Ultrasonographic screening for developmental dysplasia of the hip: the Graf method revisited.

Until the 1980s, the diagnosis of developmental dysplasia of the hip (DDH) was based on clinical examination and radiographic imaging. In 1980, Reinhard Graf developed his own ultrasonographic method for the examination of the infant hip joint. Graf's method evaluates the osseous and cartilaginous coverage of the femoral head by the acetabulum in the infantile hip joint by measuring the angles α and ß. The validity of Graf method is that with these measurements the hip joint is further classified by Graf classification into types I to IV that guide treatment. Currently, Graf method is considered the gold standard examination for the diagnosis of DDH in many European countries. This review article aims to discuss the incidence, risk factors and pathophysiology of DDH, and to emphasize on the Graf method for the evaluation, classification, prevention and further management of this entity.

Association of aortic stiffness early post myocardial infarction with left ventricular remodelling.

BACKGROUND: Adverse left ventricular (LV) remodelling after myocardial infarction is associated with heart failure. We investigated whether aortic stiffness during acute ST-segment elevation myocardial infarction is associated with LV remodelling at long-term follow-up. METHODS: In 109 patients within 48 h of myocardial infarction post-primary percutaneous coronary intervention and after 2 years, we measured: (a) carotid to femoral pulse wave velocity (PWV), (b) LV global longitudinal strain (GLS) and left atrial strain using speckle-tracking echocardiography, (c) PWV/GLS ratio as a surrogate marker of ventricular-arterial interaction, and (d) LV end-diastolic and end-systolic volumes. A > 15% decrease from the baseline in LV end-systolic volume at 2-year follow-up was considered as a criterion of reverse LV remodelling. RESULTS: Compared with baseline, all patients had reduced PWV, LV end-diastolic and end-systolic volumes while PWV/GLS, GLS and reservoir left atrial strain were improved (p < .05) after 2 years. Baseline values of PWV, GLS, PWV/GLS ratio and reservoir left atrial strain were associated with percentage change of LV end-systolic volume at 2 years (p < .05). Multivariable analysis revealed that lower baseline values of PWV and a less impaired GLS and PWV/GLS were independently associated with reverse LV remodelling at 2 years with a C-statistic of .748, .711 and .787, respectively. CONCLUSION: Aortic stiffness early post-infarction determines LV remodelling after 2 years of the ischemic event despite post successful revascularization. CLINICAL TRIAL REGISTRATION-URL: http://www. CLINICALTRIALS: gov. Unique identifier: NCT03984123, 30/04/2020.

Hospitalization for acute heart failure during non-working hours impacts on long-term mortality: the REPORT-HF registry.

AIMS: Hospital admission during nighttime and off hours may affect the outcome of patients with various cardiovascular conditions due to suboptimal resources and personnel availability, but data for acute heart failure remain controversial. Therefore, we studied outcomes of acute heart failure patients according to their time of admission from the global International Registry to assess medical practice with lOngitudinal obseRvation for Treatment of Heart Failure. METHODS AND RESULTS: Overall, 18 553 acute heart failure patients were divided according to time of admission into 'morning' (7:00-14:59), 'evening' (15:00-22:59), and 'night' (23:00-06:59) shift groups. Patients were also dichotomized to admission during 'working hours' (9:00-16:59 during standard working days) and 'non-working hours' (any other time). Clinical characteristics, treatments, and outcomes were compared across groups. The hospital length of stay was longer for morning (odds ratio: 1.08; 95% confidence interval: 1.06-1.10, P < 0.001) and evening shift (odds ratio: 1.10; 95% confidence interval: 1.07-1.12, P < 0.001) as compared with night shift. The length of stay was also longer for working vs. non-working hours (odds ratio: 1.03; 95% confidence interval: 1.02-1.05, P < 0.001). There were no significant differences in in-hospital mortality among the groups. Admission during working hours, compared with non-working hours, was associated with significantly lower mortality at 1 year (hazard ratio: 0.88; 95% confidence interval: 0.80-0.96, P = 0.003). CONCLUSIONS: Acute heart failure patients admitted during the night shift and non-working hours had shorter length of stay but similar in-hospital mortality. However, patients admitted during non-working hours were at a higher risk for 1 year mortality. These findings may have implications for the health policies and heart failure trials.

What do hip fracture patients die from?

Hip fractures in the elderly are associated with an increased mortality rate, even if they are operated within the recommended time window. However, the causes of mortality vary considerably depending on the postoperative period and the patients' comorbidities. In the 30-day postoperative period, the most common causes of death are acute processes such as bacterial and aspiration pneumonia followed by myocardial infarction, cancer, gastrointestinal hemorrhage, stroke, pulmonary embolism, and acute renal failure. In the 6-month and 1-year postoperative period, chronic processes appear to be the most important causes of death, as well as decompensation of patients' chronic diseases. To enhance the literature, we performed this literature review to summarize and discuss the causes of mortality of elderly hip fracture patients depending on the postoperative period that they occur, and possibly to address the question what do hip fracture patients die from? Our aim was to perform an interesting and concise paper that the curious reader will find interesting and informative.

Orthopaedic cardiac considerations in emergency.

Orthopaedic patients undergoing emergency orthopaedic surgery should be referred for cardiac evaluation only when they are symptomatic or when a specific cardiac intervention is expected to reduce the surgical risk. A preoperative delay of 24-48 h of emergency orthopaedic operations has been associated with increased mortality and poor functional status of the patients. Research in the preoperative setting is almost exclusively retrospective because randomized studies are difficult to be performed and pose serious ethical concerns. Moreover, inevitably, guidelines have a low level of evidence and do not always provide a straightforward framework for the preoperative care of the patients. This editorial revisits the most common clinical cardiology dilemmas for emergency orthopaedic surgery to explore controversies of current recommendations and elaborate on the role of echocardiography in the perioperative period in emergency orthopaedic surgery.

Optimal Blood Pressure Control Improves Left Ventricular Torsional Deformation and Vascular Function in Newly Diagnosed Hypertensives: a 3-Year Follow-up Study.

We investigated the effects of optimizing blood pressure control on cardiac deformation and vascular function. For this purpose, in 200 untreated patients with essential hypertension, we assessed at baseline as well as after 3 years of optimal blood pressure control: arterial stiffness and coronary microcirculatory function as well as longitudinal and torsional deformation parameters. Compared to baseline, after 3 years of optimal blood pressure control, there was an improvement of longitudinal strain, twisting as well as untwisting parameters of the left ventricle. In parallel, there was an improvement in coronary microcirculatory function, arterial stiffness, left ventricular mass, and ventricular-arterial interaction. The reduction of arterial stiffness was independently associated with the respective improvement of cardiac deformation markers and coronary flow reserve after adjusting for blood pressure improvement. Blood pressure optimization improves LV longitudinal and torsional mechanics in hypertensives in parallel with arterial stiffness, resulting in improved ventricular-arterial interaction and coronary flow reserve. Trial registration: ClinicalTrials.gov Identifier: NCT02346695.

Pulse wave velocity to global longitudinal strain ratio in hypertension.

BACKGROUND: Arterial elastance to left ventricular elastance ratio assessed by echocardiography is widely used as a marker of ventricular-arterial coupling. MATERIALS AND METHODS: We investigated whether the ratio of carotid-femoral pulse wave velocity, as a marker of arterial stiffness, to global longitudinal strain, as a marker of left ventricular performance, could be better associated with vascular and cardiac damage than the established arterial elastance/left ventricular elastance index. In 299 newly-diagnosed untreated hypertensives we measured, carotid-femoral pulse wave velocity, and carotid intima-media thickness, coronary-flow reserve, arterial elastance/left ventricular elastance, global longitudinal strain, and markers of left ventricular diastolic function (E/A and E') by echocardiography. RESULTS: Pulse wave velocity-to-global longitudinal strain ratio (PWV/GLS) was lower in hypertensives than controls (-0.61 ± 0.21 vs -0.45 ± 0.11 m/sec%, P < 0.001). Low PWV/GLS values were associated with carotid-intima media thickness > 0.9 mm (P = 0.003), E/A ≤ 0.8 (P = 0.019) and E' ≤ 9 cm/sec (P = 0.002) and coronary-flow reserve < 2.5 (P = 0.017), after adjustment for age, sex and mean arterial pressure. Low PWV/GLS was also associated with increased left ventricular mass and left atrial volume in the univariate (P = 0.003 and 0.038) but not in the multivariate model. In hypertensives, there was no significant association of arterial elastance-to-left ventricular elastance index with carotid intima media thickness, coronary flow reserve, E/A, E', or left atrial volume with the exception of an inverse association with left ventricular mass (P = 0.027). CONCLUSIONS: Pulse wave velocity-to-global longitudinal strain ratio but not the echocardiography-derived arterial elastance-to left ventricular elastance index is related to impaired carotid-intima media thickness, coronary-flow reserve and diastolic function in hypertensives.

S100B Levels in Patients with Type 2 Diabetes Mellitus and Co-Occurring Depressive Symptoms.

Depression is a comorbid condition in patients with Type 2 Diabetes mellitus (T2DM). S100B, a glia derived protein, is linked to depression and has been suggested as a biomarker for depression outcomes in several populations. However, to date there is no data about S100B levels and depression in patients with T2DM. Objective. We hypothesized that S100B serum levels are increased in patients with T2DM and recently diagnosed, drug-free depressive symptoms, and could be used for the diagnosis of depression in T2DM. Methods. Overall 52 patients (62 ± 12 years, female 66, 7%) with no history of depression deriving from the Diabetes out-patient clinic of our University Hospital underwent a one-to-one interview with a psychiatrist and filled a self-assessment (Zung) questionnaire. Serum S00B levels were compared between 30 (63±12 years, female 66, 7%) diabetic patients without depressive symptoms vs 22 patients (62 ±12 years, female 68, 2%) with T2DM and depressive symptoms. Results. There was no difference in serum levels of S100B between patients with T2DM without depressive symptoms vs diabetic patients suffering from depressive symptoms (2.1 (1.9-10.9) pg/ml vs 2.4 (1.9-14.8) pg/ml, p=0. 637+). Moreover, linear regression analysis did not show any association between lnS100B levels and depressive symptoms (ß = 0.084, 95% CI 0.470-0.871, and p=0.552), Zung self-assessment score (ß = 0.048, 95% CI -0.024-0.033, and p=0.738), and other patients' characteristics. Conclusions. In patients with T2DM there is no correlation between S100B serum levels and newly detected mild depressive symptoms. The brain biochemistry pathways of depression in T2DM warrant further investigation in a larger scale population.

Overview of mitral regurgitation in Europe: results from the European Registry of mitral regurgitation (EuMiClip).

Aims: To determine the prevalence of mitral regurgitation (MR) in a large cohort of consecutive patients undergoing clinically indicated echocardiography and to examine the distribution of primary and secondary MR. Methods and results: All patients undergoing an echocardiographic study in 19 European centres within a 3-month period were prospectively included. MR assessment was performed as recommended by the European Association of Cardiovascular Imaging (EACVI). MR was classified according to mechanism as primary or secondary and aetiologies were reported. A total of 63 463 consecutive echocardiographic studies were reviewed. Any degree of MR was described in 15 501 patients. Concomitant valve disease of at least moderate grade was present in 28.5% of patients, being tricuspid regurgitation the most prevalent. In the subgroup of moderate and severe MR (n = 3309), 55% of patients had primary MR and 30% secondary MR. Both mechanisms were described in 14% of the studies. According to Carpentier's classification, 26.7% of MR were classified as I, 19.9% of MR as II, 22.4% of MR as IIIa, and 31.1% of MR as IIIb. Conclusion: To date, this is the largest echocardiography-based study to analyse the prevalence and aetiology distribution of MR in Europe. The burden of secondary MR was higher than previously described, representing 30% of patients with significant MR. In our environment, degenerative disease is the most common aetiology of primary MR (60%), whereas ischaemic is the most common aetiology of secondary MR (51%). Up to 70% of patients with severe primary MR may have a Class I indication for surgery. However, the optimal therapeutic approach for secondary MR remains uncertain.

Relationship Between Myocardial Function, Body Mass Index, and Outcome After ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: Better survival for overweight and obese patients after ST-segment-elevation myocardial infarction (STEMI) has been demonstrated. The association between body mass index (BMI), outcome, and left ventricular (LV) structure and function after STEMI, including LV longitudinal strain (global longitudinal strain), was evaluated. METHODS AND RESULTS: First patients with STEMI undergoing primary percutaneous coronary intervention (n=1604; mean age, 61±12 years; 75% men) had BMI measured on admission, and 2-dimensional transthoracic echocardiography performed within 48 hours. Patients were categorized based on standard criteria (normal/underweight, BMI<25 kg/m2 [n=486]; overweight, 25≤BMI<30 kg/m2 [n=820]; obese, BMI≥30 kg/m2 [n=298]). LV global longitudinal strain was measured using speckle-tracking analysis. Primary outcome measure was all-cause mortality. Compared with normal/underweight patients, obese patients were younger and more likely to have diabetes mellitus, hypertension, and hyperlipidemia and have higher discharge blood pressures. Despite no significant differences in infarct size, obese patients had significantly more impaired LV global longitudinal strain (-13.7±3.8 versus -15.0±4.2% and -15.0±4.1%; P<0.001) compared with normal/underweight and overweight patients, respectively. Although normal/underweight patients had the worst overall survival (log-rank P=0.04) after STEMI during a median follow-up of 5.2 (3.6, 6.9) years on Kaplan-Meier analysis, a significant nonlinear association between BMI and all-cause mortality across the range of BMI was seen, persisting after adjustment for age and sex. CONCLUSIONS: Obese patients demonstrate greater adverse LV remodeling and more impaired LV deformation after STEMI compared with those with normal BMI, amid similar infarct characteristics. Normal weight patients continue to demonstrate the worst survival, suggesting that the potential nonadverse effect of higher BMI in this population is independent of LV function.

Transcatheter aortic valve thrombosis: the relation between hypo-attenuated leaflet thickening, abnormal valve haemodynamics, and stroke.

AIMS: The presence of hypo-attenuated leaflet thickening (HALT) and/or reduced leaflet motion on multi-detector row computed tomography (MDCT) has been proposed as a possible marker for early transcatheter aortic valve thrombosis. However, its association with abnormal valve haemodynamics on echocardiography (another potential marker of thrombosis) and clinical outcomes (stroke) remains unclear. The present study evaluated the prevalence of HALT on MDCT and abnormal valve haemodynamics on echocardiography. In addition, the occurrence of ischemic stroke and/or transient ischemic attack (TIA) was assessed. METHODS AND RESULTS: A total of 434 patients (mean age 80 ± 7 years, 51% male) who underwent transcatheter aortic valve replacement (TAVR) were evaluated. Transcatheter valve haemodynamics were assessed on echocardiography at discharge, 6 months, and thereafter yearly (up to 3 years post-TAVR). The presence of HALT and/or reduced leaflet motion was assessed on MDCT performed 35 days [interquartile range 19-210] after TAVR in 128 of these 434 patients. Possible TAVR valve thrombosis was defined by mean transvalvular gradient ≥20 mmHg and aortic valve area (AVA) ≤1.1cm2 on echocardiography or by the presence of HALT or reduced leaflet motion on MDCT. The occurrence of ischemic stroke/TIA at follow-up was recorded. HALT and/or reduced leaflet motion was present in 12.5% of 128 patients undergoing MDCT, and was associated with a slightly higher mean transvalvular gradient (12.4 ± 8.0 mmHg vs. 9.4 ± 4.3 mmHg; P = 0.026) and smaller AVA (1.49 ± 0.39 cm2 vs. 1.78 ± 0.45 cm2, P = 0.017). Only one patient with HALT on MDCT revealed abnormal valve haemodynamics on echocardiography. At 3-year follow-up, abnormal valve haemodynamics on echocardiography were observed in 3% of patients. HALT on MDCT and abnormal valve haemodynamics on echocardiography were not associated with increased risk of ischemic stroke/TIA. CONCLUSION: On MDCT, 12.5% of patients showed HALT or reduced leaflet motion, whereas only one of these patients had abnormal valve haemodynamics on echocardiography. Neither HALT nor increased transvalvular gradient were associated with stroke/TIA.

Cardiac Biomarkers Predict 1-Year Mortality in Elderly Patients Undergoing Hip Fracture Surgery.

This prospective study included 152 elderly patients (mean age, 80 years; range, 72-88 years) with a hip fracture treated surgically. Comorbidities were evaluated, and B-type natriuretic peptide was measured at baseline and at postoperative days 4 and 5 in addition to troponin I. Major cardiac events were recorded, and 1-year mortality was assessed. Comorbidity models with the important multivariate predictors of 1-year mortality were analyzed. Overall, 9 patients (6%) experienced major cardiac events postoperatively during their hospitalization. Three patients (2%) died postoperatively, at days 5, 7, and 10, from autopsy-confirmed myocardial infarction. Three patients (2%) experienced a nonfatal myocardial infarction, and 3 patients (2%) experienced acute heart failure. At 1-year follow-up, 37 patients (24%) had died. Age older than 80 years (P=.000), renal failure (P=.016), cardiovascular disease (P=.003), respiratory disease (P=.010), Parkinson disease (P=.024), and dementia (P=.000) were univariate predictors of 1-year mortality. However, in the multivariate model, only age older than 80 years (P=.000) and dementia (P=.024) were important predictors of 1-year mortality. In all comorbidity models, age older than 80 years and dementia were important predictors of 1-year mortality. Postoperative increase in B-type natriuretic peptide was the most important predictor of 1-year mortality. Receiver operating characteristic curve analysis showed a threshold of 90 ng/mL of preoperative B-type natriuretic peptide (area under the curve=0.773, 95% confidence interval, 0.691-0.855, P<.001) had 82% sensitivity and 62% specificity to predict 1-year mortality. Similarly, a threshold of 190 ng/mL of postoperative B-type natriuretic peptide (area under the curve=0.753, 95% confidence interval, 0.662-0.844, P<.001) had 70% sensitivity and 77% specificity to predict the study endpoint. [Orthopedics. 2017; 40(3):e417-e424.].

Acute heart failure with mid-range left ventricular ejection fraction: clinical profile, in-hospital management, and short-term outcome.

BACKGROUND: Heart failure with mid-range left ventricular ejection fraction (HFmrEF) is a poorly characterized population as it has been studied either in the context of HF with reduced (HFrEF) or preserved (HFpEF) left ventricular ejection fraction (LVEF) depending on applied LVEF cutoffs. We sought to investigate the clinical profile, in-hospital management, and short-term outcome of HFmrEF patients in comparison with those with HFrEF or HFpEF in a large acute HF cohort. METHODS AND RESULTS: The Acute Heart Failure Global Registry of Standard Treatment (ALARM-HF) included 4953 patients hospitalized for HF in nine countries in Europe, Latin America, and Australia. Baseline characteristics, clinical presentation, in-hospital therapies, and short-term mortality (all-cause in-hospital or 30-day mortality, whichever first) were compared among HFrEF (LVEF <40%), HFmrEF (LVEF 40-49%), and HFpEF (LVEF ≥50%) patients. Among 3257 patients with documented LVEF, 52% had HFrEF, 25% HFmrEF, and 23% HFpEF. Patients with HFmrEF had a distinct demographic and clinical profile with many intermediate features between HFrEF and HFpEF. In addition, they had a higher prevalence of hypertension (p < 0.001), a lower prevalence of chronic renal disease (p = 0.003), more hospitalizations for acute coronary syndrome (p < 0.001), or infection (p = 0.003), and were more frequently treated with intravenous vasodilators compared to HFrEF or HFpEF. Adjusted short-term mortality in HFmrEF was lower than HFrEF [hazard ratio (HR) = 0.635 (0.419, 0.963), p = 0.033] but similar to HFpEF [HR = 1.026 (0.605, 1.741), p = 0.923]. CONCLUSION: Hospitalized HFmrEF patients represent a demographically and clinically diverse group with many intermediate features compared to HFrEF and HFpEF and carry a lower risk of short-term mortality than HFrEF but a similar risk with HFpEF.

Influence of Myocardial Ischemia Extent on Left Ventricular Global Longitudinal Strain in Patients After ST-Segment Elevation Myocardial Infarction.

Two-dimensional echocardiographic left ventricular (LV) global longitudinal strain (GLS) after ST-segment elevation myocardial infarction (STEMI) is moderately correlated with infarct size and reflects the residual LV systolic function. This correlation may be influenced by the presence of myocardial ischemia. The present study investigated how myocardial ischemia modulates the correlation between LV GLS and infarct size determined with single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in patients with first STEMI treated with primary coronary intervention. A total of 1,128 patients (age 60 ± 11 years) who underwent SPECT MPI for the evaluation of infarct size and residual ischemia were evaluated. LV GLS was measured on transthoracic echocardiography. The time interval between echocardiography and SPECT MPI was 1 ± 1 month. A moderate correlation between echocardiographic LV GLS and infarct size on SPECT MPI was observed (r = 0.58, p <0.001). This correlation was weakened by the presence or extent of ischemia; in the group of patients without ischemia, the correlation between LV GLS and infarct size on SPECT MPI was r = 0.66 (p <0.001), whereas in patients with mild or moderate-to-severe ischemia, the correlations were r = 0.56 and 0.38, respectively (both p <0.001). Moderate-to-severe myocardial ischemia was independently associated with more impaired LV GLS after adjusting for infarct size, age, diabetes mellitus, and hypertension (ß 0.60, 95% confidence interval 013 to 1.06). In conclusion, the presence of myocardial ischemia after STEMI impacts on the correlation between echocardiographic LV GLS and infarct size measured on SPECT MPI. Residual ischemia is independently associated with more impaired LV GLS.

Left Atrial Dysfunction in the Pathogenesis of Cryptogenic Stroke: Novel Insights from Speckle-Tracking Echocardiography.

BACKGROUND: Myocardial strain analysis by speckle-tracking echocardiography, which can detect subtle abnormalities in left atrial (LA) function, may offer unique insights into LA pathophysiology in patients with cryptogenic stroke (CS). The aim of this study was to investigate whether LA reservoir strain by speckle-tracking echocardiography, as a measure of LA compliance, is impaired in patients with CS and no history of atrial fibrillation. METHODS: A retrospective case-control study of 742 patients (mean age, 59 ± 13 years; 54% men; 371 with CS and 371 control subjects) was conducted. LA reservoir strain was quantified using speckle-tracking echocardiography. RESULTS: LA strain was significantly lower among patients with CS than control subjects (30 ± 7.3% vs 34 ± 6.7%, P < .001). Current smoking (odds ratio [OR], 2.6; 95% CI, 1.7-4.0; P < .001), systolic blood pressure (OR, 1.17 per 10 mm Hg increase; 95% CI, 1.06-1.29; P = .001), antihypertensive treatment (OR, 0.45; 95% CI, 0.30-0.66; P < .001), larger indexed left ventricular end-systolic volume (OR, 1.04; 95% CI, 1.01-1.07; P = .02), higher E/E' ratio (OR, 1.06; 95% CI, 1.01-1.11; P = .01), mitral regurgitation (OR, 1.8; 95% CI, 1.2-2.7; P = .003), and lower LA reservoir strain (OR, 1.07 per 1% reduction; 95% CI, 1.05-1.10; P < .001) were independently associated with CS. Importantly, LA reservoir strain conferred incremental discriminatory value in the identification of patients with CS (likelihood ratio P < .001). CONCLUSIONS: Subtle LA dysfunction, as assessed by LA reservoir strain with speckle-tracking echocardiography, is associated with CS independent of other cardiovascular risk factors. These findings suggest a potential role for LA strain to risk-stratify patients in the prevention of stroke.

Prevalence and Correlates of Early Right Ventricular Dysfunction in Sarcoidosis and Its Association with Outcome.

BACKGROUND: Right ventricular (RV) function has not been systematically assessed in sarcoidosis. The aim of this study was to assess the prevalence and associates of RV dysfunction in sarcoidosis using global longitudinal peak systolic strain (GLS). Furthermore, whether RV dysfunction was associated with clinical outcomes was investigated. METHODS: A total of 88 patients with sarcoidosis (mean age, 54 ± 13 years; 51% men) without known sarcoid-related or other structural heart disease or alternative etiologies of pulmonary hypertension were retrospectively included. RV GLS was measured using two-dimensional speckle-tracking echocardiography, and patients were stratified (using a previously defined cutoff value) as having preserved (RV GLS < -19%) or impaired (RV GLS ≥ -19%) RV function. An age- and gender-matched control group (n = 50) was included. The main outcome was all-cause mortality or clinical heart failure (hospitalization or New York Heart Association functional class ≥ III and/or deterioration by one or more classes). RESULTS: RV GLS was significantly reduced (-20.1 ± 4.6 vs -24.6 ± 1.8%, P = .001) in patients compared with control subjects. Patients with impaired RV function (n = 41) were older and had worse pulmonary function, worse left ventricular diastolic function, and lower tricuspid annular plane systolic excursion compared with patients with preserved RV function (n = 47). Lower tricuspid annular plane systolic excursion and diabetes were independent correlates of RV GLS. Over a median follow-up period of 37 months, 19 clinical end points occurred. Patients with impaired RV function were more likely to experience the clinical end point (log-rank P = .003). CONCLUSIONS: RV contractile dysfunction, identified using RV GLS, is common in patients with sarcoidosis without manifest cardiac involvement or pulmonary hypertension and is associated with adverse outcome. RV GLS may therefore be useful to detect sarcoidosis-related RV dysfunction at an earlier and potentially modifiable stage.

Prognostic Implications of Elevated Pulmonary Artery Pressure After ST-Segment Elevation Myocardial Infarction.

Elevated systolic pulmonary artery pressure (SPAP) after ST-segment elevation myocardial infarction (STEMI) has been associated with adverse outcome. However, little is known about the development of increased SPAP after STEMI treated with primary percutaneous coronary intervention. The aims of this study were to investigate the incidence and determinants of elevated SPAP (SPAP ≥36 mm Hg at 12 months) after first STEMI and to analyze its prognostic implications. A total of 705 patients (60 ± 12 years; 75% men; left ventricular ejection fraction [LVEF] 47 ± 9%) with first STEMI treated with primary percutaneous coronary intervention were evaluated. Two-dimensional echocardiography was available at baseline and 12-month follow-up. Data on all-cause mortality were collected at long-term follow-up. Incident elevated SPAP was present in 5% (n = 38) of patients. Patients with incident elevated SPAP were older (66 ± 12 vs 60 ± 11 years, p = 0.001), had more systemic hypertension (58% vs 30%, p <0.001) and lower LVEF (43 ± 9% vs 48 ± 8%, p <0.001) than their counterparts. Left atrial volume was larger (23 ± 11 vs 18 ± 6 ml/m(2), p = 0.006), and moderate to severe mitral regurgitation was more prevalent in patients with incident elevated SPAP (16% vs 7%, p = 0.05). Independent correlates of incident elevated SPAP at 12-month follow-up were age (odds ratio [OR] 1.04, 95% CI 1.01 to 1.08, p = 0.01), hypertension (OR 2.52, 95% CI 1.23 to 5.14, p = 0.01), baseline LVEF (OR 0.94, 95% CI 0.90 to 0.98, p = 0.003), and baseline left atrial volume (OR 1.08, 95% CI 1.03 to 1.12, p = 0.001). Incident elevated SPAP was independently associated with all-cause mortality (hazard ratio 3.84, 95% CI 1.76 to 8.39, p = 0.001). In conclusion, although the incidence of elevated SPAP after STEMI is low, its presence is independently associated with increased risk of all-cause mortality at follow-up.

Combining angiotensin II receptor 1 antagonism and neprilysin inhibition for the treatment of heart failure.

Sacubitril/valsartan is a novel, first-in-class drug, which combines a neprilysin inhibitor with an angiotensin receptor blocker. Sacubitril inhibits neprilysin endopeptidase, blocking the catabolism of natriuretic peptides (NP), thereby increasing their bioavailability. Valsartan counterbalances the increase of angiotensin II that results from neprilysin inhibition, exerting also the beneficial effects of angiotensin receptor blockers seen in previous HF trials. PARADIGM-HF trial has proved the superiority of sacubitril/valsartan (LCZ696) over ACE inhibitor enalapril to reduce mortality and morbidity of symptomatic HF patients with reduced ejection fraction (HFrEF), setting the grounds for the replacement of ACE inhibitors by sacubitril/valsartan in the management of HFrEF. Sacubitril/valsartan is currently being tested in a phase III trial (PARAGON-HF) in patients with HF with preserved EF. PARAGON-HF is also expected to provide further data regarding the long-term safety of sacubitril/valsartan, hopefully to alleviate concerns regarding the effects of neprilysin inhibition on cognitive function.