The Atrioventricular Coupling in Heart Failure: Pathophysiological and Therapeutic Aspects.

For a long time, the study of heart failure focused on single heart chamber disease. There is, instead, growing attention on the interplay between the atria and the ventricles during the cardiac cycle and on the consequences of an altered chamber coupling on global heart performance and heart failure. This review aimed to explore the principles of atrioventricular (AV) function and coupling of the left heart and the consequences that their disruption could have in several diseases. Furthermore, we will examine echocardiographic tips for analyzing the chamber function and the AV coupling. Finally, we will explore the most recent pharmacological acquisitions and the device therapies we have for use.

Relationship between the strain measures of left atrial function and heart failure worsening.

BACKGROUND: Two-dimensional speckle tracking evaluation (2D-STE) is a useful tool to evaluate the complexity of atrial function by the analysis of the different phases of atrial deformation and by the combination with Doppler measurements of diastolic function. AIM OF THE STUDY: To evaluate the role of the left atrial (LA) strain parameters to predict worsening chronic heart failure (CHF). METHODS: We enrolled outpatients affected by CHF referred to our heart failure unit. Each patient underwent a medical visit, an electrocardiogram (ECG), and an echocardiographic examination. LA function was assessed by 2D-STE. The three phases of LA strain, that is, the reservoir (LAr), the conduit (LAcd), and the contraction (LAct)-were evaluated. Moreover, the ratio between E and LAr (E/LAr) and those between LAr and septal (LAr/Ees), lateral (LAr/Eel), and septal-lateral (LAr/Eem) E/e' were measured. During follow-up, the events related to worsening of heart failure were evaluated. RESULTS: Two hundred eleven patients were enrolled. During a mean follow-up of 14 ± 7 months, 37 patients showed at least one event related to heart failure worsening. At univariate Cox regression analysis, LAr, LAcd, LAct, E/LAr, LAr/Ees, LAr/Eel, and LAr/Eem were all associated with events related to heart failure worsening, but at multivariate regression analyses, only LAr (Hazard Ratio, HR: .95; 95% Confidence Interval, CI: .92-.99; p: .031), LAct (HR: 1.06; 95% CI: 1.01-1.12; p: .027), E/LAr (HR: 1.10; 95%CI: 1.0-1.16; p < .001), LAr/Ees (HR: .57; 95% CI: .37-.87; p: .010), and LAr/Eem (HR: .71; 95% CI: .53-.96; p: .026) remained significantly associated with the events. Finally, in a predictive model including the other relevant echocardiographic parameters LAr < 18%, LAct > -10.0%, LAr/Ees < 1.28, and E/LAr > 3.70 were associated with a statistically significant overall net reclassification improvement. CONCLUSIONS: In CHF patients, the measure of the LA reservoir and contraction by 2D-STE is independently associated with heart failure worsening, but the accuracy in predicting the events is even greater when the reservoir is combined with the Doppler measures of diastolic function.

Introduction of SGLT2 Inhibitors and Variations in Other Disease-Modifying Drugs in Heart Failure Patients: A Single-Centre Real-World Experience.

BACKGROUND: The sodium-glucose cotransporter-2 inhibitors (SGLT2i) have emerged as a crucial therapeutic option for patients with chronic heart failure with reduced ejection fraction (HFrEF). The aim of this study was to evaluate, in a real-world population from a single centre, the feasibility of introducing SGLT2i and their interaction with other recommended drug classes. METHODS: Consecutive patients affected by chronic heart failure (CHF) were evaluated beginning in January 2022. At the baseline clinical visit, both the patient's current medication and the prescribed treatments were recorded. Over a 6- to 12-month follow-up, changes in concomitant therapy were analysed. RESULTS: At baseline, among 350 patients evaluated, only 17 (5%) were already taking SGLT2i: 13 with HFrEF, five with mildly reduced (HFmrEF), preserved (HFpEF) or improved (HFimpEF) ejection fraction. After the baseline assessment, SGLT2i were prescribed to 224 (64%) of the patients, including 179 (84%) with HFrEF, 27 (42%) with HFmrEF/HFimpEF, and 18 (22%) with HFpEF/HFimpEF. After follow-up, SGLT2i therapy was well tolerated and was associated with a significant increase in sacubitril/valsartan prescriptions and a decrease in diuretic use. Finally, a significant improvement in functional status and left ventricular systolic function after SGLT2i therapy was observed. CONCLUSIONS: In this single-centre, real-world study, SGLT2i were primarily prescribed to HFrEF patients who were already on other recommended drug classes for their treatment. Additionally, there was a noticeable enhancement in the prescribed therapy during a short-term follow-up. These findings further bolster the inclusion of this therapeutic approach in regular clinical practice.

Improvement in Left and Right Ventricular Function after Introduction of SGLT2 Inhibitors in Heart Failure Outpatients with Reduced Ejection Fraction.

BACKGROUND: Type 2 sodium-glucose cotransporter inhibitors (SGLT2i) are among the main therapeutic options for patients with chronic heart failure with reduced ejection fraction (HFrEF). The aim of this study was to evaluate the effects of SGLT2i on the echocardiographic parameters of left (LV) and right (RV) ventricular function among outpatients with a long history of HFrEF, in optimized therapy. METHODS: We evaluated consecutive patients affected by HFrEF in whom the SGLT2i therapy was prescribed. Following a baseline evaluation (T0), in which SGLT2i was prescribed, patients were re-evaluated at 3 (T3), 6 (T6), and 12 (T12) months. RESULTS: We considered 60 patients for the analysis with a median history of HFrEF of more than seven years in optimal medical and electrical therapy. After SGLT2i therapy, LV ejection fraction and LV global longitudinal strain improved from baseline at T3, T6, and T12. Analogously, RV global and free wall longitudinal strain improved at T3 and T6. CONCLUSIONS: Our study shows that the addition of SGLT2i to the optimized therapy for HFrEF was associated with a significant improvement in both LV and RV function, thus highlighting a possible mechanism responsible for the benefit obtained with this class of drugs.

Renal resistance index independently predicts worsening of renal function after coronary angiography.

The renal resistance index (RRI) has been demonstrated to be a useful parameter that can detect patients at a high risk of worsening of renal function (WRF). This study was designed to evaluate the role of the RRI in predicting WRF mediated by the intravascular administration of contrast media. We enrolled patients who were referred for coronary angiography. Renal arterial echo-color Doppler was performed to calculate the RRI. WRF was defined as an increase of > 0.3 mg/dL and at least 25% of the baseline value in creatinine concentration 24-48 h after coronary angiography. Among the 148 patients enrolled in this study, 18 (12%) had WRF. In the multivariate logistic analysis, the RRI was independently associated with WRF (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.09-1.36; p = 0.001). After angiography, the RRI significantly increased in both patients with and without WRF. In the receiver operating characteristic curve analyses for WRF, the RRI at baseline and after angiography showed similar accuracy, and the best cutoff value for predicting WRF was 70%. In patients undergoing coronary angiography, the RRI is independently associated with WRF, probably because it provides more accurate information about cardiorenal pathophysiological factors and reflects kidney hemodynamic status and flow reserve.

Brain Natriuretic Peptide Biomarkers in Current Clinical and Therapeutic Scenarios of Heart Failure.

Brain natriuretic peptide (BNP) and its inactive N-terminal fragment, NT-proBNP, are serum biomarkers with key roles in the management of heart failure (HF). An increase in the serum levels of these peptides is closely associated with the pathophysiological mechanisms underlying HF such as the presence of structural and functional cardiac abnormalities, myocardial stretch associated with a high filling pressure and neuro-hormonal activation. As BNP and NT-proBNP measurements are possible, several studies have investigated their clinical utility in the diagnosis, prognostic stratification, monitoring and guiding therapy of patients with HF. BNP and NT-proBNP have also been used as criteria for enrollment in randomized trials evaluating the efficacy of new therapeutic strategies for HF. Nevertheless, the use of natriuretic peptides is still limited in clinical practice due to the controversial aspect of their use in different clinical settings. The purpose of this review is to discuss the main issues associated with using BNP and NT-proBNP serum levels in the management of patients with HF under current clinical and therapeutic scenarios.

Effects of Sacubitril/Valsartan on the Renal Resistance Index.

BACKGROUND: Sacubitril/valsartan plays a key role in improving left ventricular remodeling and prognosis in patients with heart failure with a reduced ejection fraction (HFrEF). Moreover, some data support its role in preserving renal function. In order to better clarify the effects of sacubitril/valsartan in cardiorenal syndrome, this study evaluated its effects on the renal resistance index (RRI). METHODS: A group of patients with HFrEF was enrolled. The RRI was assessed with renal echo-color Doppler at enrollment and again after at least six months of sacubitril/valsartan treatment. In a subgroup of patients, the RRI was also evaluated at least six months before enrollment. The variations in echocardiographic parameters reflecting the left and right ventricular function, as well as creatinine and the estimated glomerular filtration rate, were also evaluated. RESULTS: After treatment with sacubitril/valsartan, significant improvements in the left ventricular ejection fraction, and a decrease in the left atrial and ventricular volumes were observed. The RRI also showed a significant decrease. No relationship was found between the improvements in the parameters reflecting cardiac function and changes in the RRI. CONCLUSIONS: Treatment with sacubitril/valsartan is associated with improvements in both left ventricular function and renal perfusion, through decreasing the renal resistance. These data help to clarify the effects of the drug on cardiorenal syndrome progression.

The role of cardiovascular ultrasound in diagnosis and management of pulmonary embolism.

The diagnosis of acute pulmonary embolism (PE) is one of the most important problems in medical emergencies. Commonly accepted criterion for diagnosis of deep venous thrombosis is the lack of vein compressibility assessed by Compression UltraSonography. Echocardiography represents an easily available and reliable imaging technique in the clinical setting of hemodynamic instability and in the direct visualization of thromboembolic masses in the right heart chambers. Moreover, echocardiography is useful for prognostic stratification after acute PE as right ventricular dysfunction is the most important predictor of mortality in this context. This review aims to highlight usefulness, potentialities and perspectives of standard and advanced echocardiography in evaluating patients affected by PE.