Aortopathy and aortic valve surgery in patients with bicuspid aortic valve with and without raphe.

AIM: To evaluate the association between raphe in bicuspid aortic valve (BAV) patients and valve dysfunction, aortopathy and aortic valve surgery in the REBECCA registry [REgistro della valvola aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging (SIECVI)]. METHODS: Prevalence of aortic valve dysfunction and aortopathy was investigated in BAV patients with and without raphe. Aortic valve dysfunction (regurgitation or stenosis) was categorized as mild, moderate and severe. Aortopathy was defined as annulus ≥14 mm/m2; root ≥20 mm/m2; sinotubular junction ≥16 mm/m2; ascending aorta ≥17 mm/m2, and classified in Type A, isolated ascending aorta dilatation; Type B, aortic root and ascending aorta dilatation; and Type C, isolated aortic root dilatation. RESULTS: Overall, 695 patients with BAV were enrolled; 520 (74.8%) with raphe and 175 (25.2%) without raphe. BAV patients with raphe presented more frequently with moderate or severe aortic stenosis than BAV patients without raphe (183 [35.2%] vs 34 [19.4%], p < 0.001). A higher prevalence of aortopathy, particularly Type B, was observed in patients with vs without raphe. At multivariable analysis, raphe was a predictor of aortic valve surgery at three-year follow-up (odds ratio 2.19, 95% confidence interval 1.08-4.44, p < 0.001). CONCLUSIONS: Patients with BAV and raphe have a higher prevalence of significant aortic stenosis, aortopathy, especially Type B, and a higher risk of undergoing aortic valve surgery at three-year follow-up.

Heart valve calcification and cardiac hemodynamics.

PURPOSE: Heart valve calcification (VC) is associated with increased cardiovascular risk, but the hemodynamic and functional profile of patients affected by VC has not been fully explored. METHODS: The study population was formed by consecutive unselected patients included in seven echocardiographic laboratories in a 2-week period. A comprehensive echocardiographic examination was performed. VC was defined by the presence of calcification on at least one valve. RESULTS: Population was formed of 1098 patients (mean age 65 ± 15 years; 47% female). VC was present in 31% of the overall population. Compared with subjects without VC, VC patients were older (60 ± 14 vs 75 ± 9; P < .0001), had more hypertension (40% vs 57%; P = .0005), diabetes (11% vs 18%; P = .002), coronary artery disease (22% vs 38%; P = .04), and chronic kidney disease (4% vs 8%; P = .007). Furthermore, VC patients had lower ejection fraction (55 ± 14 vs 53 ± 25; P < .0001), worse diastolic function (E/e' 8.5 ± 4.6 vs 13.0 ± 7.1; P < .0001) and higher pulmonary artery pressure (29 ± 9 vs 37 ± 12; P < .0001). The association between VC and EF was not independent of etiology (p for VC 0.13), whereas the association with E/e' and PASP was independent in a full multivariate model (P < .0001 and P = .0002, respectively). CONCLUSION: Heart valve calcification patients were characterized by a worse functional and hemodynamic profile compared to patients with normal valve. The association between VC and diastolic function and PASP were independent in comprehensive multivariate models.

Refined 4-group classification of left ventricular hypertrophy based on ventricular concentricity and volume dilatation outlines distinct noninvasive hemodynamic profiles in a large contemporary echocardiographic population.

BACKGROUND: Left ventricular hypertrophy (LVH) may reflect a wide variety of physiologic and pathologic conditions. Thus, it can be misleading to consider all LVH to be homogenous or similar. Refined 4-group classification of LVH based on ventricular concentricity and dilatation may be identified. To determine whether the 4-group classification of LVH identified distinct phenotypes, we compared their association with various noninvasive markers of cardiac stress. METHODS: Cohort of unselected adult outpatients referred to a seven tertiary care echocardiographic laboratory for any indication in a 2-week period. We evaluated the LV geometric patterns using validated echocardiographic indexation methods and partition values. RESULTS: Standard echocardiography was performed in 1137 consecutive subjects, and LVH was found in 42%. The newly proposed 4-group classification of LVH was applicable in 88% of patients. The most common pattern resulted in concentric LVH (19%). The worst functional and hemodynamic profile was associated with eccentric LVH and those with mixed LVH had a higher prevalence of reduced EF than those with concentric LVH (P < .001 for all). CONCLUSIONS: The new 4-group classification of LVH system showed distinct differences in cardiac function and noninvasive hemodynamics allowing clinicians to distinguish different LV hemodynamic stress adaptations in patients with LVH.

Is anti-platelet therapy always necessary in asymptomatic 30-40% carotid stenosis?

Asymptomatic mild carotid artery stenosis is relatively frequent and associated with an increased risk of cardiovascular events. Its recognition is clinically relevant for appropriate prevention strategies. These include a healthy lifestyle approach and a careful pharmacologic control of cardiovascular risk factors, such as hypertension, hypercholesterolemia, and diabetes. Furthermore, interventions able to reduce the risk of atherothrombotic events, such as antiplatelet drugs, should be considered. Noninvasive imaging of carotid artery plaque and stenosis severity and morphology may add relevant information for the risk stratification of these subjects.

Scar Detection by Pulse-Cancellation Echocardiography: Validation by CMR in Patients With Recent STEMI.

OBJECTIVES: This study sought to assess an echocardiographic approach (scar imaging echocardiography with ultrasound multipulse scheme [eSCAR]), based on existing multipulse ultrasound scheme, as a marker of myocardial scar in humans, compared with cardiac magnetic resonance assessing late gadolinium enhancement (CMR-LGE). BACKGROUND: The detection of myocardial scar impacts patient prognosis and management in coronary artery disease and other types of cardiac disease. The clinical experience with echocardiography suggests that the reflected ultrasound signal is often significantly enhanced in infarcted myocardial segments. METHODS: Twenty patients with a recent ST-segment elevation myocardial infarction (STEMI) (cases) and 15 patients with absent CMR-LGE (negative controls) were imaged with both the eSCAR pulse-cancellation echocardiography and CMR-LGE to assess their potential association. RESULTS: Scar was detectable at CMR-LGE in 19 of 20 STEMI patients (91%), whereas all (100%) demonstrated eSCAR at echocardiography. In the 19 STEMI patients in whom CMR-LGE was detected, regional matching between eSCAR and CMR-LGE was total, although the segmental extent of detected scar was not always superimposable, particularly in the most apical segments, a region in which eSCAR demonstrated undersensitivity for the true extent of scar. CONCLUSIONS: A 2-dimensional multipulse echocardiography allows detection of myocardial scar, reliably matching the presence and site of CMR-LGE at 30 days after STEMI, or its absence in negative controls.

Differential incremental value of ultrasound carotid intima-media thickness, carotid plaque, and cardiac calcium to predict angiographic coronary artery disease across Framingham risk score strata in the APRES multicentre study.

AIMS: According to recent data, more accurate selection of patients undergoing coronary angiography for suspected coronary artery disease (CAD) is needed. From the Active PREvention Study multicentre prospective study, we further analyse whether carotid intima-media thickness (cIMT), carotid plaques (cPL), and echocardiographic cardiac calcium score (eCS) have incremental discriminatory and reclassification predictive value for CAD over clinical risk score in subjects undergoing coronary angiography, specifically depending on their low, intermediate, or high class of clinical risk. METHODS AND RESULTS: In eight centres, 445 subjects without history of prior CAD but with chest pain of recent onset and/or a positive/inconclusive stress test for ischaemia prospectively underwent clinically indicated elective coronary angiography after cardiac and carotid ultrasound assessments with measurements of cIMT, cPL, and eCS. The study population was divided into subjects at low (10%), intermediate (10-20%), and high (>20%) Framingham risk score (FRS). Ultrasound parameters were tested for their incremental value to predict CAD over FRS, in each pre-test risk category. No significant difference could be appreciated between the discrimination value of FRS and Diagnostic Imaging for Coronary Artery Disease score for the presence of CAD. eCS or cPL demonstrated significant incremental prediction over FRS, consistently in the three FRS categories (P < 0.01); this applied to both discrimination and reclassification, with the exception of high-risk subjects, in whom cPL was apparently not incremental over FRS, and eCS was only of borderline significance for better discrimination. CONCLUSIONS: Ultrasound eCS and cPL assessments were significant predictors of angiographic CAD in patients without prior CAD but with signs or symptoms suspect for CAD, independently and incrementally to FRS, across all pre-test risk probability strata, although in high-risk subjects, only eCS maintained an incremental value. The use of cIMT was not significantly incrementally useful in any FRS risk category.

Prognostic value of echocardiographic calcium score in patients with a clinical indication for stress echocardiography.

OBJECTIVES: The value of the echocardiographic calcium score (eCS) was evaluated to predict cardiac events in a multicenter cohort of subjects without known coronary disease, who underwent stress echocardiography (SE) for suspected coronary artery disease (CAD). BACKGROUND: Several studies have established that aortic valve sclerosis and/or calcification and mitral calcification, as detected by echocardiography, predict cardiovascular morbidity and mortality. The use of a semiquantitative total cardiac calcium score (eCS) to assess aortic and mitral valves, papillary muscles, and the ascending aorta has never been tested in multicenter studies; the inherent subjectivity and clinical applicability of such a parameter remains a concern. METHODS: We identified 1,303 patients from 5 Italian institutions and 1 U.S. institution, who had no known CAD and who underwent clinically-indicated pharmacological or exercise SE. They were followed up for myocardial infarction (MI) and all-cause death. eCS was assessed from archived images, and its discrimination and reclassification prognostic potential was determined. RESULTS: Fifty-eight patients met the combined endpoint of all-cause death (n = 37; 2.8%) or MI (n = 21; 1.6%) during a median follow-up of 808 days. Age, diabetes mellitus, eCS >0, and ischemic SE were multivariate predictors of hard events. Kaplan-Meier curves demonstrated that patients with ischemic SE or eCS >0 had worse outcomes. When both variables were abnormal, the prognosis was worse (p < 0.001). The multivariate model demonstrated that both eCS and ischemic SE independently contributed to risk prediction more than clinical variables. Both wall motion during SE and eCS were able to significantly reclassify the risk of events, but only stress wall motion demonstrated an incremental discrimination value. CONCLUSIONS: eCS demonstrated significant prognostic value in predicting hard cardiac events in a multicenter population of patients who required noninvasive evaluation. Its value was independent from clinical assessment and wall motion during SE, although it did not show incremental value over these factors for discrimination of patients with and without events.

Multiparametric carotid and cardiac ultrasound compared with clinical risk scores for the prediction of angiographic coronary artery disease: a multicenter prospective study.

OBJECTIVE: Cardiovascular risk prediction is deemed fundamental and the assessment of organ damage is emerging as a potentially 'downstream' picture of individual risk. Our aim was to assess the feasibility and value of prediction of coronaropathy [coronary artery disease (CAD)] of integrated cardiovascular ultrasound examination. METHODS: This multicenter study involved eight cardiology centers that enrolled 457 consecutive patients. Blood pressures, carotid intima-media thickness (cIMT), carotid pulse wave velocity (cPWV), semiquantitative score of cardiac calcifications, global myocardial longitudinal strain (GLS), and rest Doppler flow velocity on the left anterior descending (LAD) coronary artery were measured. After coronary angiography, patients were divided in CAD, n = 273, at least one coronary stenosis higher than 50%, and no CAD, n = 184. RESULTS: CAD were older (65.9 ±â€Š10.7 versus 63.1 ±â€Š11.2 years, mean ±â€Šstandard deviation, P = 0.01), and had higher blood pressure (137.0 ±â€Š18.8/77.5 ±â€Š11.1 versus 130.2 ±â€Š17.4/75.1 ±â€Š9.7 mmHg, P < 0.02), cIMT (791.4 ±â€Š165.5 versus 712.0 ±â€Š141.5 mcm, P < 0.0001), cPWV (median: 9 versus 8.1 m/s, P < 0.01), score of calcium (median, 2 versus 1, P < 0.0001), LAD velocity (median, 38 versus 36, P < 0.07), and lower GLS (-17.6 ±â€Š4.3 versus -19.3 ±â€Š5.1, P < 0.05) than no CAD. Score of calcium was feasible in the totality of patients, cIMT in 97%, cPWV in 86%, GLS in 88%, and LAD in 84%. A combination of at least three variables was measurable in 80% of the patients. All ultrasound parameters significantly predicted CAD. However, in a stepwise logistic regression, the only combined predictors of obstructive CAD were score of calcium, cIMT, and LAD velocity. CONCLUSION: In Echo-Lab, Rome, Italy, the integrated cardiovascular ultrasound study is feasible in a high percentage of patients. The combination of three parameters, that is, score of calcium, cIMT, and LAD velocity, has incremental predictive value for obstructive CAD.

Does treatment assignment influence the prognosis of patients with symptomatic severe aortic stenosis?

OBJECTIVE: Aortic valve replacement (AVR) is the standard therapy in patients with symptomatic aortic stenosis (AS). In high surgical risk patients, alternative therapeutic options to medical treatment (MT) such as trans-catheter aortic valve implantation (TAVI) or balloon aortic valvuloplasty (BAV) have been proposed. In this study we evaluated whether treatment assignment influences per se the prognosis of these subjects. PATIENTS AND METHODS: Criteria for treatment assignment were based on patient's clinical conditions, Logistic EuroSCORE and other co-morbidities ignored by EuroSCORE. Due to baseline clinical differences between patients with diverse treatment assignment, we used propensity score matching to achieve balance. RESULTS: 368 patients were studied: 141 underwent AVR, 127 TAVI, 49 BAV and 51 MT. 84 events (deaths for all causes) occurred during 14 months of follow-up: 11 AVR (8%), 26 TAVI (20%), 18 MT (35%), 29 BAV group (59%). Traditional Cox analysis identified treatment assignment as independent predictor of events (HR 1.82 [CI 1.10-3.25]) together with lower left ventricular ejection fraction, impaired renal function and history of heart failure. Matched Cox analysis by propensity score confirmed treatment assignment as an independent prognosticator of events (HR 1.90 [CI 1.27-2.85]), and showed similar rate events in TAVI and AVR patients, while it was significantly increased in BAV and MT patients. CONCLUSIONS: Treatment assignment may influence outcome of symptomatic patients with AS.

Cardiac calcium score on 2D echo: correlations with cardiac and coronary calcium at multi-detector computed tomography.

BACKGROUND: To test the hypothesis that a semi-quantitative echocardiographic calcium score (eCS) significantly correlates with cardiac calcium measured by coronary computed tomography angiography (CCTA) and, secondarily, severe coronary artery calcifications and stenosis. METHODS: This is a retrospective, observational study, conducted in a tertiary centre. eCS was compared with CCTA scores of non-coronary cardiac calcium (nCACS), coronary cardiac calcium (CACS) and number of diseased coronary vessels, in 141 subjects without known coronary artery disease (CAD), who underwent both echocardiography and CCTA for clinical reasons. RESULTS: Age, prevalence of hypertension and all measures of calcium (eCS, nCACS and CACS) differed significantly between the no-CAD and CAD subgroups. eCS was positively correlated with nCACS (Spearman rho = 0.64, p < 0.0001), CACS (rho = 0.46, p < 0.01) and weakly with the number of diseased coronary vessels (rho = 0.28, p < 0.05). eCS and nCACS had similar area under the curve (AUC) for the prediction of severe CACS (≥400) (0.77, 95% CI 0.68-0.86 and 0.79, 95% CI 0.72-0.88) or obstructive CAD (0.63, 95% CI 0.54-0.72 and 0.63, 95% CI 0.55-0.73). CONCLUSIONS: eCS, a calcium score easily obtainable during standard echocardiography, is moderately to strongly correlated with nCACS by CCTA. The full eCS score correlates with nCACS better than its single components. It correlates with CACS and predicts severe coronary calcification (CACS > 400), a known predictor of cardiovascular morbidity and mortality. The eCS also predicts obstructive CAD, incrementally to age and clinical variables, although for this purpose CACS remains the most accurate score.

Worksite health and wellness in the European union.

In recent years, trends in cardiovascular disease (CVD) incidence and prevalence in Europe have shown a significant decline. Nonetheless, CVD still remains the main cause of morbidity and mortality and, as such, more efficient intervention strategies are needed. In this context, workplace health promotion is universally viewed as a potential resource for further reducing CVD burden. Currently, the most active organizations for promoting workplace health promotion are the European Agency for Safety and Health at Work, the European Network for Workplace Health Promotion and the Wellness International. The idea of wellbeing in the workplace has multiple meanings across organizations and countries in Europe and no comprehensive surveys examining its exact prevalence and overall impact are currently available. This review will describe the current state of workplace health promotion in Europe and address future directions for this potentially important intervention strategy.

Effects of spironolactone on long-term mortality and morbidity in patients with heart failure and mild or no symptoms.

BACKGROUND: The purpose of this study is to evaluate long-term effects of spironolactone, an affordable and widely used aldosterone receptor blocker, in patients with heart failure (HF) and mild or no symptoms. METHODS: The study is a single-blind, placebo-controlled, blinded endpoint, randomized study. Patients with New York Heart Association (NYHA) classes I to II HF and left ventricular ejection fraction < 40% were randomized to spironolactone or placebo in addition to optimal therapy. The primary endpoint was the composite of death from any cause or cardiovascular hospitalization. RESULTS: A total of 130 patients were randomized to spironolactone (n = 65) or placebo (n = 65). Patients on spironolactone had a better event-free survival for cardiovascular death or cardiovascular hospitalizations and for cardiovascular hospitalizations alone. At multivariable analysis, only spironolactone therapy, left ventricular ejection fraction and serum creatinine levels had an independent prognostic value for the combined endpoint, whereas only spironolactone therapy and serum creatinine levels had an independent prognostic value for cardiovascular hospitalizations alone. CONCLUSIONS: Administration of spironolactone reduced the composite of death and cardiovascular hospitalization in patients with NYHA classes I to II HF. These results suggest that spironolactone could be beneficial when administered on top of optimal therapy among patients with HF and mild or no symptoms.

The increasing detection of asymptomatic left ventricular dysfunction in patients with type 2 diabetes mellitus without overt cardiac disease: data from the SHORTWAVE study.

AIMS: Type 2 diabetes mellitus (DM) is associated with higher risk of heart failure. Over the last three decades several studies demonstrated the presence of asymptomatic systolic and/or diastolic left ventricular (LV) dysfunction (asymLVD) in patients with normal LV ejection fraction (LVEF). Purpose of our study was to assess the prevalence and factors associated with asymLVD in DM patients by echocardiographic indexes more sensitive than LVEF and transmitral flow detected by pulsed Doppler. METHODS: 386 DM patients without overt cardiac disease were enrolled from January to October 2011. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S') were considered as indexes of systolic function of circumferential and longitudinal myocardial fibers, respectively. Early diastolic velocity of transmitral flow was divided by early diastolic Tissue Doppler velocity of mitral annulus for identifying diastolic LVD. RESULTS: asymLVD was detected in 262 patients (68%). 106 (27%) had isolated systolic asymLVD, 61 (16%) isolated diastolic asymLVD; in 95 (25%) systolic and diastolic asymLVD coexisted. Patients with asymLVD were older, had lower glomerular filtration rate, higher levels of glycated hemoglobin, C reactive protein, LV mass, relative wall thickness and prevalence of valve calcifications. Older age (HR 1.1 [1.02-1.18], p=0.01), aortic valve calcifications (HR 6.3 [1.31-30.31], p=0.02), LV concentric geometry defined as relative wall thickness ≥0.43 (HR 15.44 [2.96-80.44], p=0.001) were independent predictors of asymLVD at multivariate analysis. CONCLUSIONS: Using suitable echocardiographic indexes, asymLVD is detectable in two/third of DM patients without overt cardiac disease and is predicted by older age, cardiac valve calcifications and LV concentric remodeling.

[Cardiovascular risk profile and lifestyle habits in a cohort of Italian cardiologists. Results of the SOCRATES survey]. / Profilo di rischio cardiovascolare e stili di vita in una coorte di cardiologi Italiani. risultati della survey SOCRATES (Survey on Cardiac Risk Profile and Lifestyle Habits in a Cohort of Italian Cardiologists).

OBJECTIVES: To offer a snapshot of the personal health habits of Italian cardiologists, the Survey on Cardiac Risk Profile and Lifestyle Habits in a Cohort of Italian Cardiologists (SOCRATES) study was undertaken. BACKGROUND: Cardiologists' cardiovascular profile and lifestyle habits are poorly known worldwide. METHODS: A Web-based electronic self-reported survey, accessible through a dedicated website, was used for data entry, and data were transferred via the web to a central database. The survey was divided in 4 sections: baseline characteristics, medical illnesses and traditional cardiovascular risk factors, lifestyle habits and selected medication use. The e-mail databases of three national scientific societies were used to survey a large and representative sample of Italian cardiologists. RESULTS: During the 3-month period of the survey, 1770 out of the 5240 cardiologists contacted (33.7%) completed and returned one or more sections of the questionnaire. More than 49% of the participants had 1 out of 5 classical risk factors (e.g. hypertension, hypercholesterolemia, active smoking, diabetes and previous vascular events). More than 28% of respondents had 2 to 5 risk factors and only 22.1% had none and therefore, according to age and sex, could be considered at low-intermediate risk. Despite the reported risk factors, more than 90% of cardiologists had a self-reported risk perception quantified as mild, such as low or intermediate. Furthermore, overweight/obesity, physical inactivity and stress at work or at home were commonly reported, as well as a limited use of cardiovascular drugs, such as statins or aspirin. CONCLUSIONS: The average cardiovascular profile of Italian cardiologist is unlikely to be considered ideal or even favorable according to recent statements and guidelines regarding cardiovascular risk. Thus, there is a large room for improvement and a need for education and intervention.

Tricuspid valve myxoma in a patient with congestive heart failure.

Myxomas are the most frequent benign primary cardiac tumours (50% of benign heart tumours). This kind of tumour is most likely to be localized in the left atrium, followed by the right atrium, right ventricle and left ventricle. Quite exceptional is the presence of a myxoma originating from the tricuspid valve or from the Eustachian valve. We describe the case of a woman with moderate dyspnoea of unknown origin and the presence of tricuspid myxoma who underwent tricuspid valve curettage.