Long-Term Incremental Prognostic Value of Cardiovascular Magnetic Resonance After ST-Segment Elevation Myocardial Infarction: A Study of the Collaborative Registry on CMR in STEMI.

OBJECTIVES: This study sought to investigate whether early post-infarction cardiac magnetic resonance (CMR) parameters provide additional long-term prognostic value beyond traditional outcome predictors in ST-segment elevation myocardial infarction (STEMI) patients. BACKGROUND: Long-term prognostic significance of CMR in STEMI patients has not been assessed yet. METHODS: This was a longitudinal study from a multicenter registry that prospectively included STEMI patients undergoing CMR after infarction. Between May 2003 and August 2015, 810 revascularized STEMI patients were included. CMR was performed at a median of 4 days after STEMI. Infarct size, microvascular obstruction (MVO), and left ventricular (LV) volumes and function were measured. Primary endpoint was a composite of all death and decompensated heart failure (HF). RESULTS: During median follow-up of 5.5 years (range 1.0 to 13.1 years), primary endpoint occurred in 99 patients (39 deaths and 60 HF hospitalization). MVO was a strong predictor of the composite endpoint after correction for important clinical, CMR, and angiographic parameters, including age, LV systolic function, and infarct size. The independent prognostic value of MVO was confirmed in all multivariate models irrespective of whether it was included as a dichotomous (presence of MVO, hazard ratio [HR]: 1.985 to 1.995), continuous (MVO extent as % LV, HR: 1.095 to 1.097), or optimal cutoff value (MVO extent ≥2.6% of LV; HR: 3.185 to 3.199; p < 0.05 for all). MVO extent ≥2.6% of LV was a strong independent predictor of all death (HR: 2.055; 95% confidence interval: 1.076 to 3.925; p = 0.029) and HF hospitalization (HR: 5.999; 95% confidence interval: 3.251 to 11.069; p < 0.001). Finally, MVO extent ≥2.6% of LV provided incremental prognostic value over traditional outcome predictors (net reclassification improvement index: 0.16 to 0.30; p < 0.05 for all models). CONCLUSIONS: Early post-infarction CMR-based MVO is a strong independent prognosticator in revascularized STEMI patients. Remarkably, MVO extent ≥2.6% of LV improved long-term risk stratification over traditional outcome predictors.

Prognostic Stratification of Patients With ST-Segment-Elevation Myocardial Infarction (PROSPECT): A Cardiac Magnetic Resonance Study.

BACKGROUND: Cardiac magnetic resonance (CMR) is a robust tool to evaluate left ventricular ejection fraction (LVEF), myocardial salvage index, microvascular obstruction, and myocardial hemorrhage in patients with ST-segment-elevation myocardial infarction. We evaluated the additional prognostic benefit of a CMR score over standard prognostic stratification with global registry of acute coronary events (GRACE) score and transthoracic echocardiography LVEF measurement. METHODS AND RESULTS: Two hundred nine consecutive patients with ST-segment-elevation myocardial infarction (age, 61.4±11.4 years; 162 men) underwent transthoracic echocardiography and CMR after succesful primary percutaneous coronary intervention. Major adverse cardiac events (MACE) were assessed at a mean follow-up of 2.5±1.2 years. MACE occurred in 24 (12%) patients who at baseline showed higher GRACE risk score (P<0.01), lower LVEF with both transthoracic echocardiography and CMR, lower myocardial salvage index, and higher per-patient myocardial hemorrhage and microvascular obstruction prevalence and amount as compared with patients without MACE (P<0.01). The best cut-off values of transthoracic echocardiography-LVEF, CMR-LVEF, myocardial salvage index, and microvascular obstruction to predict MACE were 46.7%, 37.5%, 0.4, and 2.6% of left ventricular mass, respectively. Accordingly, a weighted CMR score, including the following 4 variables (CMR-LVEF, myocardial salvage index, microvascular obstruction, and myocardial hemorrhage), with a maximum of 17 points was calculated and included in the multivariable analysis showing that only CMR score (hazard ratio, 1.867 per SD increase [1.311-2.658]; P<0.001) was independently associated with MACE with the highest net reclassification improvement as compared to GRACE score and transthoracic echocardiography-LVEF measurement. CONCLUSIONS: CMR score provides incremental prognostic stratification as compared with GRACE score and transthoracic echocardiography-LVEF and may impact the management of patients with ST-segment-elevation myocardial infarction.

Peculiar alexithymic traits in burning mouth syndrome: case-control study.

OBJECTIVES: The present case-control study aims to assess the occurrence of alexithymic traits in burning mouth syndrome (BMS) subjects and to correlate alexithymic traits to anxious and depressive traits in BMS subjects. MATERIALS AND METHODS: Prospectively enrolled BMS and control subjects were administered the 20-item Toronto Alexithymia Scale (TAS-20). Anxiety and depressive traits were assessed using the Hamilton Anxiety Rating Scale and the Montgomery and Asberg Depression Rating Scale. Occurrence of alexithymic traits was compared between BMS and control subjects. Correlation tests were used to measure the importance of alexithymic traits related to demographic characteristics, pain intensity (VAS score), and to the other psychometric scores. RESULTS: Fifty-eight BMS subjects (46 females and 12 males) had a mean TAS-20 score significantly higher when compared to controls (p < 0.001; r = 0.72), corresponding to an occurrence rate of alexithymic traits of 79.3 versus 6.9%. Alexithymic traits in BMS subjects were just related to depressive traits (p = 0.02; ρ = 0.31). CONCLUSIONS: The high occurrence of alexithymia in BMS is an adjunctive issue in favor of its multifactorial pathogenesis, with a not negligible role for somatization. CLINICAL RELEVANCE: Clinicians should be aware of the high occurrence of alexithymic traits among BMS subjects as such traits may affect the doctor-patient relationship.

Elevated heart rate at 24-36h after admission and in-hospital mortality in acute in non-arrhythmic heart failure.

BACKGROUND: Elevated resting heart rate is associated with worse outcomes in chronic heart failure (HF) but little is known about its prognostic impact in acute setting. The main aim of the present study was to examine the relationship between resting heart rate obtained 24-36h after admission for acute non-arrhythmic HF and in-hospital mortality. METHODS AND RESULTS: We examined the association of heart rate with in-hospital mortality in a cohort of 712 patients admitted for acute HF. None of the patients had significant arrhythmias, required invasive ventilation, or presented with acute coronary syndrome or primary valvular disease. Forty patients (5.6%) died during the hospital stay. Those patients were significantly older (78±9 vs. 72±12years; p=0.0021), had higher heart rate (92±22 vs. 78±18bpm; p<0.0001), NT pro-BNP (p=0.0005), creatinine (p=0.023), were often diabetics (p=0.026) and had lower systolic and diastolic blood pressures (p<0.05). There was a significant graded relationship between the increase in mortality rate and tertile of heart rate (p<0.01). With multivariable analysis, age (p=0.037), heart rate (p<0.0001), diastolic blood pressure (p<0.001), prior ischemic heart disease (p=0.02) and creatinine (p=0.019) emerged as independent predictors of in-hospital mortality. After adjusting for predictors of poor prognosis, patients in the highest heart rate tertile had worst outcomes when compared with those in the lowest heart rate group (p=0.007). CONCLUSIONS: Higher heart rate 24-36h after admission for acute non-arrhythmic HF is associated with increased risk of in-hospital mortality. Early targeting of elevated heart rate might represent a complementary therapeutic challenge.

Association between asymptomatic carotid atherosclerosis and degenerative aortic stenosis.

OBJECTIVE: Degenerative aortic stenosis shows similarities with atherosclerosis. To confirm the hypothesis that aortic stenosis is an "atherosclerosis-like" disease, we investigated the association between degenerative aortic stenosis and atherosclerosis of carotid arteries. METHODS: We studied 270 consecutive patients, 135 with degenerative aortic stenosis (trans-aortic peak velocity ≥ 2 m/sec) and other 135 subjects without aortic valve disease. All patients underwent echocardiography and ultrasound scan of the supra-aortic trunks to assess the presence of plaque and/or intima-media thickening (IMT). RESULTS: Atherosclerosis of carotid arteries (IMT and plaque) was significantly more frequent in patients with aortic stenosis than in controls (95.5% vs. 66.6%, p < 0.0001). The same result was confirmed as concerns carotid plaques (69.6% vs. 42.2%, p < 0.0001). In addition, there was a significant association between aortic stenosis and degenerative carotid plaque (OR = 3.13; 95% C.I. = 1.90-5.17). Thus the presence of a linear correlation between the trans-aortic peak velocity of the cases and the thickness of the plaques and IMT was evaluated by calculating the coefficient of correlation (R = 0.15 for plaque and R = 0.53 for IMT). CONCLUSIONS: The presence of carotid atherosclerosis is associated with degenerative aortic stenosis and the severity of aortic stenosis corresponds to an increase of the thickness of plaque and IMT. This relationship is quite new. Our result strengthens the pathogenetic hypothesis "atherosclerosis-like" of degenerative aortic stenosis and suggest the ultrasound scan as a non invasive method for risk stratification in patient with aortic stenosis, with therapeutic implications especially for higher risk subgroups.

Patent foramen ovale and thromboembolic complications.

The foramen ovale, an atrial septal defect which is essential in the fetal circulation, remains patent through adulthood in approximately 25% of the general population and so it represents the most common persistent abnormality of fetal origin. Patent foramen ovale (PFO) allows interatrial right-to-left blood shunting during those periods of the cardiac cycle in which the right atrial pressure exceeds the left one. An increasing number of pathological manifestations of PFO has been recently identified; among these, paradoxical systemic embolism, refractory hypoxemia in patients with right ventricular myocardium infarction or severe pulmonary disease, orthostatic oxygen desaturation in the rare platypnea-orthodeoxia syndrome, neurological decompression illness in divers, high altitude pilots and astronauts, and finally, migraine headache with aura. Nowadays many techniques allow to detect a PFO. In this study we investigated each of them, assessing their potential diagnostic role even in comparison with the main features of the other methods.

Takotsubo cardiomiopathy after acute diarrhea.

Takotsubo cardiomyopaty is a recently described syndrome characterized by transient left ventricular dysfunction, mimicking an acute coronary syndrome and usually precipitated by a physical or emotional stress. We report the first case of Takotsubo cardiomyopathy after acute diarrhea in a man. It may be argued that severe diarrhea in predisposed individuals may cause an acute stress resulting in increased sympathetic activity leading to this syndrome. Probably the relationship between the adrenergic system and the heart is more complex than general thought and the stimuli which favor an autonomic imbalance and precipitate the syndrome are very disparate in clinical practice.

The PFO anatomy evaluation as possible tool to stratify the associated risks and the benefits arising from the closure.

AIMS: According to the current guidelines, the patent foramen ovale (PFO) is still considered a qualitative factor and, as a consequence, its closure is recommended just on the basis of its 'presence'. METHODS AND RESULTS: In the year 2008, we evaluated 25 patients (mean age 62.7) with acute cerebrovascular event and 92 patients (mean age 27.3) suffering from migraine with aura. No PFO was reported in 79 patients. A venous-to-arterial circulation shunt had been shown in 38 patients (29 subjects with migraine and 9 subjects with prior stroke). According to the number of microbubbles arrived during the Valsava manoeuvre, we found: 25 small PFO, 6 moderate PFO, and 6 severe PFO. In the baseline population with migraine (n = 92), 32% (n = 29) had a PFO. A 'large' foramen was reported in approximately 9% of the migraine subjects. In the population with prior stroke (n=25), 9 patients (36%) had a PFO. A 'large' foramen was reported in 45% of the patients with ischaemic stroke. We found embryonic recesses in 13% (n = 4) of the patients with migraine and PFO (n=29) vs. 66% (n=6) of the patients with ischaemic stroke and PFO (P= 0.01). CONCLUSION: It is possible to suppose that not all PFO have the same prognostic value. The evaluation of two anatomical characteristics can allow to identify those foramina at higher risk and, as a consequence, the patients who could have a major benefit from the closure.