization Therapy and Renal Function.

BACKGROUND: Cardiac resynchronization therapy (CRT) nonresponse remains a major clinical problem. Autoantibodies specific for the ß1-adrenergic (ß1-AAbs) and muscarinic (M2-AAbs) receptors are found in patients with chronic heart failure (HF) of various etiologies. MATERIALS AND METHODS: We retrospectively analyzed 73 HF patients (median age 67 years, 84% males, New York Heart Association II-IV, in sinus rhythm, left ventricular ejection fraction <35%) who received CRT defibrillator (CRT-D) from 2010 to 2013. ß1-AAbs and M2-AAbs were measured by enzyme-linked immunosorbent assay. Echocardiography was used to assess CRT response (reduction >15% in left ventricular end-systolic volume at 6 months follow-up). Renal function (RF) parameters (creatinine [Cr], blood urea nitrogen [BUN], estimated glomerular filtration rate [eGFR Modified Diet in Renal Disease], cystatin C [Cys-C], and neutrophil gelatinase-associated lipocalin [NGAL]) were also evaluated. RESULTS: A significantly higher percentage of patients positive for ß1-AAbs (OD sample/OD reference ratio >2.1) in nonresponders than in responder patients was observed (57% vs 27%, P = 0.004). No influence of M2-AAbs on CRT-D response was demonstrated. ß1-AAbs were predictive of a poor CRT-D response (odds ratio [OR] [95% confidence interval (CI)] 3.64 [1.49-8.88], P = 0.005), also after adjustment for RF parameters (OR [95% CI] 4.95 [1.51-16.26], P = 0.008) observed to influence CRT-D response (Cr P = 0.03, BUN P = 0.009, Cys-C P = 0.02). The positive rates of ß1-AABs in patients with abnormal blood level of Cr, eGFR, Cys-C, and NGAL were significantly higher than those with normal levels (P = 0.03, P = 0.02, P = 0.001, P = 0.007, respectively). CONCLUSIONS: Our study suggests that (1) the evaluation of ß1-AAb is useful to identify responders to CRT-D; (2) the presence of ß1-AAbs is in relationship with elevated renal function parameters.

Hyperglycemia, acute insulin resistance, and renal dysfunction in the early phase of ST-elevation myocardial infarction without previously known diabetes: impact on long-term prognosis.

We evaluated the relationship between admission renal function (as assessed by estimated glomerular filtration rate (eGFR)), hyperglycemia, and acute insulin resistance, indicated by the homeostatic model assessment (HOMA) index, and their impact on long-term prognosis in 825 consecutive patients with ST-elevation myocardial infarction (STEMI) without previously known diabetes who underwent primary percutaneous coronary intervention (PCI). Admission eGFR showed a significant indirect correlation with admission glycemia (Spearman's ρ -0.23, P < 0.001) and insulin values (Spearman's ρ -0.11, P = 0.002). The incidence of patients with admission glycemia ≥140 mg/dl was significantly higher in patients with eGFR <60 ml/min/m(2) (P < 0.001) as well as the incidence of HOMA positivity (P = 0.002). According to our data, a relationship between renal function and glucose values and acute insulin resistance in the early phase of STEMI was detectable, since a significant, indirect correlation between eGFR, insulin values, and glycemia was observed. Patients with renal dysfunction (eGFR <60 ml/min/1.73 m(2)) exhibited higher glucose values and a higher incidence of acute insulin resistance (as assessed by HOMA index) than those with normal renal function (eGFR ≥60 ml/min/1.73 m(2)). The prognostic role of glucose values for 1-year mortality was confined to patients with eGFR ≥60 ml/min/m(2), who represent the large part of our population and are thought to be at lower risk. In these patients, an independent relationship between 1-year mortality and glucose values was detectable not only for admission glycemia but also for glucose values measured at discharge.

The impact of admission procalcitonin on prognosis in acute coronary syndromes: a pilot study.

BACKGROUND: Available evidence on the prognostic role of procalcitonin levels in acute coronary syndromes (ACS) is so far controversial. AIMS: To evaluate the association between procalcitonin, major cardiovascular events (MACE) and total mortality in acute coronary syndromes. METHODS: Procalcitonin levels were measured in 247 patients admitted to our Intensive Cardiac Care Unit (ICCU) with ACS. Three subgroups were considered according to procalcitonin levels. RESULTS: At Cox regression analysis, procalcitonin levels were both an unadjusted and an adjusted predictor (corrected for diagnosis and TnI) of intra-ICCU mortality and of 1-year follow-up MACE and total mortality. CONCLUSIONS: In ACS, admission procalcitonin values identify a "higher risk" group of patients for short and long-term mortality.

Discordant electrical and mechanical atrial delays affect intracavitary electrogram-based cardiac resynchronization therapy optimization.

AIMS: It has been shown that atrioventricular (AV) delay optimization improves cardiac resynchronization therapy (CRT) response. Recently, an automatic algorithm (QuickOpt™, St Jude Medical), able to quickly identify the individual optimal AV interval, has been developed. The algorithm suggests an AV delay based on atrial intracavitary electrogram (IEGM) duration. We hypothesized that the difference between electrical and mechanical atrial delays could affect the effectiveness of QuickOpt method. The aim of this study was to test this hypothesis in 23 CRT patients who were recipients of St. Jude Medical devices. METHODS AND RESULTS: Using echocardiography, aortic flow velocity time integral (VTI) was evaluated at baseline, at QuickOpt suggested AV delay and after reducing it by 25 and 50%. Mechanical inter-atrial delay (MIAD) derived from echo/Doppler and electrical inter-atrial delay (EIAD) derived from IEGM were also analysed. Optimal AV delay was identified by the maximal VTI. In 11 patients (Group 1) the maximal VTI was achieved at the AV delay suggested by the algorithm, in 6 patients (Group 2) after a 25% reduction, and in 6 patients (Group 3) after a 50% reduction. While EIAD was similar among the three groups, MIAD was significantly different (P< 0.001). MIAD was longer than EIAD in Group 1 (P= 0.028) and shorter than EIAD in Groups 2 (P= 0.028) and 3. (P< 0.001). Mechanical inter-atrial delay was the only independent predictor of the AV interval associated with the best VTI (R(2) = 0.77; P< 0.001). CONCLUSION: Our results show that MIAD plays the main role in determining the optimal AV delay, thus caution should be taken when optimizing AV by IEGM-based methods.

Microalbuminuria in non-diabetic STEMI: an independent predictor for acute kidney injury.

AIMS: To assess the impact of microalbuminuria on the development of acute kidney injury and to investigate its prognostic role at long term follow-up in 526 consecutive patients with ST elevation myocardial infarction without previously known diabetes. METHODS: Microalbuminuria was measured using immunonephelemetry in the urine collected in the night. RESULTS: Patients with microalbuminuria were older (p = 0.013). They showed higher values of peak glycemia (p = 0.017), peak Tn I (p < 0.001), NT-pro BNP (p = 0.020), ESR (p = 0.003), CRP (p = 0.020), and leukocyte count (p < 0.001). Lower eGFR was observed in patients with microalbuminuria both on admission and during ICCU stay (p = 0.048 and p = 0.003, respectively). A positive correlation was observed between CRP and microalbuminuria (Spearman's rho 0.114, p = 0.024). The composite end point was observed in 73 patients (18 patients died and 59 patients developed acute kidney injury). At multivariable regression analysis, microalbuminuria was an independent predictor of acute kidney injury. At follow-up [42.6 (25th-75th percentile, 17.5-56.8) months], Kaplan-Meier curve analysis showed that patients with microalbuminuria had a lower survival rate in respect to patients without microalbuminuria. Cox regression analysis documented that microalbuminuria was an independent predictor of long term mortality (HR: 1.089; 97% CI 1.036-1.145; p < 0.001). CONCLUSIONS: In a large series of STEMI patients without previously known diabetes submitted to PCI, microalbuminuria, as a marker of endothelial permeability following higher systemic inflammatory activation and larger infarct lesions, is an independent predictor for the development acute kidney injury. Furthermore, microalbuminuria identifies a subset of patients at higher risk for long term mortality.

Impact of hypertension on short- and long-term prognoses in patients with ST elevation myocardial infarction and without previously known diabetes.

Hypertension is well established as a risk factor for the development of atherosclerosis. Data on the impact of hypertension in patients with ST elevation myocardial infarction are so far inconsistent, and are mainly related to studies performed in the thrombolytic era. We assessed the impact of hypertension over the short and long term in 560 patients with ST elevation myocardial infarction (STEMI) and without previously known diabetes, all of whom were submitted to mechanical revascularization and consecutively admitted to our Intensive Cardiac Care Unit. Hypertensive patients were older (p < 0.001), more frequently male (0.005), and they showed a reduced eGFR (p < 0.001). Smoking was more frequent in nonhypertensive patients (p < 0.001), while the incidence of three-vessel coronary artery disease was higher in hypertensive patients (p = 0.003). No difference in the in-hospital mortality rates for the two subgroups was detected. At follow-up (median 32.5 months, 25th-75th percentile 16.9-47.3 months), Kaplan-Meier survival analysis detected no differences in mortality between hypertensive and nonhypertensive patients (log rank χ(2) 0.38, p = 0.538). According to our data, obtained from a large series of consecutive STEMI patients without previously known diabetes, all of whom were submitted to primary PCI, a history of hypertension does not affect mortality over either the short or the long term. Moreover, hypertensive patients showed an altered glucose response to stress, as indicated by higher admission glucose values, poorer in-hospital glucose control, and a higher incidence of acute insulin resistance (as indicated by the HOMA index). Hypertensive patients therefore appear to warrant careful metabolic management during their hospital courses.

The challenge of integrated echocardiographic approach in percutaneous closure of paravalvular leak.

Paravalvular leak after prosthetic mitral valve surgery may lead to symptomatic mitral regurgitation and hemolytic anemia requiring reoperation. Percutaneous closure of paravalvular leaks is a relatively recent technique still considered a challenging procedure burdened by possible complications, to be offered only to poor redo surgical candidate patients. Multimodality imaging is advocated to plan and guide the procedure, to minimize the risk of complications. We report on a case of dehisced prosthetic mitral valve in which transthoracic real time three-dimensional echocardiography was used to locate the dehiscence area and characterize mitral paraprosthesis leak, whereas intracardiac echocardiography was used to guide and monitor the percutaneous closure procedure.

Liver dysfunction as predictor of prognosis in patients with amyloidosis: utility of the Model for End-stage Liver disease (MELD) scoring system.

Amyloidosis prognosis is often related to the onset of heart failure and a worsening that is concomitant with kidney-liver dysfunction; thus the Model for End-stage Liver disease (MELD) may be an ideal instrument to summarize renal-liver function. Our aim has been to test the MELD score as a prognostic tool in amyloidosis. We evaluated 128 patients, 46 with TTR-related amyloidosis and 82 with AL amyloidosis. All patients had a complete clinical and echocardiography evaluation; overall biohumoral assessment included troponin I, NT-proBNP, creatinine, total bilirubin and INR ratio. The study population was dichotomized at the 12 cut-off level of MELD scores; those with MELD score >12 had a lower survival compared to controls in the study cohort (40.7 vs 66.3 %; p = 0.006). Either as a continuous and dichotomized variable, MELD shows its independent prognostic value at multivariable analysis (HR = 1.199, 95 % CI 1.082-1.329; HR = 2.707, 95 % CI 1.075-6.817, respectively). MELD shows a lower prognostic sensitivity/specificity ratio than troponin I and NT-proBNP in the whole study population and AL subgroup, while in TTR patients MELD has a higher sensitivity/specificity ratio compared to troponin and NT-proBNP (ROC analysis-AUC: 0.853 vs 0.726 vs 0.659). MELD is able to predict prognosis in amyloidosis. A MELD score >12 selects a subgroup of patients with a higher risk of death. The predictive accuracy seems to be more evident in TTR patients in whom currently no effective scoring systems have been validated.

Left ventricular rotational dyssynchrony before cardiac resynchronization therapy: a step forward into ventricular mechanics.

AIMS: Heart failure patients show impaired left ventricular rotation and twist. In patients undergoing cardiac resynchronization therapy (CRT) significance of preimplant left ventricular rotational timing between different ventricular regions is unknown. We thoroughly evaluated, in patients eligible for CRT, baseline left ventricular rotational mechanics, also assessing segmental rotational timing, and investigated whether the presence of rotational dyssynchrony may be associated with echocardiographic response. METHODS: By two-dimensional speckle-tracking echocardiography, baseline peak apical and basal rotation, peak twist, and time-related parameters, such as delays between opposite segments at base and apex, were assessed in 55 CRT patients and 11 healthy participants. RESULTS: At 6 months, 30 (54%) patients were echocardiographic responders. Left ventricular rotation and twist had no association with response. All time-related parameters were significantly altered in CRT patients. Maximum basal and apical segments delay, and anteroseptal-posterior delays at base and apex, were longer in responders than in nonresponders (P < 0.05 for all), regardless of the presence of left bundle branch block (LBBB) and QRS duration. At multivariable analysis, apical anteroseptal-posterior delay resulted as independently associated with response [odds ratio (OR): 1.022 (1.007-1.038); P = 0.004]. A cut-off value of 97.5 ms for apical anteroseptal-posterior delay predicted response with 96% specificity and 57% sensitivity (AUC = 0.83). Magnitude of left ventricular reverse remodeling was significantly related to apical anteroseptal-posterior delay (P = 0.001). CONCLUSION: In heart failure patients eligible for CRT, left ventricular rotational timing is altered. Dyssynchrony in rotational mechanics shows a specific pattern in responders regardless of the presence of LBBB. Apical anteroseptal-posterior rotational delay is independently associated with left ventricular reverse remodeling.

Early glucose variability in cardiogenic shock following acute myocardial infarction: a pilot study.

BACKGROUND: No data are so far available on the association between glycaemic variability and outcomes in patients with cardiogenic shock (CS) following ST elevation myocardial infarction (STEMI). METHODS: We assessed the relationship between glycaemic variability and mortality, both short term and long term, in 67 consecutive patients with cardiogenic shock following STEMI admitted to our Intensive Cardiac Care Unit. Glycaemic variability was measured in the first 48 h by means of standard deviation (SD) of glucose values and the mean absolute glucose change per hour (MAGC) defined as the sum of all absolute glucose change divided by the time in hours. RESULTS: Lower glycaemic variability was observed in survivors when compared with nonsurvivors, as indicated by lower values of SD and MAGC, respectively. In Cox regression analysis, MAGC and SD were independent predictors of death (MAGC: adjusted hazard ratio [HR]: 8.60, 95% confidence interval [CI]: 2.21-33.41, p = 0.002; SD: adjusted HR: 6.64, 95% CI: 1.92-22.99, p = 0.003), as well as peak glycaemia (adjusted HR: 1.95, 95% CI: 1.20-3.15, p = 0.007). CONCLUSIONS: According to our results, in patients with CS following acute myocardial infarction, early glycaemic variability is an independent predictor of mortality. Further studies are needed to confirm our results in larger cohorts and eventually to assess the effect of strategies specifically targeting glucose variability reduction on mortality.

Glycated haemoglobin and long-term mortality in patients with ST Elevation Myocardial Infarction.

BACKGROUNDS/OBJECTIVES: We aimed at assessing the impact of increased HbA1c (≥6.5%) on 1-year mortality in consecutive patients with ST Elevation Myocardial Infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI). METHODS: The study population comprises 1205 STEMI patients treated with primary PCI and consecutively admitted to our Center from 1 January 2004 to 31 December 2011. RESULTS: Two hundred and seventy-six patients with previously diagnosed diabetes (276/1205, 22.9%, Group A), 78 patients without previously known diabetes and HbA1c at least 6.5% (78/1205, 6.5%, Group B) and 851 patients without previously known diabetes and HbA1c less than 6.5% (851/1205, 70.1%, Group C).At Cox regression analysis, HbA1c at least 6.5% was not related to 1-year postdischarge mortality in patients with previously diagnosed diabetes nor in those without previously known diabetes.Kaplan-Meier survival curve analysis showed that patients in Group A exhibited the lowest survival rate, while patients in Group B (i.e. patients without previously known diabetes and with HbA1c ≥6.5%) showed a significant reduction in their survival rate since 6 months after discharge. CONCLUSION: In a large series of STEMI patients submitted to primary PCI, HbA1c levels were not related with outcomes at multivariable analysis.

Acidemia in severe acute cardiogenic pulmonary edema treated with noninvasive pressure support ventilation: a single-center experience.

In clinical practice, acidotic patients with acute cardiogenic pulmonary edema (ACPE) are commonly considered more severe in comparison with nonacidotic patients, and data on the outcome of these patients treated with noninvasive pressure support ventilation (NIV) are lacking.The present investigation was aimed at assessing whether acidosis on admission (pH < 7.35) was associated with adverse outcome in 65 consecutive patients with ACPE treated with NIV and admitted to our Intensive Cardiac Care Unit (ICCU).In our population, 28 patients were acidotic (28 of 65, 43.1%), whereas 41 patients were not (37 of 65, 56.9%). According to the Repeated Measures General Linear Model, pCO2 values significantly changed throughout the 2-h NIV treatment (P = 0.019) in both groups (P = 0001). In acidotic patients, pCO2 significantly decreased (51.9 ±â€Š15.3 → 47.0 ±â€Š12.8 → 44.8 ±â€Š12.7), whereas they increased in the nonacidotic subgroup (36.8 ±â€Š6.5 → 36.9 ±â€Š7.2 → 37.6 ±â€Š6.4). No difference was observed in intubation rate between acidotic (eight patients, 28.6%) and nonacidotic patients (12 patients, 32.4%) (P = 0.738). In-ICCU mortality rate did not differ between (13 patients, 35.1%) and nonacidotic patients (nine patients, 32.1%) (P = 0.801).Our data strongly suggest that in patients with severe ACPE treated with NIV, the presence of acidosis is not associated with adverse outcomes (early mortality and intubation rates) in these patients.

Age-related differences in glucose abnormalities in women with ST-elevation myocardial infarction submitted to percutaneous coronary intervention: a single-center experience.

No datum is so far available on the relation between age and the acute glucose response to stress in women with ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI).We evaluated the age-related differences in the acute glucose response in 373 STEMI women submitted to PCI. The oldest women, when compared to the other age subgroups, showed the higher admission and peak glycemia (P < 0.001 and P < 0.001, respectively) in the lack of differences in insulin, C-peptide, hemoglobin-glycated values and discharge glycemia values. At logistic regression analysis, the following variables were independent predictors of in-Intensive Cardiac Care Unit mortality: age (1-year step) [odds ratio 1.09, 96% confidence interval (CI) 1.04-1.15, P = 0.001], admission glycemia (1g/l step) (odds ratio 2.05, 96% CI 1.35-3.12, P < 0.001). At Cox regression analysis the following variables were associated with 1-year mortality (when adjusted for discharge glycemia): age (1-year step) (hazard ratio 1.13, 95% CI 1.04-1.22, P = 0.005), estimated glomerular filtration rate (1 g/l step) (hazard ratio 0.93, 95% CI 0.90-0.96, P < 0.001).Age affects the acute glucose response to myocardial injury since older women showed the higher admission glucose values and the poorer in-hospital glucose control, in the lack of differences of insulin-resistance incidence. Glucose values were independent predictors of in-hospital mortality, but were not related to long-term survival.

Left ventricular mass and progenitor cells in chronic heart failure patients.

The aim of the study was to evaluate the association between circulating (CPCs) and endothelial (EPCs) progenitor cells and left ventricular (LV) remodeling in chronic heart failure (HF). 85 HF patients, ranging 29-89 years, 83.5% males, 45.9% ischemic, NYHA functional class II-IV, with a LV ejection fraction ≤40% were studied. LV ejection fraction, LV end-diastolic and end-systolic (LVESV) volumes, LV mass and tricuspid annular plane systolic excursion (TAPSE) were evaluated, and, when indicated, indexed for body surface area (BSA). CPCs and EPCs number was assessed using flow cytometry. CPCs were defined as CD34+, CD133+ and CD34+/CD133+. EPCs, identified through their expression of KDR, were defined as CD34+/KDR+, CD133+/KDR+ and CD34+/CD133+/KDR+. All EPCs were negatively related to LVESV/BSA (r = -0.24, p = 0.02 for all EPC's populations), and to LVmass/BSA (CD34+KDR+; r = -0.30, p = 0.005; CD133+KDR+; r = -0.31, p = 0.004; CD34+CD133+KDR+; r = -0.29, p = 0.007). No differences in EPCs levels in relation to cardiovascular risk factors, medications, etiology, age or gender were observed. CPCs number was higher in women, and lower in ischemic patients. In logistic regression analyses, the low EPCs' number was associated with an increased likelihood of abnormal LVmass/BSA. CPCs proved to be higher and EPCs lower in patients with severely abnormal LVmass/BSA (gr/m(2), ≥122 in women and ≥149 in men). Our results suggest a correlation between LV remodeling and progenitor cells. This is noteworthy considering that it has been suggested that bone marrow-derived EPCs participate in cardiac regeneration and function recovery in the setting of progressive HF.

QRS duration in left bundle branch block does not affect left ventricular twisting in chronic systolic heart failure.

PURPOSE: Left ventricular (LV) torsion is an important parameter of LV performance and can be influenced by several factors. Aim of this investigation was to evaluate whether QRS prolongation in left bundle branch block (LBBB) may influence global LV twist and twisting/untwisting rate in chronic systolic heart failure (HF) patients. METHODS: We prospectively evaluated 30 healthy subjects (control group) and 100 chronic HF patients with severely impaired LV systolic function (ejection fraction ≤ 35%). Patients were divided into three groups according to QRS duration: A: QRS < 120 ms (n 49), B: 120 ≤ QRS ≤ 150 ms (n 28) and C: QRS > 150 ms (n 23). Patients in groups B and C presented LBBB. All subjects underwent standard trans-thoracic echocardiography and two-dimensional speckle-tracking echocardiography evaluation. Categorical variables were compared by the chi-square or the Fisher's exact test. Continuous variables were compared using the ANOVA test. Correlations between variables were analysed with linear regression. RESULTS: Control subjects presented higher torsion parameters, when compared with patients in any HF group. Among the three HF groups, no differences were detected in global twist (4.79 ± 3.54, 3.8 ± 3.0 and 4.15 ± 3.14 degrees, respectively), twist rate max (44.81 ± 25.03, 37.94 ± 19.09 and 37.61 ± 24.49 degrees s(-1), respectively) and untwist rate max (-36.31 ± 30.89, -27.68 ± 34.67 and -39.62 ± 26.27 degrees s(-1), respectively) (P>0.05 for all). At linear regression analysis, there was no relation between QRS duration and any torsion parameter (P>0.05 for all). CONCLUSIONS: In patients with chronic severe systolic heart failure, QRS duration and LBBB morphology do not affect LV twisting and untwisting.

Echocardiographic and biohumoral characteristics in patients with AL and TTR amyloidosis at diagnosis.

BACKGROUND: Few studies have analyzed the clinical and echocardiographic differences between light-chain (AL) and transthyretin (TTR) amyloidosis. HYPOTHESIS: The aim of the present research was to compare, in a real-world setting, the clinical and echocardiographic profiles of these kinds of amyloidosis, at the time of diagnosis, using new-generation echocardiography. METHODS: Seventy-nine patients with AL and 48 patients with TTR amyloidosis were studied. RESULTS: According to the criterion of mean left ventricular (LV) thickness >12 mm, 45 AL (C-AL) and all TTR patients had cardiac amyloidotic involvement, whereas 34 AL patients did not. TTR patients had increased right ventricular (RV) and LV chambers with increased RV and LV wall thickness and reduced LV ejection fraction and fractional shortening. Furthermore, TTR patients showed lower N-terminal pro Brain Natriuretic Peptide concentrations and New York Heart Association functional class when compared with C-AL. CONCLUSIONS: Our data show that at time of first diagnosis, TTR patients have a more advanced amyloidotic involvement of the heart, despite less severe symptoms and biohumoral signs of heart failure. We can hypothesize that we observed different diseases at different stages. In fact, AL amyloidosis is a multiorgan disease with quick progression rate, that becomes rapidly symptomatic, whereas TTR amyloidosis might have a slow progression rate and might remain poorly symptomatic for a greater amount of time.

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.

Biohumoral markers as predictor of right ventricular dysfunction in AL Amyloidosis.

AIM: In AL amyloidosis, the importance of right ventricle (RV) involvement has recently been underlined and its role in predicting prognosis has been emphasized. Little is known about the relationship between RV involvement, N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin levels. Aim of our study was to clarify the relationship between NT-proBNP and troponin and RV involvement and analyze their independent value as predictors of RV dysfunction. METHODS AND RESULTS: We examined 76 consecutive patients with biopsy-proven AL amyloidosis. Each patient received complete clinical evaluation, troponin I, NT-proBNP assay and comprehensive echocardiographic evaluation. Considering a tricuspidal annulus plane systolic excursion (TAPSE) value <16 mm, 23 patients (30%) presented RV systolic dysfunction, whereas 53 (70%) did not. Patient with reduced TAPSE had thicker left ventricle (LV) walls and RV free walls, reduced LV fractional shortening, impaired LV diastolic function and worse LV and RV myocardial performance index. For RV dysfunction the best predictive value for NT-proBNP was identified as 2977 ng/l with sensitivity and specificity of 87% and 84%, respectively; best cut-off for troponin I was identified as 0.085 ng/l, with sensitivity and specificity of 85% and 90% respectively. At multivariable logistic regression analysis, both NT-proBNP and troponin I emerged as independent predictors of RV dysfunction presence but troponin appears to have a higher predictive power. CONCLUSION: Our study demonstrated that cut-off values of 2977 ng/ml for NT-proBNP and 0.085 ng/l for troponin were able to identify a subgroup of AL patients with RV dysfunction. Troponin I is more accurate and seems to be the best biohumoral marker of RV dysfunction.