Renin Angiotensin System Blockers and Risk of Mortality in Hypertensive Patients Hospitalized for COVID-19: An Italian Registry.

BACKGROUND: It is uncertain whether exposure to renin-angiotensin system (RAS) modifiers affects the severity of the new coronavirus disease 2019 (COVID-19) because most of the available studies are retrospective. METHODS: We tested the prognostic value of exposure to RAS modifiers (either angiotensin-converting enzyme inhibitors [ACE-Is] or angiotensin receptor blockers [ARBs]) in a prospective study of hypertensive patients with COVID-19. We analyzed data from 566 patients (mean age 75 years, 54% males, 162 ACE-Is users, and 147 ARBs users) hospitalized in five Italian hospitals. The study used systematic prospective data collection according to a pre-specified protocol. All-cause mortality during hospitalization was the primary outcome. RESULTS: Sixty-six patients died during hospitalization. Exposure to RAS modifiers was associated with a significant reduction in the risk of in-hospital mortality when compared to other BP-lowering strategies (odds ratio [OR]: 0.54, 95% confidence interval [CI]: 0.32 to 0.90, p = 0.019). Exposure to ACE-Is was not significantly associated with a reduced risk of in-hospital mortality when compared with patients not treated with RAS modifiers (OR: 0.66, 95% CI: 0.36 to 1.20, p = 0.172). Conversely, ARBs users showed a 59% lower risk of death (OR: 0.41, 95% CI: 0.20 to 0.84, p = 0.016) even after allowance for several prognostic markers, including age, oxygen saturation, occurrence of severe hypotension during hospitalization, and lymphocyte count (adjusted OR: 0.37, 95% CI: 0.17 to 0.80, p = 0.012). The discontinuation of RAS modifiers during hospitalization did not exert a significant effect (p = 0.515). CONCLUSIONS: This prospective study indicates that exposure to ARBs reduces mortality in hospitalized patients with COVID-19.

Joint effect of heart failure and coronary artery disease on the risk of death during hospitalization for COVID-19.

AIMS: heart failure (HF) and coronary artery disease (CAD) are independent predictors of death in patients with COVID-19. The adverse prognostic impact of the combination of HF and CAD in these patients is unclear. METHODS AND RESULTS: we analysed data from 954 consecutive patients hospitalized for SARS-CoV-2 in five Italian Hospitals from February 23 to May 22, 2020. The study was a systematic prospective data collection according to a pre-specified protocol. All-cause mortality during hospitalization was the outcome measure. Mean duration of hospitalization was 33 days. Mortality was 11% in the total population and 7.4% in the group without evidence of HF or CAD (reference group). Mortality was 11.6% in the group with CAD and without HF (odds ratio [OR]: 1.6, p = 0.120), 15.5% in the group with HF and without CAD (OR: 2.3, p = 0.032), and 35.6% in the group with CAD and HF (OR: 6.9, p<0.0001). The risk of mortality in patients with CAD and HF combined was consistently higher than the sum of risks related to either disorder, resulting in a significant synergistic effect (p<0.0001) of the two conditions. Age-adjusted attributable proportion due to interaction was 64%. Adjusting for the simultaneous effects of age, hypotension, and lymphocyte count did not significantly lower attributable proportion which persisted statistically significant (p = 0.0360). CONCLUSION: The combination of HF and CAD exerts a marked detrimental impact on the risk of mortality in hospitalized patients with COVID-19, which is independent on other adverse prognostic markers.

Pre-existing type 2 diabetes is associated with increased all-cause death independently of echocardiographic predictors of poor prognosis only in ischemic heart disease.

BACKGROUND AND AIMS: It is unknown whether the prognostic role of diabetes (T2DM) in outpatients with chronic heart failure (CHF) is independent of the most important echocardiographic markers of poor prognosis. The aims of this analysis were to evaluate whether T2DM modifies the risk of mortality in CHF patients stratified by etiology of disease or by right-ventricular to pulmonary arterial coupling at echocardiography and to evaluate how T2DM interacts with the prognostic role of cardiac plasma biomarkers. METHODS AND RESULTS: This is a retrospective analysis of 1627 CHF outpatients who underwent a complete echocardiographic examination. During a median follow-up period of 63 months 255 patients died. Poor right-ventricular to pulmonary arterial coupling and reduced left ventricular ejection fraction were independent predictors of outcome, whereas ischemic etiology and T2DM were not. T2DM interacted with etiology increasing the risk of mortality by 32% among patients with ischemic disease (p = 0.003). Elevated hsTNI plasma levels were associated with poor survival in T2DM but not in non-diabetic patients. CONCLUSION: T2DM signals a worse outcome in ischemic CHF patients regardless of the echocardiographic phenotype. High plasma levels of hsTNI are stronger predictors of mortality in CHF patients with T2DM than in patients without diabetes.

Automatic implantable cardioverter defibrillator: when not to implant.

The implantable cardioverter-defibrillator (ICD) is the mainstay therapy for primary prevention of sudden cardiac death in patients with heart failure with a reduced ejection fraction. Current indications for prophylactic ICD are based on the results of randomized controlled trials dating back to 15-20 years ago, which have usually enrolled highly selected patients with few comorbidities and only a small number of patients aged >75 years. Existing literature suggest an age-dependent attenuation of the efficacy of the ICD. Because of the ageing of the population, there is need for data addressing device efficacy among older patients that also considers the impact of geriatric syndromes on health status. The assessment of frailty may be of value in identifying elderly patients who may or may not benefit from ICD placement for primary prevention of sudden cardiac death.

[The ICD-ICF clinical model of hospital care]. / Il modello clinico ICD-ICF di cure ospedaliere.

SUMMARY: Because of the demographic shift and the increased proportion of patients surviving acute critical illnesses, the number of people living with severely disabling chronic diseases and, consequently, the demand for rehabilitation are expected to increase sharply overtime. As underscored by theWorld Health Organization (WHO), there is substantial evidence that the provision of inpatient rehabilitation in specialized rehabilitation units to people with complex needs is effective in fostering functional recovery, improving health-related quality of life, increasing independence, reducing institutionalization rate, and improving prognosis. Recent studies in the real-world setting reinforce the evidence that patients with ischemic heart disease or stroke benefit from rehabilitation in terms of improved prognosis. In addition, there is evidence of the effectiveness of rehabilitation for the prevention of functional deterioration in patients with complex and/or severe chronic diseases. Given this evidence of effectiveness, rehabilitation should be regarded as an essential part of the continuum of care (transitional care). Nonetheless, rehabilitation still is underdeveloped and underused. A new model based on ICD and ICF WHO disease and disfunctioning classification respectively and on pre-set clinical pathways is described. The aim of this model is to optimize clinical care in times of shortage of resources and huge increase in older chronic multi morbid patients.

[Diagnostic and therapeutic therapeutic pathways, including rehabilitative ones or only "discharge" rehabilitation?] / Percorsi diagnostico terapeutici assistenziali anche riabilitativi o riabilitazione "da scarico"?

SUMMARY: Due to epidemiological and social changes related to the increase in the average life expectancy, hospital users are characterized by elderly chronic and comorbid patients who require recurrent hospitalizations often with disability outcomes. In this framework, an innovative clinical and management hospitalization model is the adequate answer to systematically promote the patient independence. Main features are interdisciplinary and integrated care pathways facing both disease and disability biologically and functionally diagnosed by ICD and ICF. The definition, personalization of pathways/protocols and outcome evaluation represent the foundations of this new model for patient care. The digitalization of hospital clinical data and medical knowledge make the model feasible and fitting the recent WHO guideline: recommendations on digital interventions for health system strengthening.

Additive Value of Biomarkers and Echocardiography to Stratify the Risk of Death in Heart Failure Patients with Reduced Ejection Fraction.

BACKGROUND: Risk stratification is a crucial issue in heart failure. Clinicians seek useful tools to tailor therapies according to patient risk. METHODS: A prospective, observational, multicenter study on stable chronic heart failure outpatients with reduced left ventricular ejection fraction (HFrEF). Baseline demographics, blood, natriuretic peptides (NPs), high-sensitivity troponin I (hsTnI), and echocardiographic data, including the ratio between tricuspid annular plane excursion and systolic pulmonary artery pressure (TAPSE/PASP), were collected. Association with death for any cause was analyzed. RESULTS: Four hundred thirty-one (431) consecutive patients were enrolled in the study. Fifty deaths occurred over a median follow-up of 32 months. On the multivariable Cox model analysis, TAPSE/PASP ratio, number of biomarkers above the threshold values, and gender were independent predictors of death. Both the TAPSE/PASP ratio ≥0.36 and TAPSE/PASP unavailable groups had a three-fold decrease in risk of death in comparison to the TAPSE/PASP ratio <0.36 group. The risk of death increased linearly by 1.6 for each additional positive biomarker and by almost two for women compared with men. CONCLUSIONS: In a HFrEF outpatient cohort, the evaluation of plasma levels of both NPs and hsTnI can contribute significantly to identifying patients who have a worse prognosis, in addition to the echocardiographic assessment of right ventricular-arterial coupling.

Role and efficacy of cardiac rehabilitation in patients with heart failure.

Despite improvements in treatments, the prognosis of heart failure remains poor. Elderly patients with heart failure are burdened with multiple co-morbidities and polypharmacy. Multidisciplinary disease-management programs are recommended as standard care for patients at high risk of hospitalization. Cardiac rehabilitation is defined a coordinated multidimensional intervention that integrates the basic elements in multidisciplinary management programs with a continuing program of physical activity and exercise training. Cardiac rehabilitation services can be provided on an inpatient or outpatient basis according to the clinical characteristics and severity of the disease. Data support the usefulness of inpatient cardiac rehabilitation interventions soon after hospitalization for acute decompensated heart failure as a "transition care service" to overcome the particularly high risk "vulnerable" phase. Although in the elderly, physical activity is conditioned by the general clinical conditions, the presence of comorbidities and frailty, several data underscore the importance of improving exercise capacity in the elderly vulnerable patient.

Transthoracic echocardiographic assessment of cardiac output in mechanically ventilated critically ill patients by intensive care unit physicians / Avaliação ecocardiográfica transtorácica do débito cardíaco feita por médicos da unidade de terapia intensiva em pacientes críticos sob ventilação mecânica

Abstract Background and objectives: Transthoracic echocardiography may potentially be useful to obtain a prompt, accurate and non-invasive estimation of cardiac output. We evaluated whether non-cardiologist intensivists may obtain accurate and reproducible cardiac output determination in hemodynamically unstable mechanically ventilated patients. Methods: We studied 25 hemodynamically unstable mechanically ventilated intensive care unit patients with a pulmonary artery catheter in place. Cardiac output was calculated using the pulsed Doppler transthoracic echocardiography technique applied to the left ventricular outflow tract in apical 5 chamber view by two intensive care unit physicians who had received a basic Transthoracic Echocardiography training plus a specific training focused on Doppler, left ventricular outflow tract and velocity-time integral determination. Results: Cardiac output assessment by transthoracic echocardiography was feasible in 20 out of 25 enrolled patients (80%) and showed an excellent inter-operator reproducibility (Pearson correlation test r = 0.987; Cohen's K = 0.840). Overall, the mean bias was 0.03 L.min-1, with limits of agreement -0.52 and +0.57 L.min-1. The concordance correlation coefficient (ρc) was 0.986 (95% IC 0.966-0.995) and 0.995 (95% IC 0.986-0.998) for physician 1 and 2, respectively. The value of accuracy (Cb) of COTTE measurement was 0.999 for both observers. The value of precision (ρ) of COTTE measurement was 0.986 and 0.995 for observer 1 and 2, respectively. Conclusions: A specific training focused on Doppler and VTI determination added to the standard basic transthoracic echocardiography training allowed non-cardiologist intensive care unit physicians to achieve a quick, reproducible and accurate snapshot cardiac output assessment in the majority of mechanically ventilated intensive care unit patients.

Resumo Justificativa e objetivos: A ecocardiografia transtorácica pode ser potencialmente útil para obter uma estimativa rápida, precisa e não invasiva do débito cardíaco. Avaliamos se os intensivistas não cardiologistas podem obter uma determinação precisa e reprodutível do débito cardíaco em pacientes mecanicamente ventilados e hemodinamicamente instáveis. Métodos: Avaliamos 25 pacientes em unidade de terapia intensiva, mecanicamente ventilados, hemodinamicamente instáveis, com cateteres de artéria pulmonar posicionados. O débito cardíaco foi calculado com a técnica de ecocardiografia transtorácica com Doppler pulsátil aplicada à via de saída do ventrículo esquerdo no corte apical (5-câmaras) por dois médicos intensivistas que receberam treinamento básico em ecocardiografia transtorácica e treinamento específico focado em Doppler, via de saída do ventrículo esquerdo e determinação da integral de tempo-velocidade. Resultados: A avaliação do débito cardíaco pelo ecocardiograma transtorácico foi factível em 20 dos 25 pacientes inscritos (80%) e mostrou excelente reprodutibilidade entre operadores (teste de correlação de Pearson r = 0,987; K de Cohen = 0,840). No geral, o viés médio foi de 0,03 L.min-1, com limites de concordância de -0,52 e +0,57 L.min-1. O coeficiente de correlação de concordância (ρc) foi 0,986 (95% IC 0,966-0,995) e 0,995 (95% IC 0,986-0,998) para os médicos 1 e 2, respectivamente. O valor de precisão (Cb) da mensuração de COTTE foi de 0,999 para ambos os observadores. O valor de precisão (ρ) da mensuração de COTTE foi de 0,986 e 0,995 para os observadores 1 e 2, respectivamente. Conclusões: Um treinamento específico focado na determinação do Doppler e VTI, adicionado ao treinamento padrão em ecocardiografia transtorácica básica, permitiu que médicos não cardiologistas da unidade de terapia intensiva obtivessem uma avaliação rápida, reprodutível e precisa do débito cardíaco instantâneo na maioria dos pacientes mecanicamente ventilados em unidade de terapia intensiva.

[Transthoracic echocardiographic assessment of cardiac output in mechanically ventilated critically ill patients by intensive care unit physicians]. / Avaliação ecocardiográfica transtorácica do débito cardíaco feita por médicos da unidade de terapia intensiva em pacientes críticos sob ventilação mecânica.

BACKGROUND AND OBJECTIVES: Transthoracic echocardiography may potentially be useful to obtain a prompt, accurate and non-invasive estimation of cardiac output. We evaluated whether non-cardiologist intensivists may obtain accurate and reproducible cardiac output determination in hemodynamically unstable mechanically ventilated patients. METHODS: We studied 25 hemodynamically unstable mechanically ventilated intensive care unit patients with a pulmonary artery catheter in place. Cardiac output was calculated using the pulsed Doppler transthoracic echocardiography technique applied to the left ventricular outflow tract in apical 5 chamber view by two intensive care unit physicians who had received a basic Transthoracic Echocardiography training plus a specific training focused on Doppler, left ventricular outflow tract and velocity-time integral determination. RESULTS: Cardiac output assessment by transthoracic echocardiography was feasible in 20 out of 25 enrolled patients (80%) and showed an excellent inter-operator reproducibility (Pearson correlation test r=0.987; Cohen's K=0.840). Overall, the mean bias was 0.03L.min-1, with limits of agreement -0.52 and +0.57L.min-1. The concordance correlation coefficient (ρc) was 0.986 (95% IC 0.966-0.995) and 0.995 (95% IC 0.986-0.998) for physician 1 and 2, respectively. The value of accuracy (Cb) of COTTE measurement was 0.999 for both observers. The value of precision (ρ) of COTTE measurement was 0.986 and 0.995 for observer 1 and 2, respectively. CONCLUSIONS: A specific training focused on Doppler and VTI determination added to the standard basic transthoracic echocardiography training allowed non-cardiologist intensive care unit physicians to achieve a quick, reproducible and accurate snapshot cardiac output assessment in the majority of mechanically ventilated intensive care unit patients.

Prognostic impact of digoxin use for rate control of atrial fibrillation in patients ≥75 years of age.

Digoxin use remains a common therapeutic option in the pharmacological control of heart rate in patients with atrial fibrillation, endorsed in current guidelines with the same level of evidence than beta-blockers in patients with and without heart failure. Digoxin has a narrow therapeutic range and is influenced by drug-to-drug interactions, serum electrolyte concentrations, and renal function. Conflicting data exist regarding adverse outcomes that are associated with digoxin use in patients with atrial fibrillation. It remains unclear whether the association between digoxin use and worse clinical outcome is causal or may be the result of confounding by differences in the characteristics of patents including age, comorbidities and treatment. Particularly in older patients with atrial fibrillation, who are frequently prescribed a multitude of agents for stroke prevention, treatment of cardiovascular disease and other comorbidities, use of digoxin should be cautious and instituted with assessment of drug concentrations.

Haemodynamic effects of an acute vasodilator challenge in heart failure patients with reduced ejection fraction and different forms of post-capillary pulmonary hypertension.

AIMS: The most recent European guidelines have proposed new definitions of pulmonary hypertension (PH) in left heart disease, to better approach the characteristics required to reflect the presence of pulmonary vascular disease. The purpose of this study was to assess whether different haemodynamic definitions of post-capillary PH imply a different reversibility of PH in response to acute vasodilator administration in heart failure patients with reduced ejection fraction and PH (HFrEF-PH). METHODS AND RESULTS: Right heart catheterization and reversibility testing was performed in 156 HFrEF-PH patients. Patients were classified as combined post-capillary and pre-capillary pulmonary hypertension (Cpc-PH) vs. isolated post-capillary pulmonary hypertension (Ipc-PH) and on the basis of diastolic pulmonary gradient (DPG) ≥ 7 vs. < 7 mmHg or of transpulmonary gradient (TPG) >12 vs. ≤12 mmHg. After vasodilator administration, Cpc-PH patients showed a greater per cent improvement in pulmonary vascular resistance (PVR), DPG and TPG as compared with Ipc-PH patients (all Pint < 0.001); only pulmonary compliance (PCa) improved less in Cpc-PH than in Ipc-PH patients (Pint = 0.007). However, despite vasodilatation, Cpc-PH patients remained in an unfavourable portion of the inverse hyperbolic relationship between PVR and PCa. The number of patients in whom PVR was reduced below 2.5 wood units was similar in Cpc-PH, DPG ≥7 mmHg and TPG >12 mmHg groups (28.3, 26.7 and 18.9%, respectively). CONCLUSION: Although substantial improvements in PVR, DPG and TPG were observed in Cpc-PH patients after acute vasodilator administration, this response was associated with persistent abnormalities in the PVR vs. PCa relationship. The link between baseline right heart haemodynamics and pulmonary vascular disease remains elusive.

The reduction of central sleep apnoea severity in the left lateral position is not due to an improvement in cardiac haemodynamics in patients with chronic heart failure.

OBJECTIVE: The severity of central sleep apnoea (CSA), a common comorbidity in patients with chronic heart failure (CHF) and reduced ejection fraction, markedly decreases from the supine to the lateral sleeping position, with no difference between the left and right positions. The mechanisms responsible for this beneficial effect have not yet been elucidated. METHODS: We tested the hypothesis that CSA attenuation in the left lateral position is due, at least in part, to an improvement in cardiac haemodynamics. Sixteen CHF patients (male, aged 60 ± 7 years, New York Heart Association class 2.6 ± 0.5, left ventricular ejection fraction [LVEF] 30% ± 5%) with moderate-to-severe CSA underwent two consecutive tissue Doppler echocardiography examinations in random order, one in the left lateral position (90°) and the other in the supine position (0°). The following parameters were obtained: left ventricular end-diastolic volume (LVEDV) and LVEF, left atrial volume (LAV) and right atrial volume (RAV), mitral regurgitation (MR), cardiac output (CO), transmitral protodiastolic (E) wave deceleration time (DT), E/e' ratio, tricuspid annular plane systolic excursion (TAPSE), and right ventricular-atrial gradient (RVAG). RESULTS: The LAV, MR, E/e', RAV, and RVAG significantly increased, whereas the LVEF and TAPSE significantly decreased in the left lateral position. All changes, however, were of negligible clinical significance. No significant changes were observed in CO, DT, and LVEDV. CONCLUSIONS: This study shows that the reduction of CSA severity from the supine to the left lateral position in patients with CHF is not due to an improvement in cardiac haemodynamics. Other, noncardiac factors are likely to represent the main cause.

Different correlates but similar prognostic implications for right ventricular dysfunction in heart failure patients with reduced or preserved ejection fraction.

AIMS: To evaluate whether the clinical and echocardiographic correlates and the prognostic significance of right ventricular (RV) dysfunction are different in heart failure patients with reduced (HFrEF), mid-range (HFmrEF), or preserved (HFpEF) left ventricular ejection fraction. METHODS AND RESULTS: The study included 1663 patients with heart failure caused by ischaemic or hypertensive heart disease or by idiopathic cardiomyopathy. Left ventricular ejection fraction was <40% in 1123 patients (HFrEF), 40-49% in 156 patients (HFmrEF) and ≥50% in 384 patients (HFpEF). Imaging of the right ventricle was performed by echocardiography; RV function was defined on the basis of tricuspid annular plane systolic excursion (TAPSE) and its normalization for pulmonary artery systolic pressure (PASP). All-cause mortality was the endpoint of survival analysis. Non-sinus rhythm, high heart rate, ischaemic aetiology and E-wave deceleration time <140 ms were associated with a reduced TAPSE in HFrEF patients, whereas PASP >40 mmHg was by far the strongest correlate of a reduced TAPSE in HFpEF and HFmrEF patients (interaction analysis, P = 0.0011). TAPSE/PASP proved to be a powerful predictor of prognosis in all patients. CONCLUSIONS: The correlates of RV dysfunction differ in HFrEF compared with HFpEF and HFmrEF patients. Regardless of the extent of LV dysfunction, the TAPSE/PASP ratio is a powerful independent predictor of prognosis in all heart failure patients.

EaRly-start ExerciSe training afTer acute hemodynAmic decompensation in patients with chRonic hearT failure (RE-START). A multicenter, randomized, controlled trial on short-term feasibility and impact on functional capacity, symptoms and neurohumoral activation .

RE-START is a multicenter, randomized, prospective, open, controlled trial aiming to evaluate the feasibility and the short- and medium-term effects of an early-start AET program on functional capacity, symptoms and neurohormonal activation in chronic heart failure (CHF) patients with recent acute hemodynamic decompensation. Study endpoints will be: 1) safety of and compliance to AET; 2) effects of AET on i) functional capacity, ii) patient-reported symptoms and iii) AET-induced changes in beta-adrenergic receptor signaling and circulating angiogenetic and inflammatory markers. Two-hundred patients, randomized 1:1 to training (TR) or control (C), will be enrolled. Inclusion criteria: 1) history of systolic CHF for at least 6 months, with ongoing acute decompensation with need of intravenous diuretic and/or vasodilator therapy; 2) proBNP > 1000 pg/mI at admission. Exclusion criteria: 1) ongoing cardiogenic shock; 2) need of intravenous inotropic therapy; 3) creatinine > 2.5 mg/dl at admission. After a 72-hour run-in period, TR will undergo the following 12-day early-start AET protocol: days 1-2: active/passive mobilization (2 sessions/day, each 30 minutes duration); days 3-4: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 5-10 minutes duration); days 5-8: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 15-20 minutes duration); days 9-12: as days 1-2 + bedside cycle ergometer at 10-20 W (3 sessions/day, each 15-20 minutes duration). During the same period, C will undergo the same activity protocol as in days 1-2 for TR. All patients will undergo a 6-min WT at day 1, 6, 12 and 30 and echocardiogram, patient-reported symptoms on 7-point Likert scale and measurement of lymphocyte G protein coupled receptor kinase, VEGF, angiopoietin, TNF alfa, IL-1, IL-6 and eNOS levels at day 1, 12 and 30.

On site assessment of cardiac function and neural regulation in amateur half marathon runners.

OBJECTIVE: Strenuous exercise variably modifies cardiovascular function. Only few data are available on intermediate levels of effort. We therefore planned a study in order to address the hypothesis that a half marathon distance would result in transient changes of cardiac mechanics, neural regulation and biochemical profile suggestive of a complex, integrated adaptation. METHODS: We enrolled 35 amateur athletes (42±7 years). Supine and standing heart rate variability and a complete echocardiographic evaluation were assessed on site after the completion of a half marathon (postrace) and about 1 month after (baseline). Biochemical tests were also measured postrace. RESULTS: Compared to baseline, the postrace left ventricular end-diastolic volume was smaller, peak velocity of E wave was lower, peak velocity of A wave higher, and accordingly the E/A ratio lower. The postrace heart and respiratory rate were higher and variance of RR interval lower, together with a clear shift towards a sympathetic predominance in supine position and a preserved response to orthostasis. At baseline, athletes were characterised by a lower, although still predominant, sympathetic drive with a preserved physiological response to standing. CONCLUSIONS: Immediately after a half marathon there are clear marks that an elevated sympathetic cardiac drive outlasts the performance, together with decreased left ventricular diastolic volumes and slight modifications of the left ventricular filling pattern without additional signs of diastolic dysfunction or indices of transient left or right ventricular systolic abnormalities. Furthermore, no biochemical indices of any permanent cardiac damage were found.

Prognostic significance of tissue-Doppler imaging in chronic heart failure patients on transplant waiting list: a comparative study with right heart catheterization.

AIMS: Several echo-Doppler parameters, particularly the E/e' ratio, have been explored in the attempt to improve prognostic stratification in chronic heart failure (CHF) patients. In most studies, however, left ventricular filling pressure was not measured and patients with severe impairment of left ventricular function were not considered. The aim of this study was to assess the prognostic value of E/e' when compared with both traditional echo-Doppler parameters and pulmonary wedge pressure (PWP) in patients with advanced CHF. METHODS AND RESULTS: Right heart catheterization and a two-dimensional echo-Doppler examination were performed at baseline in 49 patients (male: 88%, age: 53 ± 9 years, New York Heart Association class: 2.7 ± 0.7, left ventricular ejection fraction: 29 ± 7%). Traditional pulsed-wave and tissue Doppler velocity parameters (DT, E, SFPVF, E', and E/e') were measured. Endpoint of survival analysis was cardiac death or urgent transplantation. During a median follow-up of 47 months (range: 1-58), 18 patients had experienced a major event (cardiac death or urgent transplantation). Both DT and E/e' were significantly and independently associated with the outcome (the Cox analysis), but the strength of the association was stronger for the latter (P= 0.008 vs. P= 0.03). Moreover, DT became non-significant when adjusted for PWP, whereas E/e' preserved its prognostic value (P= 0.04). The prognostic value of E' and PWP was borderline non-significant or clearly non-significant in both univariate and multivariable analyses. CONCLUSION: Among the echo-Doppler parameters, E/e' shows the highest predictive value in patients with advanced CHF and provides prognostic information independent of PWP. These results support the use of the feasible and easy obtainable E/e' ratio as a prognostic indicator in these patients.