Cardiovascular Damage in COVID-19: What We Know Two Years Later.

PURPOSE OF THE REVIEW: The Coronavirus disease 2019 (COVID-19) pandemic has profoundly influenced cardiological clinical and basic research in the past two years. In the present review, we summarize the current knowledge on myocardial involvement in COVID-19, providing an overview on the incidence, the pathogenetic mechanisms, and the clinical implications of cardiac injury in this setting. RECENT FINDINGS: The possibility of heart involvement in patients with COVID-19 has received great attention since the beginning of the pandemic. After more than two years, several steps have been taken in understanding the mechanisms and the incidence of cardiac injury during COVID-19 infection. Similarly, studies globally have clarified the implications of co-existing heart disease and COVID-19. Severe COVID-19 infection may be complicated by myocardial injury. To date, a direct damage from the virus has not been demonstrated. The presence of myocardial injury should be systematically assessed for a prognostication purpose and for possible therapeutic implications.

Lyme Carditis: From Pathophysiology to Clinical Management.

Cardiac involvement is a rare but relevant manifestation of Lyme disease that frequently presents as atrioventricular block (AVB). Immune-mediated injury has been implicated in the pathogenesis of Lyme carditis due to possible cross-reaction between Borrelia burgdorferi antigens and cardiac epitopes. The degree of the AVB can fluctuate rapidly, with two-thirds of patients progressing to complete AVB. Thus, continuous heart rhythm monitoring is essential, and a temporary pacemaker may be necessary. Routinely permanent pacemaker implantation, however, is contraindicated because of the frequent transient nature of the condition. Antibiotic therapy should be initiated as soon as the clinical suspicion of Lyme carditis arises to reduce the duration of the disease and minimize the risk of complications. Diagnosis is challenging and is based on geographical epidemiology, clinical history, signs and symptoms, serological testing, ECG and echocardiographic findings, and exclusion of other pathologies. This paper aims to explain the pathophysiological basis of Lyme carditis, describe its clinical features, and delineate the treatment principles.

[Make a point on left ventricular noncompaction]. / Facciamo il punto: miocardio non compatto.

Hypertrabeculation is a feature of the left ventricle that, by itself, does not coincide with left ventricular non compaction (LVNC), which represents a specific cardiomyopathy. Nowadays, in the absence of gold standard diagnostic criteria, the clinician must integrate imaging aspects together with medical history. The family inheritance for LVNC, presence of neuromuscular disorders, symptoms or signs of heart failure, thromboembolic events, unexplained syncope, pathological findings at rest ECG, Holter ECG, stress test, systolic/diastolic dysfunction at rest echocardiogram, late gadolinium enhancement at cardiac magnetic resonance, and identification of specific mutations are all considered features useful for the diagnosis. Many aspects are not fully understood: multicenter studies, registers and observational studies are needed for a better comprehension of the pathology, adequate risk stratification and targeted follow-up.

Pharmacokinetics and pharmacodynamics of ticagrelor when treating non-ST elevation acute coronary syndromes.

INTRODUCTION: ADP-induced platelet activation via P2Y12 receptor plays a pivotal role in the pathophysiology of arterial thrombosis and acute coronary syndrome. The value of dual antiplatelet therapy with the addition of the thienopyridine clopidogrel to aspirin has been widely established. Prasugrel, another thienopyridine, has demonstrated more potent platelet inhibition and efficacy than clopidogrel, although this drug requires metabolic activation and is associated with increased risk of bleedings. AREAS COVERED: In this article, we discuss the role of ticagrelor in the management of non-ST elevation acute coronary syndromes treatment. We describe the unique pharmacokinetic and pharmacodynamic properties of this drug and the extensive data obtained by preclinical and Phase II and III clinical studies. EXPERT OPINION: Current guidelines recommend ticagrelor, in addition to aspirin, for patients with non-ST-segment elevation acute coronary syndromes at moderate to high-risk regardless of initial therapeutic strategy. Benefit of ticagrelor, as regard mortality, may be related to off-target effects of the drug, especially those involving the metabolism of adenosine. Ticagrelor represents a cost-effective alternative in the spectrum of P2Y12 inhibitors; however, further studies are required to enable the physician to choose the most appropriate antiplatelet agent for each patient.

[A pediatric case of Schoenlein-Henoch purpura with clinical, serologic and electrocardiographic signs of myocardial damage]. / Un caso pediatrico di porpora di Schoenlein-Henoch con segni clinici, sierologici ed elettrocardiografici di danno miocardico.

The Schoenlein-Henoch purpura is a vascular disease that affects blood vessels and/or capillaries. It usually occurs in children, particulary male, between 2 and 8 years of age. The clinical presentation is characterized by purple spots on the skin, joint pain, gastrointestinal symptoms, and kidney disorders. Occasionally, it may affect the lungs, testicles, heart, and central neervous system. Interestingly, heart involvement appears as myocarditis or arrythmia due to vascular damage of coronary arteries and tiny intramyocardial capillaries. We here describe a case of Schoenlein-Henoch purpura with clinical, electrocardiographic and serologic signs of myocardial ischemia, likely due to capillary vasculitis associated with streptococcus infection.

[Ventricular preexcitation: is risk stratification feasible?]. / Preeccitazione ventricolare: è possibile una stratificazione del rischio?

The Wolff-Parkinson-White syndrome is a current debated clinical issue. Although the anatomical characteristics, polymorphic electrocardiographic features, and electrophysiological mechanisms of arrhythmias and sudden cardiac death are well known, the identification of patients at risk of sudden cardiac death remains challenging. Owing to the lack of effective therapeutic strategies, in the pre-ablation era many studies have been conducted to define the prognostic value of clinical and instrumental tests, and to define the actual risk of sudden cardiac death in patients with ventricular preexcitation. Nowadays, radiofrequency transcatheter ablation of anomalous atrioventricular pathways is a strong therapeutic option for all patients, independent of the risk of sudden cardiac death. However, radiofrequency ablation is associated with serious complications, but many studies confirm an overall good prognosis for most of the patients with electrocardiographic pattern of ventricular preexcitation. The aim of this review is to assess the prognostic value of clinical and instrumental tests in patients with ventricular preexcitation, referring to the latest knowledge.

B-type natriuretic Peptide-guided treatment for predicting outcome in patients hospitalized in sub-intensive care unit with acute heart failure.

BACKGROUND: Studies with natriuretic peptides have suggested that physicians do not treat heart acute failure (AHF) aggressively enough, and predischarge B-type natriuretic peptide (BNP) levels may be a useful reminder that more treatment is required. The purpose of this study was to demonstrate that variations in BNP levels during hormone-guided treatment and measured body hydration status enable the timing of the patient's discharge to be optimized. METHODS AND RESULTS: We retrospectively evaluated 186 patients admitted for AHF. All subjects underwent serial bioelectrical impedance analysis and BNP measurement. Therapy was titrated according to BNP value to reach a BNP value of <250 pg/mL, whenever is possible. A BNP value on discharge of <250 pg/mL (obtained in 54% of the patients) predicted a 16% event rate within 6 months, whereas a value >250 pg/mL was associated with a far higher percentage (78%) of adverse events. Among the former, no significant differences in event rate were seen in relation to the time necessary to obtain a reduction in BNP values below 250 pg/mL (14 versus 18%, chi-square = 0.3, NS). Cox regression showed that a BNP cutoff value of 250 pg/mL is the most accurate predictors of events. CONCLUSIONS: Our study demonstrates the usefulness of BNP in intrahospital stratification of AHF, in the decision-making process, and as a tool for "tailored therapy." Integrating this approach into the routine assessment of HF patients would allow clinicians to more accurately identify high-risk patients, who may derive increased benefit from intensive in-hospital management strategies.

[BNP-guided therapy optimizes the timing of discharge and the medium term risk stratification in patients admitted for congestive heart failure]. / La terapia guidata dal BNP consente l'ottimizzazione del timing di dimissione e la stratificazione del rischio a medio termine nel paziente ricoverato per scompenso cardiaco.

BACKGROUND: Congestive heart failure (HF) is one of the most important cause of hospitalizations and is associated with high cost. Despite a consistent body of data demonstrating the benefits of drug therapy in HF, persistently high rates of readmission, especially within six months of discharge, continue to be documented. Neurohormonal activation characterizes the disease; plasma brain natriuretic peptide (BNP), is correlated with the severity of left ventricular dysfunction and relates to outcome. OBJECTIVE: The aim of the study was to evaluate if plasma levels of BNP would provide an index to guide drug treatment and to predict medium-term prognosis in HF patients (pts) after hospital discharge. METHODS AND RESULTS: We evaluated 200 consecutive pts (age 77 +/- 10 (35-96) years, 49% male versus 51% female) hospitalized for HF (DRG 127). Standard echocardiography was performed and left ventricular systolic/diastolic function was assessed; plasma BNP levels were measured with a rapid point-of-care assay (Triage BNP Test, Biosite Inc, San Diego, CA) on days 1 and after initial treatment. Using a cut-off of 240 pg/ml and/or changes in plasma BNP (days 2-3 after admission), 2 groups were identified: the low BNP group-responders (n = 68, BNP < 240 pg/ml and/or > or = 30% reduction) and the high BNP group-non responders (n = 132, BNP > or = 240 pg/ml and/or < 30% reduction). The high BNP group showed a different pattern of clinical variables according to the severity of the disease New York Heart Association (NYHA) functional class, left ventricular ejection fraction, ischemic etiology and age. A sustained elevation of plasma BNP (> 240 pg/mL) indicated the presence of a clinical unstable condition requiring further intervention whereas pts with low BNP values were discharged after 24 hours. During a mean follow-up period of 3 months, there were 62 cardiac events, including 15 cardiac deaths, 22 readmissions for worsening heart failure and 25 clinical decompensation requiring diuretic treatment. The incidence of clinical events was significantly greater in pts with higher levels of BNP (admission and discharge) than in those with lower levels (42% vs. 10%) and plasma values > 500 pg/ml identified a subgroup at high risk of death. CONCLUSIONS: The influence of BNP in the clinical course and prognosis of patients hospitalized for HF has not been studied. After initial treatment pts need to be risk stratified by means of the BNP test, to guide further management and to identify subjects with poor prognosis. An aggressive therapeutic and follow-up strategy may be justified for pts with high BNP levels and/or no changes after hospital admission for worsening HF. The changes in plasma BNP level at discharge were significantly related to cardiac events.

[Heart failure in Eastern Veneto: prevalence, hospitalization rate, adherence to guidelines and social costs]. / Lo scompenso cardiaco nel veneto orientale: prevalenza, ospedalizzazione, aderenza alle linee guida e costi sociali.

Heart failure is a prominent problem of public health, requiring innovating methods of health services organization. Nevertheless, data are still not available on prevalence, hospitalization rate, adherence to Guidelines and social costs in the general Italian population. The necessity to identifying patients with heart failure derives from the efficacy of new therapeutic interventions in reducing morbidity and mortality. In this study we aimed to identify, in a subset of the Eastern Veneto population, patients with heart failure through a pharmacologic-epidemiologic survey. The study was divided in 5 phases: (1) identification of patients on furosemide in the year 2000 in the ASL 10 of Eastern Veneto general population, through an analysis of a specific pharmaceutic service database; (2) definition of the actual prevalence of heart failure in a casual sample of these patients, through data base belonging to general practitioners, cardiologists, or others. Diagnosis was based on the following criteria: (a) previous diagnosis of heart failure; (b) previous hospitalization for heart failure; (c) clinical evidence, with echocardiographic control in unclear cases; (3) survey of hospitalizations; (4) evaluation of adhesion to guidelines, through both databases and questionnaires; (5) analysis of the social costs of the disease, with a retrospective "bottom up" approach. From a total population of 198,000 subjects, we identified 4502 patients on furosemide. In a casual sample of 10,661 subjects we defined a prevalence of heart failure in Eastern Veneto of 1.1%, that increased to 7.1% in octagenarians. The prescription of life saving drugs was satisfactory, while rather poor was the indication to echocardiography and to cardiologic consultation. Hospitalization rate for DRG 127 was low: 2.1/1000 inhabitants/year in the general population and 12.5 /1000 inhabitants/year in patients >70 years of age. Yearly mortality was 10.3%. Social costs were elevated (15.394 Euros/patient/year), due to a relevant sanitary component (hospital 53%, drugs 28%) and particularly a to an indirect cost component. In conclusion, the assumption of furosemide lends itself as a good marker for identifying patients with heart failure. Patient identification is simple, cheap and cost-efficient, and can be easily reproduced in other regional areas.

[Left ventricular geometric patterns and cardiac function in patients with chronic renal failure undergoing hemodialysis]. / Pattern geometrici e funzione cardiaca in soggetti con insufficienza renale cronica in fase dialitica.

UNLABELLED: The aim of this study was to estimate the impact and prevalence of left ventricular geometric alterations and systolic and diastolic dysfunction in hemodialysis patients, as well as the relationship with cardiac troponin as a marker of myocardial damage. METHODS: 31 patients (pts), 19 males and 12 females, age 58.1+/-16.4 (26 on hemodialysis, 5 on peritoneal dialysis) and 31 healthy normal controls were enrolled. Echocardiography measurements were carried out according to the American Society of Echocardiography recommendations. Left ventricular mass was calculated, according to the Devereux formula and indexed to height and weight 2.7. Doppler echocardiography was performed to study diastolic function by measurements of isovolumetric relaxation period (IVRT), E wave deceleretion time (DTE) and E/A ratio. Cardiac troponin was measured by a third generation electro-chemiluminescence immunoassay. Statistical analysis was performed using the t-test for between-group comparisons and the Pearson and Spearman's tests to investigate correlations; p values of <0.05 were considered statistically significant. RESULTS: Eccentric hypertrophy was the most frequent pattern (n=17; 55%), followed by normal cardiac geometry (n=7; 23%), and concentric hypertrophy (n=5; 16%). Only 6% of pts (n=2) showed concentric remodelling. Systolic dysfunction was present in terms of endocardial parameters in 3 pts (9%) (fractional shortening <25%, EF<50%), but in terms of midwall myocardial shortening in 51% (n=16). Diastolic dysfunction was present in 87% (n=27) with a pattern of impaired relaxation (in 5 without left ventricular hypertrophy). E/A was negatively correlated with age (r=-0.41, p=0.02); DTE was positively correlated with posterior wall thickness (r=0.36, p=0.05) and interventricular septum thickness (r=0.45, p=0.01); cardiac troponin was positively correlated with age (r=0.50, p=0.00), left ventricular mass (r=0.41, p=0.02), posterior wall thickness (r=0.41; p=0.02) and interventricular septum thickness (r=0.39, p=0.03) but not with diastolic dysfunction parameters. No significant difference was found in terms of duration of dialysis between patients with normal left ventricular geometry and those with left ventricular hypertrophy, but a significant difference in age was found (p=0.03). Pts with diastolic dysfunction had more frequent hypotensive episodes during dialysis (p<0.01). CONCLUSION: Impaired geometry and cardiac function is frequently observed in pts undergoing hemodialysis. Diastolic dysfunction is associated to a geometric pattern of left ventricular hypertrophy, although it can be an isolated initial manifestation of myocardial damage. Depressed midwall myocardial shortening can discriminate left ventricular dysfunction better than traditional endocardial systolic indexes.

[Echocardiography in the diagnostic and prognostic evaluation of thromboembolic pulmonary hypertension]. / L'ecocardiografia nella valutazione diagnostic e prognostica della ipertensione polmonare tromboembolica.

Pulmonary arterial hypertension frequently develops after a thromboembolic pulmonary event. The difference in degree of pulmonary artery pressure depends mainly on the size and location of the pulmonary embolus and presence of pre-existing cardiopulmonary diseases. Right ventricle (RV) afterloading from an acute obstruction of the pulmonary vasculature causes an increase of RV volume and dysfunction of right heart cavities, the varying levels of severity of which explain the multiple clinical expression of pulmonary embolism (PE). While the diagnostic approach, therapeutic management and prognostic evaluation are now well defined, the natural progression of PE is still not completely understood. In particular, insufficient data exist on the rate, timing and modalities of development of chronic thromboembolic pulmonary hypertension (CTPH). The aim of this review is to evaluate the role of echocardiography in detecting patients with CTPH, and in assessing hemodynamic consequences on RV and related prognostic implications.