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1.
Eur Heart J Suppl ; 26(Suppl 1): i113-i116, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-38867870

RESUMEN

Moderate aortic stenosis is associated with a worse prognosis than milder degrees. Pathophysiologically, this condition in a dysfunctional ventricle could lead to a further mechanism of haemodynamic worsening, so its treatment should lead to clinical advantages for the patient. The low risk of complications associated with percutaneous correction of aortic valve disease (transcatheter aortic valve implantation) should also be considered, which would seem to favour an interventional approach even in the aforementioned condition. However, sparse data and small population studies make this approach still controversial. Three randomized controlled trials are underway to shed definitive light on the topic.

2.
ESC Heart Fail ; 11(5): 3350-3359, 2024 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-38965689

RESUMEN

AIMS: The identification of subjects at higher risk for incident heart failure (HF) with preserved ejection fraction (EF) suitable for more intensive preventive programmes remains challenging. We applied phenomapping to the DAVID-Berg population, comprising subjects with preclinical HF, aiming to refine HF risk stratification. METHODS: The DAVID-Berg study prospectively enrolled 596 asymptomatic outpatients with EF > 40% with hypertension, diabetes mellitus or known cardiovascular disease. In this cohort, we performed an unsupervised cluster analysis on 591 patients, including clinical, laboratory, electrocardiographic and echocardiographic parameters. We tested the association between each cluster and a composite outcome of HF/death. RESULTS: The median age was 70 years, 55.5% were males and the median EF was 61.0%. Phenomapping provided three different clusters. Subjects in Cluster 3 were the oldest and had the highest prevalence of atrial fibrillation, the lowest estimated glomerular filtration rate (eGFR), the highest N-terminal pro-brain natriuretic peptide (NT-proBNP) and the largest left atrium. During a median follow-up of 5.7 years, 13.4% of subjects experienced HF/death events (N = 79). Compared with Clusters 1 and 2, Cluster 3 had the worst prognosis (log-rank test: Cluster 3 vs. 1 P < 0.001; Cluster 3 vs. 2 P = 0.008). Cluster 3 was associated with a risk of HF/death 2.5 times higher than Cluster 1 [adjusted hazard ratio (HR) = 2.46, 95% confidence interval (CI) 1.24-4.90]. CONCLUSIONS: Based on phenomapping, older patients with lower kidney function and worse diastolic function might represent a subset of preclinical HF with EF > 40% who deserve more efforts to prevent clinical HF.


Asunto(s)
Insuficiencia Cardíaca , Volumen Sistólico , Humanos , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/epidemiología , Masculino , Femenino , Volumen Sistólico/fisiología , Anciano , Estudios Prospectivos , Estudios de Seguimiento , Pronóstico , Factores de Tiempo , Ecocardiografía , Medición de Riesgo/métodos , Función Ventricular Izquierda/fisiología , Tasa de Supervivencia/tendencias , Electrocardiografía , Factores de Riesgo
3.
Eur J Prev Cardiol ; 28(9): 937-945, 2021 08 09.
Artículo en Inglés | MEDLINE | ID: mdl-34402871

RESUMEN

BACKGROUND: Natriuretic peptides and diastolic dysfunction have prognostic value in asymptomatic subjects at risk for heart failure. Their integration might further refine the risk stratification process in this setting. Aim of this paper was to explore the possibility to predict heart failure and death combining diastolic dysfunction and natriuretic peptides in an asymptomatic population at risk for heart failure. METHODS: Among 4047 subjects aged ≥55/≤80 years followed by 10 general practitioners in Italy, the DAVID-Berg study prospectively enrolled 623 asymptomatic outpatients at increased risk for heart failure. Baseline evaluation included electrocardiogram, echocardiogram, and natriuretic peptides collection. Based on diastolic dysfunction and natriuretic peptides, subjects were classified in four groups: control group (no diastolic dysfunction/normal natriuretic peptides, 57%), no diastolic dysfunction/high natriuretic peptides (9%), diastolic dysfunction/normal natriuretic peptides (24%), and diastolic dysfunction/high natriuretic peptides (11%). We applied Cox multivariable and Classification and Regression Tree analyses. RESULTS: The mean age of the population was 69 ± 7 years, 44% were women, mean left ventricular ejection fraction was 61%, and 35% had diastolic dysfunction. During a median follow-up of 5.7 years, 95 heart failure/death events occurred. Overall, diastolic dysfunction and natriuretic peptides were predictive of adverse events (respectively, hazard ratio 1.91, confidence interval 1.19-3.05, padjusted = 0.007, and hazard ratio 2.25, confidence interval 1.35-3.74, padjusted = 0.002) with Cox analysis. However, considering the four study subgroups, only the group with diastolic dysfunction/high natriuretic peptides had a significantly worse prognosis compared to the control group (hazard ratio 4.48, confidence interval 2.31-8.70, padjusted < 0.001). At Classification and Regression Tree analysis, diastolic dysfunction/high natriuretic peptides was the strongest prognostic factor (risk range 24-58%). CONCLUSIONS: The DAVID-Berg data suggest that we look for the quite common combination of diastolic dysfunction/high natriuretic peptides to correctly identify asymptomatic subjects at greater risk for incident heart failure/death, thus more suitable for preventive interventions.


Asunto(s)
Insuficiencia Cardíaca , Disfunción Ventricular Izquierda , Anciano , Anciano de 80 o más Años , Biomarcadores , Electrocardiografía , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Péptido Natriurético Encefálico , Péptidos Natriuréticos , Pronóstico , Volumen Sistólico , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/epidemiología , Función Ventricular Izquierda
4.
Eur Heart J Cardiovasc Imaging ; 21(12): 1405-1411, 2020 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-31808506

RESUMEN

AIMS: Midwall fractional shortening (MWFS) is a measure of left ventricular (LV) systolic function that is more reliable in case of concentric LV geometry compared to LV ejection fraction (LVEF). We hypothesized that MWFS might predict heart failure (HF) and death in a high-risk asymptomatic population, beyond other echocardiographic parameters. METHODS AND RESULTS: Among 4047 subjects aged ≥55/≤80 years followed by 10 general practitioners in northern Italy, the DAVID-Berg study prospectively enrolled 623 asymptomatic outpatients at increased risk for HF. Baseline evaluation included clinical visit, electrocardiogram, N-terminal pro-brain natriuretic peptide (NT-proBNP), and echocardiogram. Mean age of the population was 69 ± 7 years, 56% were men, 88% had hypertension, mean LVEF was 61 ± 9%, and mean MWFS 16.2 ± 3.3. During a median follow-up of 5.7 years, 95 subjects experienced HF/death events. At Cox analysis, lower MWFS was the only echocardiographic parameter, among structural/functional ones, associated with higher risk of HF/death [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.84-0.95, Padjusted < 0.001]. The risk of HF/death related to clinical data and NT-proBNP (baseline model) was reclassified by echocardiography only when MWFS was included into the model (baseline C-statistics 0.761; adding conventional structural/functional echocardiographic data 0.776, P = 0.09; adding MWFS 0.791, P = 0.007). Compared to subjects with normal LVEF and MWFS, only subjects with combined systolic dysfunction (11% of the population) were at higher risk (P = 0.001 for both abnormal; P > 0.24 for either LVEF or MWFS abnormal). CONCLUSION: DAVID-Berg data suggest to include MWFS assessment in clinical practice, a simple and reliable echocardiographic parameter able to improve risk stratification in subjects at high risk for HF.


Asunto(s)
Insuficiencia Cardíaca , Disfunción Ventricular Izquierda , Anciano , Biomarcadores , Insuficiencia Cardíaca/diagnóstico por imagen , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Péptido Natriurético Encefálico , Fragmentos de Péptidos , Factores de Riesgo , Volumen Sistólico , Disfunción Ventricular Izquierda/diagnóstico por imagen , Función Ventricular Izquierda
5.
Eur J Heart Fail ; 22(12): 2228-2237, 2020 12.
Artículo en Inglés | MEDLINE | ID: mdl-33200458

RESUMEN

AIMS: Interstitial pneumonia due to coronavirus disease 2019 (COVID-19) is often complicated by severe respiratory failure. In addition to reduced lung compliance and ventilation/perfusion mismatch, a blunted hypoxic pulmonary vasoconstriction has been hypothesized, that could explain part of the peculiar pathophysiology of the COVID-19 cardiorespiratory syndrome. However, no invasive haemodynamic characterization of COVID-19 patients has been reported so far. METHODS AND RESULTS: Twenty-one mechanically-ventilated COVID-19 patients underwent right heart catheterization. Their data were compared both with those obtained from non-mechanically ventilated paired control subjects matched for age, sex and body mass index, and with pooled data of 1937 patients with 'typical' acute respiratory distress syndrome (ARDS) from a systematic literature review. Cardiac index was higher in COVID-19 patients than in controls [3.8 (2.7-4.5) vs. 2.4 (2.1-2.8) L/min/m2 , P < 0.001], but slightly lower than in ARDS patients (P = 0.024). Intrapulmonary shunt and lung compliance were inversely related in COVID-19 patients (r = -0.57, P = 0.011) and did not differ from ARDS patients. Despite this, pulmonary vascular resistance of COVID-19 patients was normal, similar to that of control subjects [1.6 (1.1-2.5) vs. 1.6 (0.9-2.0) WU, P = 0.343], and lower than reported in ARDS patients (P < 0.01). Pulmonary hypertension was present in 76% of COVID-19 patients and in 19% of control subjects (P < 0.001), and it was always post-capillary. Pulmonary artery wedge pressure was higher in COVID-19 than in ARDS patients, and inversely related to lung compliance (r = -0.46, P = 0.038). CONCLUSIONS: The haemodynamic profile of COVID-19 patients needing mechanical ventilation is characterized by combined cardiopulmonary alterations. Low pulmonary vascular resistance, coherent with a blunted hypoxic vasoconstriction, is associated with high cardiac output and post-capillary pulmonary hypertension, that could eventually contribute to lung stiffness and promote a vicious circle between the lung and the heart.


Asunto(s)
COVID-19/fisiopatología , Hemodinámica/fisiología , Hipertensión Pulmonar/fisiopatología , Hipoxia/fisiopatología , Síndrome de Dificultad Respiratoria/fisiopatología , Resistencia Vascular/fisiología , Vasoconstricción/fisiología , Anciano , COVID-19/terapia , Cateterismo Cardíaco , Gasto Cardíaco/fisiología , Estudios de Casos y Controles , Ecocardiografía , Femenino , Humanos , Hipoxia/terapia , Rendimiento Pulmonar/fisiología , Masculino , Persona de Mediana Edad , Respiración Artificial , Síndrome de Dificultad Respiratoria/terapia , Estudios Retrospectivos , SARS-CoV-2 , Relación Ventilacion-Perfusión
6.
Eur J Heart Fail ; 11(6): 581-7, 2009 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-19398488

RESUMEN

AIMS: To assess long-term prognosis in patients with functional mitral regurgitation (FMR) and left ventricular (LV) dysfunction, receiving current standard pharmacological therapy. METHODS AND RESULTS: We prospectively enrolled 404 consecutive patients (mean age 70.2 +/- 10 years) with ischaemic (76.5%) and non-ischaemic (23.5%) LV dysfunction (ejection fraction 34.4 +/- 10.8%) and at least mild MR. Results are reported at 4 years' follow-up. Survival free of all-cause mortality was 53% and cardiac death was 74%. Survival free of all-cause mortality was 50% (95% CI 35-72) for patients with moderate MR, 49% (95% CI 27-65) for severe MR, and 64% (95% CI 47-78) for mild MR (P = 0.03). Survival free of cardiac death was 57% (95% CI 38-74) for patients with moderate MR, 55% (95% CI 30-77) for severe MR, and 94% (95% CI 59-98) for mild MR (P = 0.003). Moderate-to-severe MR [relative risk (RR) 2.7, 95% CI 1.2-6.1, P = 0.003] was an independent predictor of cardiac death but not of all-cause mortality. Survival free of heart failure (HF) was 32%. Survival free of HF was 20% (95% CI 17-35) for patients with moderate MR, 18% (95% CI 15-32) for severe MR, and 62% (95% CI 45-72) for mild MR (P = 0.0001). Moderate-to-severe MR (RR 3.2, 95% CI 1.9-5.2, P = 0.0001) was an independent predictor of HF. CONCLUSION: The mortality and morbidity of patients with LV dysfunction and FMR remain high despite current standard pharmacological therapy. Moderate-to-severe MR is an independent predictor of cardiac death and HF.


Asunto(s)
Antagonistas Adrenérgicos beta/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Insuficiencia de la Válvula Mitral/tratamiento farmacológico , Disfunción Ventricular Izquierda/tratamiento farmacológico , Anciano , Causas de Muerte/tendencias , Supervivencia sin Enfermedad , Quimioterapia Combinada , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Italia/epidemiología , Masculino , Insuficiencia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/fisiopatología , Pronóstico , Estudios Prospectivos , Volumen Sistólico/fisiología , Tasa de Supervivencia/tendencias , Factores de Tiempo , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/fisiopatología
8.
Eur J Heart Fail ; 20(11): 1540-1548, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-30225956

RESUMEN

BACKGROUND: Mild asymptomatic left ventricular systolic dysfunction (ALVSD) may be associated with incident heart failure (HF). However, this gray zone group needs incremental risk refinement. We hypothesized that diastolic dysfunction (DD) may refine HF and death risk prediction in mild ALVSD. METHODS AND RESULTS: Among 4047 subjects aged ≥55/≤80 years followed by 10 general practitioners in northern Italy, the DAVID-Berg study prospectively enrolled 623 asymptomatic outpatients at increased risk for HF. Baseline evaluation included clinical visit, N-terminal pro B-type natriuretic peptide, and echocardiogram. Based on left ventricular ejection fraction (LVEF) and DD, subjects were classified as: control group (normal LVEF, n = 459, 76%), mild ALVSD (LVEF ≥40%/<53%) without DD (n = 89, 15%) and with DD (n = 54, 9%). Subjects with LVEF <40% or without full echocardiographic data were excluded from the analysis (n = 21). Mean age of the population was 69 ±7 years, 56% were men, mostly hypertensive, mean LVEF was 61%. During a median follow-up of 5.7 years, 88 subjects (15%) experienced HF/death events (59 HF events and 29 deaths). Compared to the control group, mild ALVSD was associated with a higher risk of incident HF/death (hazard ratio 1.80, 95% confidence interval 1.10-2.93, adjusted P = 0.019) according to the Cox proportional hazards model. However, this higher risk was present only in subjects with combined DD (P = 0.005) and not in those without it (P = 0.30). Results were consistent even considering the individual components of the primary outcome. CONCLUSION: In a high-risk population, an echocardiographic exam is normally performed to assess systolic dysfunction. Our data underline the importance of also relying on DD to risk stratify mild ALVSD. Mild ALVSD might be a predictor of adverse events mainly in subjects with combined DD, though further studies are needed to confirm these results.


Asunto(s)
Insuficiencia Cardíaca Sistólica/etiología , Pacientes Ambulatorios , Medición de Riesgo , Disfunción Ventricular Izquierda/complicaciones , Función Ventricular Izquierda/fisiología , Anciano , Anciano de 80 o más Años , Enfermedades Asintomáticas , Ecocardiografía , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca Sistólica/epidemiología , Insuficiencia Cardíaca Sistólica/fisiopatología , Humanos , Incidencia , Italia/epidemiología , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/fisiopatología
9.
Int J Cardiol ; 248: 414-420, 2017 Dec 01.
Artículo en Inglés | MEDLINE | ID: mdl-28709699

RESUMEN

BACKGROUND: Despite the burden of pre-clinical heart failure (HF) among diabetes mellitus (DM) patients, routine screening echocardiography is not currently recommended. We prospectively assessed risk prediction for HF/death of a screening strategy combining clinical data, electrocardiogram, NTproBNP, and echocardiogram, aiming to identify DM patients more suitable for selective echocardiography. METHODS: Among 4047 screened subjects aged≥55/≤80years, the DAVID-Berg Study prospectively enrolled 623 outpatients with DM, or hypertension, or known cardiovascular disease but with no HF history/symptoms. The present analysis focuses on data obtained during a longitudinal follow-up of the 219 patients with DM. RESULTS: Mean age was 68years, 61% were men, and median DM duration was 4.9years. During a median follow-up of 5.2years, 50 subjects developed HF or died. A predictive model using clinical data demonstrated moderate predictive power, which significantly improved by adding electrocardiogram (C-statistic 0.75 versus 0.70; p<0.05), but not NTproBNP (C-statistic 0.72, p=0.20). Subjects with normal clinical variables or abnormal clinical variables but normal electrocardiogram had low events rate (1.3 versus 2.4events/100-person-years, p=NS). Conversely, subjects with both clinical and electrocardiogram abnormalities (47%) carried higher risk (9.0events/100-person-years, p<0.001). The predictive power for mortality/HF development increased when echocardiography was added (13.6events/100-person-years, C-statistic 0.80, p<0.05). CONCLUSIONS: Our prospective study found that a selective echocardiographic screening strategy guided by abnormal clinical/electrocardiogram data can reliably identify DM subjects at higher risk for incident HF and death. This screening approach may hold promise in guiding HF prevention efforts among DM patients.


Asunto(s)
Diabetes Mellitus/diagnóstico por imagen , Diabetes Mellitus/epidemiología , Ecocardiografía/métodos , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/epidemiología , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo
10.
J Am Coll Cardiol ; 66(15): 1687-96, 2015 Oct 13.
Artículo en Inglés | MEDLINE | ID: mdl-26449139

RESUMEN

BACKGROUND: In severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM) and mild septal hypertrophy, mitral valve (MV) abnormalities may play an important role in MV displacement into the left ventricular (LV) outflow tract. Therefore, isolated myectomy may not relieve outflow obstruction and symptoms, and MV replacement is often the surgical alternative. OBJECTIVES: This study sought to assess the clinical and hemodynamic results of cutting thickened secondary MV chordae combined with a shallow septal muscular resection in severely symptomatic patients with obstructive HCM and mild septal hypertrophy. METHODS: Clinical features were compared before surgery and at most recent clinical evaluation in 39 consecutive patients with obstructive HCM. RESULTS: Over a 23 ± 2 months follow-up, New York Heart Association functional class decreased from 2.9 ± 0.5 pre-operatively to 1.1 ± 1.1 post-operatively (p < 0.001), with no patient in class III at most recent evaluation. The resting outflow gradient decreased from 82 ± 43 mm Hg to 9 ± 5 mm Hg (p < 0.001) and septal thickness decreased from 17 ± 1 mm to 14 ± 2 mm (p < 0.001). No patient had MV prolapse or flail and 1 had residual moderate-to-severe MV regurgitation at most recent evaluation. MV geometry before and after surgery was compared with that of 25 consecutive patients with similar clinical profile and septal thickness that underwent isolated myectomy. After adjustment for differences in pre-operative values between the groups, the post-operative anterior MV leaflet-annulus ratio was 17% greater and tenting area 24% smaller in patients with chordal cutting, indicating that MV apparatus had moved to a more normal posterior position within the LV cavity, preventing MV systolic displacement into the outflow tract and outflow obstruction. CONCLUSIONS: This procedure relieves heart failure symptoms, abolishes LV outflow gradient, and avoids MV replacement in patients with obstructive HCM and mild septal thickness.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos/métodos , Cardiomiopatía Hipertrófica/cirugía , Tabiques Cardíacos/cirugía , Válvula Mitral/cirugía , Obstrucción del Flujo Ventricular Externo/cirugía , Cardiomiopatía Hipertrófica/complicaciones , Cardiomiopatía Hipertrófica/diagnóstico por imagen , Ecocardiografía , Femenino , Estudios de Seguimiento , Tabiques Cardíacos/diagnóstico por imagen , Humanos , Masculino , Estudios Retrospectivos , Resultado del Tratamiento , Obstrucción del Flujo Ventricular Externo/diagnóstico por imagen , Obstrucción del Flujo Ventricular Externo/etiología
12.
Aorta (Stamford) ; 2(6): 289-92, 2014 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-26798748

RESUMEN

We report the case of a 78-year-old female who presented to our hospital with signs of hemorrhagic shock and breathlessness. A transthoracic echocardiography demonstrated pericardial effusion. Computed tomography of the chest showed a penetrating atherosclerotic ulcer of the aortic arch with an intramural hematoma of the ascending and descending aorta. Endovascular repair with stent-grafting was urgently performed and a pericardial window placement was done to reduce mediastinal bleeding.

13.
G Ital Cardiol (Rome) ; 15(5): 313-22, 2014 May.
Artículo en Italiano | MEDLINE | ID: mdl-25002172

RESUMEN

BACKGROUND: Prevalence of asymptomatic left ventricular systolic dysfunction (ALVSD) increases with age and cardiovascular (CV) risk exposure. Early diagnosis and treatment allow reducing heart failure and fatal and non-fatal event rates. Data on ALVSD prevalence in Italy are still scarce and ALVSD remains commonly under-diagnosed in primary care, where diagnostic facilities are limited. Among subjects at high CV risk in primary care, we assessed the prevalence of ALVSD and the relative predictive value of N-terminal pro-brain natriuretic peptide (NT-proBNP) and the Framingham Heart Failure Risk Score (FHFRS). METHODS: Records of 4047 subjects aged 55-80 years, without history, symptoms or signs of heart failure, registered at three primary care practices in Lombardy, Northern Italy, were reviewed; 623 subjects at high CV risk underwent visit, ECG, echocardiography, NT-proBNP and FHFRS calculation. RESULTS: ALVSD, defined as left ventricular ejection fraction <50%, was detected in 33 subjects (5.3%) who showed higher NT-proBNP (p<0.001) and FHFRS (p=0.013) than those without ALVSD. NT-proBNP levels beyond normal age and gender-specific 95th percentile had a 97.7% negative predictive value for ALVSD and were associated with a 6-fold increase in ALVSD risk. Adding NT-proBNP to FHFRS significantly improved prediction (C-statistic 0.76, 95% confidence interval [CI] 0.67-0.84 vs 0.63, 95% CI 0.53-0.73, p=0.04; net reclassification improvement 38.4%). The combination of FHFRS and major ECG abnormalities was not superior to stand alone NT-proBNP (C-statistic 0.71, 95% CI 0.63-0.80 vs 0.74, 95% CI 0.64-0.83, p=0.61). CONCLUSIONS: In subjects at high CV risk in primary care, prevalence of ALVSD is 5.3%; for diagnosis NT-proBNP adds predictive value to the FHFRS and is equivalent to the combination of FHFRS and ECG. Because of its practical advantages, NT-proBNP might be routinely used for ALVSD screening in primary care.


Asunto(s)
Tamizaje Masivo , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , Disfunción Ventricular Izquierda/diagnóstico , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Diagnóstico Precoz , Ecocardiografía , Electrocardiografía , Femenino , Humanos , Italia/epidemiología , Masculino , Registros Médicos , Persona de Mediana Edad , Pacientes Ambulatorios/estadística & datos numéricos , Valor Predictivo de las Pruebas , Prevalencia , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Muestreo , Sensibilidad y Especificidad , Disfunción Ventricular Izquierda/sangre , Disfunción Ventricular Izquierda/epidemiología , Disfunción Ventricular Izquierda/fisiopatología
14.
Int J Cardiol ; 167(1): 94-101, 2013 Jul 15.
Artículo en Inglés | MEDLINE | ID: mdl-22225709

RESUMEN

BACKGROUND: In patients with ischemic heart failure undergoing cardiac resynchronization therapy (CRT) the underlying myocardial substrate at the left ventricle (LV) pacing site may affect CRT response. However, the effect of delivering the pacing stimulus remote, adjacent to or over LV transmural scar tissue (TST) identified by echocardiography is still unknown. METHODS: First, 35 patients with healed myocardial infarction (57 ± 11 years) were prospectically studied to demonstrate the capability of echocardiographic end-diastolic wall thickness (EDWT) to identify LV-TST as defined by delayed enhancement magnetic resonance imaging (DE-MRI). Subsequently, in 136 patients (65 ± 10 years) who underwent CRT, EDWT was retrospectively evaluated at baseline. The LV catheter placement was defined over, adjacent to and remote from TST if pacing was delivered at a scarred segment, at a site 1 segment adjacent to or remote from scarred segments. CRT response was defined as LV end-systolic volume (ESV) decrease by at least 10% after 6 months. RESULTS: A EDWT ≤ 5mm identified TST at DE-MRI with 92% sensitivity and 96% specificity. In the 76 CRT responders, less overall and posterolateral TST segments and more segments paced remote from TST areas were found. At the multivariate regression analysis, the number of TST segments and scar/pacing relationship showed a significant association with CRT response. CONCLUSIONS: In addition to LV global scar burden, CRT response relates also to the myocardial substrate underlying pacing site as evaluated by standard echocardiography. This information may expand the role of echocardiography to guide pacing site avoiding pacing at TST areas.


Asunto(s)
Estimulación Cardíaca Artificial/métodos , Terapia de Resincronización Cardíaca/métodos , Cicatriz/diagnóstico por imagen , Remodelación Ventricular/fisiología , Anciano , Cardiomiopatías/diagnóstico por imagen , Cardiomiopatías/fisiopatología , Cardiomiopatías/terapia , Cicatriz/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios Retrospectivos , Resultado del Tratamiento , Ultrasonografía
16.
Atherosclerosis ; 205(2): 391-5, 2009 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-19203753

RESUMEN

OBJECTIVES: Atherosclerotic plaques contain both apoptotic cells and phagocytes. Apoptotic cells are known to exert an anti-inflammatory effect. Little is known on their action in patients with acute coronary syndromes. METHODS AND RESULTS: We challenged mononuclear phagocytes from the peripheral blood of patients with acute coronary syndromes (n=20) and healthy controls (n=30) with lipopolysaccharide (LPS, 100ng/ml) or peptidoglycan (PGN, 20microg/ml) in the presence or in the absence of apoptotic cells. After 24h, mononuclear phagocytes from patients with acute coronary syndromes produced more TNFalpha and IL-10 than controls; moreover, they were significantly more susceptible to the anti-inflammatory action of apoptotic cells. Apoptotic cells were more effective in ACS patients with C-reactive protein levels <3mg/l than in patients with CRP levels >3mg/l. CONCLUSIONS: Patients with acute coronary syndromes and low circulating C-reactive protein levels are more sensitive to the anti-inflammatory action of apoptotic cells: this suggests the existence of an enhanced anti-inflammatory feedback circuit, which could contribute to protect from plaque instability.


Asunto(s)
Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/tratamiento farmacológico , Antiinflamatorios/farmacología , Apoptosis , Anciano , Proteína C-Reactiva/metabolismo , Femenino , Células HeLa , Humanos , Interleucina-10/metabolismo , Leucocitos Mononucleares/citología , Lipopolisacáridos/metabolismo , Macrófagos/metabolismo , Masculino , Persona de Mediana Edad , Peptidoglicano/metabolismo , Fagocitos/citología , Factor de Necrosis Tumoral alfa/metabolismo
17.
J Am Soc Echocardiogr ; 22(6): 702-8, 2009 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-19423292

RESUMEN

BACKGROUND: Because echocardiography is routinely applied for left ventricle (LV) evaluation before cardiac resynchronization therapy (CRT), it is important to know whether echocardiographic assessment of myocardial scar burden may also help to predict CRT response in patients with drug-refractory systolic heart failure of ischemic origin. METHODS: Seventy-one patients with ischemic heart failure who underwent CRT were retrospectively analyzed. The number of LV scar segments was evaluated in each patient, defining transmural scar as an end-diastolic wall thickness < or = 5 mm associated with increased acoustic reflectance. CRT response was defined by LV end-systolic volume decrease by at least 10% after 6 months of treatment. The role of pacing site with respect to scar location was also assessed. RESULTS: Thirty-nine patients (55%) were responders and 32 patients (45%) were nonresponders to CRT. At baseline, responders had a lower number of scar segments (1.7 +/- 1.6 vs 3.5 +/- 2.5, P = .001). The number of scar segments was significantly associated with CRT response and correlated significantly with end-systolic volume variation (r = 0.57, P = .0001). The presence of 3 or more scar segments allowed the identification of nonresponders with a sensitivity of 62% and specificity of 71%. In responders, the pacing stimulus was more frequently delivered remote from scar segments, whereas in nonresponders it was more often delivered over the scar segments. CONCLUSION: Echocardiographic evaluation of transmural scar burden predicts CRT response after 6 months of treatment and should be performed in all candidates for CRT with ischemic heart failure before biventricular pacemaker implantation.


Asunto(s)
Estimulación Cardíaca Artificial/métodos , Ecocardiografía Doppler/métodos , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/prevención & control , Interpretación de Imagen Asistida por Computador/métodos , Aturdimiento Miocárdico/diagnóstico por imagen , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/prevención & control , Anciano , Algoritmos , Femenino , Humanos , Aumento de la Imagen/métodos , Masculino , Persona de Mediana Edad , Aturdimiento Miocárdico/prevención & control , Pronóstico , Análisis de Regresión , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y Especificidad , Programas Informáticos , Resultado del Tratamiento
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