B-Type Natriuretic Peptide-A Paradox in the Diagnosis of Acute Heart Failure with Preserved Ejection Fraction in Obese Patients.

BACKGROUND AND OBJECTIVES: B-type natriuretic peptide (BNP) represents a clinical tool for the diagnosis and prognostic evaluation of acute and chronic heart failure patients. The purpose of this retrospective study was to evaluate BNP values in obese and non-obese patients with acute heart failure with preserved ejection fraction. MATERIALS AND METHODS: In this study, we enrolled 240 patients who presented to the emergency department complaining of acute shortness of breath and fatigue. The patients were divided into two groups according to their body mass index (BMI) values. The BMI was calculated as weight (kilograms) divided by height (square meters). The BNP testing was carried out in the emergency department. RESULTS: Group I included patients with a BMI of <30 kg/m2 and group II included patients with a BMI of ≥30 kg/m2. The average age of the patients was 60.05 ± 5.02 years. The patients in group II were significantly younger compared with those included in group I. Group II included a higher number of women compared to group I. Group I had fewer patients classified within New York Heart Association (NYHA) functional classes III and IV compared with group II. Echocardiography revealed an ejection fraction of ≥50% in all participants. Lower BNP levels were observed in patients from group II (median = 56, IQR = 53-67) in comparison to group I (median = 108.5, IQR = 106-112) (p < 0.001). CONCLUSIONS: Obesity and heart failure are continuously rising worldwide. In this retrospective study, we have highlighted the necessity to lower the threshold of BNP levels in obese patients with acute heart failure and preserved ejection fraction.

Optimizing Atrial Fibrillation Care: Comparative Assessment of Anticoagulant Therapies and Risk Factors.

BACKGROUND AND OBJECTIVES: Atrial fibrillation (AF) is a common arrhythmia associated with various risk factors and significant morbidity and mortality. MATERIALS AND METHODS: This article presents findings from a study involving 345 patients with permanent AF. This study examined demographics, risk factors, associated pathologies, complications, and anticoagulant therapy over the course of a year. RESULTS: The results showed a slight predominance of AF in males (55%), with the highest incidence in individuals aged 75 and older (49%). Common risk factors included arterial hypertension (54%), dyslipidemia, diabetes mellitus type 2 (19.13%), and obesity (15.65%). Comorbidities such as congestive heart failure (35.6%), mitral valve regurgitation (60%), and dilated cardiomyopathy (32%) were prevalent among the patients. Major complications included congestive heart failure (32%), stroke (17%), and myocardial infarction (5%). Thromboembolic and bleeding risk assessment using CHA2DS2-VASc and HAS-BLED scores demonstrated a high thromboembolic risk in all patients. The majority of patients were receiving novel oral anticoagulants (NOACs) before admission (73%), while NOACs were also the most prescribed antithrombotic therapy at discharge (61%). CONCLUSIONS: This study highlights the importance of risk factor management and appropriate anticoagulant therapy in patients with AF, to reduce complications and improve outcomes. The results support the importance of tailored therapeutic schemes, for optimal care of patients with AF.

Casting Light on Early Heart Failure: Unveiling the Prognostic Potential of the E/(e' × s') Index.

It has been shown that patients with NYHA class I and II have a high morbidity and mortality burden. We investigated the value of a new tissue Doppler index, E/(e' × s'), to predict cardiac events in the long-term follow-up of patients at an early stage of heart failure (HF). Sequential echocardiography was conducted on a consecutive cohort of 212 hospitalized HF patients, pre-discharged and with three-month follow-up. The primary end point consisted of cardiac death or readmission due to HF worsening. During follow-up, cardiac events occurred in 99 patients (46.7%). The first cardiac event was represented by cardiac death in 8 patients (3.8%) and readmission for HF in 91 patients (42.9%). A Kaplan-Meier analysis did not show a significantly different event-free survival rate between patients with NYHA class I and II. The composite end point was significantly higher in patients with an E/(e' × s') >1.6. The E/(e' × s') at discharge was the best independent predictor of cardiac events. Those exhibiting an E/(e' × s') > 1.6 at discharge, with a subsequent deterioration after three months, displayed the poorest prognosis concerning cardiac events, HF-related rehospitalization, and cardiac mortality (all p < 0.05). In early-stage HF patients, an E/(e' × s') > 1.6 emerged as a robust predictor of clinical outcomes, especially when coupled with a deterioration in condition.

Assessing the Relationship between Indexed Epicardial Adipose Tissue Thickness, Oxidative Stress in Adipocytes, and Coronary Artery Disease Complexity in Open-Heart Surgery Patients.

Background and Objectives: This cross-sectional study conducted at the Timișoara Institute of Cardiovascular Diseases, Romania, and the Centre for Translational Research and Systems Medicine from "Victor Babeș" University of Medicine and Pharmacy of Timișoara, Romania, investigated the relationship between indexed epicardial adipose tissue thickness (EATTi) and oxidative stress in epicardial adipose tissue (EAT) adipocytes in the context of coronary artery disease (CAD) among open-heart surgery patients. The objective was to elucidate the contribution of EATTi as an additional marker for complexity prediction in patients with CAD, potentially influencing clinical decision-making in surgical settings. Materials and Methods: The study included 25 patients undergoing cardiac surgery, with a mean age of 65.16 years and a body mass index of 27.61 kg/m2. Oxidative stress in EAT was assessed using the ferrous iron xylenol orange oxidation spectrophotometric assay. The patients were divided into three groups: those with valvular heart disease without CAD, patients with CAD without diabetes mellitus (DM), and patients with both CAD and DM. The CAD complexity was evaluated using the SYNTAX score. Results: The EATTi showed statistically significant elevations in the patients with both CAD and DM (mean 5.27 ± 0.67 mm/m2) compared to the CAD without DM group (mean 3.78 ± 1.05 mm/m2, p = 0.024) and the valvular disease without CAD group (mean 2.67 ± 0.83 mm/m2, p = 0.001). Patients with SYNTAX scores over 32 had significantly higher EATTi (5.27 ± 0.66 mm/m2) compared to those with lower scores. An EATTi greater than 4.15 mm/m2 predicted more complex CAD (SYNTAX score >22) with 80% sensitivity and 86% specificity. The intra- and interobserver reproducibility for the EATTi measurement were excellent (intra-class correlation coefficient 0.911, inter-class correlation coefficient 0.895). Conclusions: EATTi is significantly associated with CAD complexity in patients undergoing open-heart surgery. It serves as a reliable indicator of more intricate CAD forms, as reflected by higher SYNTAX scores. These findings highlight the clinical relevance of EATTi in pre-operative assessment, suggesting its potential utility as a prognostic marker in cardiac surgical patients.

Comprehensive imaging in patients with suspected pulmonary arterial hypertension.

Currently, several imaging techniques are being used for a comprehensive evaluation of patients with suspected pulmonary hypertension (PH), in order to provide information that may clarify the presence and identify the aetiology of this complex pathology. The current paper is focused on recent updates regarding the importance of comprehensive imaging techniques for patients with suspected PH. Transthoracic echocardiography that can mainly detect right ventricle pressure overload and dysfunction is the cornerstone of imaging evaluation, while right heart catheterisation remains the gold standard assessment method. Chest radiography that may exclude pleuroparenchymal lung diseases, CT, the primary imaging modality for the assessment of lung parenchyma and CT pulmonary angiography, that allows for the non-invasive assessment of the pulmonary arteries, are equally important. Imaging techniques like dual-energy CT, single photon emission CT and ventilation perfusion scan may provide accurate diagnostic information for patients with chronic thromboembolic PH. Cardiac MRI provides the most accurate three-dimensional characterisation of the right ventricle. Accurate use of diagnostic imaging algorithms allows early detection of the disease, with the constant goal of improved PH patients prognosis.

Prevalence and Risk Factors of Metabolic Syndrome: A Prospective Study on Cardiovascular Health.

Background and objectives: This article highlights the relationship between metabolic syndrome and cardiovascular disease, providing a comprehensive overview of its risk factors and prevalence. Metabolic syndrome, characterized by a cluster of interconnected risk factors, significantly increases the risk of developing cardiovascular disease and type II diabetes. Materials and methods: This study, conducted over a one-year period, involved 117 patients aged between 30 and 79 years old. Various parameters were analyzed, such as gender, age, education level, provenance from urban or rural environment, smoking, alcohol consumption, dietary aspects, physical activity, and their contribution to the appearance of metabolic syndrome. Central adiposity and high blood pressure emerged as prominent elements of the condition. Results: The findings underscore the importance of a healthy lifestyle in the prevention and management of metabolic syndrome. Encouraging regular physical activity, maintaining a balanced diet, rich in fresh vegetables and fruits, and avoiding harmful behaviors, such as smoking or alcohol consumption, are essential in reducing the risk of metabolic syndrome and its associated cardiovascular complications. Conclusions: The study highlights the need for public health initiatives, as well as individualized preventive strategies to combat the rising prevalence of metabolic syndrome. Through promoting awareness of its risk factors and implementing effective interventions, healthcare professionals can contribute to better cardiovascular health worldwide. Further research in this area will continue to enhance our understanding of metabolic syndrome and refine preventive and therapeutic approaches for its management.

Reduced Left Ventricular Twist Early after Acute ST-Segment Elevation Myocardial Infarction as a Predictor of Left Ventricular Adverse Remodelling.

BACKGROUND: The left ventricular (LV) remodelling process represents the main cause of heart failure after a ST-segment elevation myocardial infarction (STEMI). Speckle-tracking echocardiography (STE) can detect early deformation impairment, while also predicting LV remodelling during follow-up. The aim of this study was to investigate the STE parameters in predicting cardiac remodelling following a percutaneous coronary intervention (PCI) in STEMI patients. METHODS: The study population consisted of 60 patients with acute STEMI and no history of prior myocardial infarction treated with PCI. The patients were assessed both by conventional transthoracic and ST echocardiography in the first 12 h after admission and 6 months after the acute phase. Adverse remodelling was defined as an increase in LVEDV and/or LVESV by 15%. RESULTS: Adverse remodelling occurred in 26 patients (43.33%). By multivariate regression equation, the risk of adverse remodelling increases with age (by 1.1-fold), triglyceride level (by 1.009-fold), and midmyocardial radial strain (mid-RS) (1.06-fold). Increased initial twist decreases the chances of adverse remodelling (0.847-fold). The LV twist presented the largest area under the receiver operating characteristic (ROC) curve to predict adverse remodelling (AUROC = 0.648; 95% CI [0.506;0.789], p = 0.04). A twist value higher than 11° has a 76.9% specificity and a 72.7% positive predictive value for reverse remodelling at 6 months.

Prevalence of Cardiovascular Comorbidities in Patients with Rheumatoid Arthritis.

Background and Objectives: The risk of developing cardiovascular diseases (CVD) in patients suffering from rheumatoid arthritis (RA) is two times higher compared to the general population. The objective of this retrospective study was to determine which cardiovascular complications can appear in men vs. women with rheumatoid arthritis. Early diagnosis and initiation of therapeutic measures to reduce the progression rate of rheumatoid arthritis, while also maintaining an active lifestyle, are the most important problems in young patients. Materials and Methods: We included a number of 200 patients, divided into two groups according to gender (124 women and 76 men) with rheumatoid arthritis, presenting various stages of disease concomitant with cardiovascular complications. We assessed traditional and non-traditional risk factors, as well as electrocardiographic and echocardiographic findings in both groups. Results: All patients presented an atherogenic coefficient over two, indicating a significant risk of atherogenesis. Men had elevated levels of total cholesterol compared with women (≥200 mg/dL; 77.6%-men vs. 25.8%-women, p < 0.001). The participants presented cardiac arrhythmias, especially in the active stage of RA. Women had an increased risk of atrial fibrillation by 2.308 times compared to men (p = 0.020). One of the most important complications found in young women was pulmonary arterial hypertension (p = 0.007). Conclusions: In daily clinical practice, the screening of RA is carried out in sufficiently. This disease is often undiagnosed, and the risk factors remain unassessed. As a result, RA patients continue to present an increased risk of developing CVD.

The Role of Hypomagnesemia in Cardiac Arrhythmias: A Clinical Perspective.

The importance of magnesium (Mg2+), a micronutrient implicated in maintaining and establishing a normal heart rhythm, is still controversial. It is known that magnesium is the cofactor of 600 and the activator of another 200 enzymatic reactions in the human organism. Hypomagnesemia can be linked to many factors, causing disturbances in energy metabolism, ion channel exchanges, action potential alteration and myocardial cell instability, all mostly leading to ventricular arrhythmia. This review article focuses on identifying evidence-based implications of Mg2+ in cardiac arrhythmias. The main identified benefits of magnesemia correction are linked to controlling ventricular response in atrial fibrillation, decreasing the recurrence of ventricular ectopies and stopping episodes of the particular form of ventricular arrhythmia called torsade de pointes. Magnesium has also been described to have beneficial effects on the incidence of polymorphic ventricular tachycardia and supraventricular tachycardia. The implication of hypomagnesemia in the genesis of atrial fibrillation is well established; however, even if magnesium supplementation for rhythm control, cardioversion facility or cardioversion success/recurrence of AF after cardiac surgery and rate control during AF showed some benefit, it remains controversial. Although small randomised clinical trials showed a reduction in mortality when magnesium was administered to patients with acute myocardial infarction, the large randomised clinical trials failed to show any benefit of the administration of intravenous magnesium over placebo.

Left Ventricular Remodeling and Heart Failure Predictors in Acute Myocardial Infarction Patients with Preserved Left Ventricular Ejection Fraction after Successful Percutaneous Intervention in Western Romania.

(1) Acute myocardial infarction (AMI) patients are at risk of left ventricular (LV) remodeling and heart failure (HF), even after successful revascularization by percutaneous coronary intervention (PCI). We wanted to assess the independent predictors of these outcomes in AMI patients. (2) Methods: The study enrolled patients with a LVEF ≥50% after a successful PCI for their first AMI. After 24 months, patients were separated into two groups based on whether their LVEF remained ≥50% (group I), or decreased to <50% (group II). (3) Outcomes: 26% of the patients experienced a decrease in LVEF below 50%, 41% showed LV remodeling, and 8% had experienced HF hospitalizations. HF hospitalizations were significantly more frequent in group II patients (p < 0.0001). The Killip class at admission >2, infarct-related longitudinal strain ≤−12.5%, and the presence of LV remodeling were identified as independent predictors of HF hospitalizations. (4) Conclusions: About 26% of AMI patients with normal LV function after a successful PCI developed HF. More sensitive techniques are required that allow for a more efficient risk-stratification and preventive therapy to reduce LV remodeling and HF in AMI patients with LVEF ≥50% after a successful PCI. The detection of abnormal ventricular deformation patterns after PCI by speckle-tracking echocardiography might be a valuable method in this approach.

An Up-to-Date Article Regarding Particularities of Drug Treatment in Patients with Chronic Heart Failure.

Since the prevalence of heart failure (HF) increases with age, HF is now one of the most common reasons for the hospitalization of elderly people. Although the treatment strategies and overall outcomes of HF patients have improved over time, hospitalization and mortality rates remain elevated, especially in developed countries where populations are aging. Therefore, this paper is intended to be a valuable multidisciplinary source of information for both doctors (cardiologists and general physicians) and pharmacists in order to decrease the morbidity and mortality of heart failure patients. We address several aspects regarding pharmacological treatment (including new approaches in HF treatment strategies [sacubitril/valsartan combination and sodium glucose co-transporter-2 inhibitors]), as well as the particularities of patients (age-induced changes and sex differences) and treatment (pharmacokinetic and pharmacodynamic changes in drugs; cardiorenal syndrome). The article also highlights several drugs and food supplements that may worsen the prognosis of HF patients and discusses some potential drug-drug interactions, their consequences and recommendations for health care providers, as well as the risks of adverse drug reactions and treatment discontinuation, as an interdisciplinary approach to treatment is essential for HF patients.

Arterial Hypertension: Individual Therapeutic Approaches-From DNA Sequencing to Gender Differentiation and New Therapeutic Targets.

The aim of this paper is to provide an accurate overview regarding the current recommended approach for antihypertensive treatment. The importance of DNA sequencing in understanding the complex implication of genetics in hypertension could represent an important step in understanding antihypertensive treatment as well as in developing new medical strategies. Despite a pool of data from studies regarding cardiovascular risk factors emphasizing a worse prognosis for female patients rather than male patients, there are also results indicating that women are more likely to be predisposed to the use of antihypertensive medication and less likely to develop uncontrolled hypertension. Moreover, lower systolic blood pressure values are associated with increased cardiovascular risk in women compared to men. The prevalence, awareness and, most importantly, treatment of hypertension is variable in male and female patients, since the mechanisms responsible for this pathology may be different and closely related to gender factors such as the renin-angiotensin system, sympathetic nervous activity, endothelin-1, sex hormones, aldosterone, and the immune system. Thus, gender-related antihypertensive treatment individualization may be a valuable tool in improving female patients' prognosis.

A Novel and Simple Exercise Test Parameter to Assess Responsiveness to Cardiac Resynchronization Therapy.

This study assessed the value of heart rate recovery index (HRRI), a new parameter of an exercise test, as the predictor of response to cardiac resynchronization therapy (CRT). Methods: Consecutive patients receiving a CRT device were followed up after implantation and every 6 months. An effort test (ET) was quantified by minimum heart rate/maximum heart rate, as well as acceleration and deceleration times. HRRI was calculated as the ratio between acceleration and deceleration time (AT/DT) and compared to outcome. We used logistic regression to assess the predictive value of HRRI for responders and non-responders to CRT. The area under the curve (AUC) was computed to distinguish between positive and negative outcomes. Results: A total of 109 patients (74 men, mean age 63.3 ± 9.8 years) were analyzed; permanent long-term fusion CRT pacing was possible in 65 patients. Patients were assigned to two groups: responders and non-responders (98/11 patients). During a mean follow-up of 36 months, 545 ETs were performed. HRRI was significantly higher in responders versus non-responders (3.16 ± 2 vs. 1.4 ± 0.5, p < 0.001). The optimal cutoff value for HRRI as a predictor of CRT response was 1.51 (area under the receiver operating characteristic (ROC) curve = 0.844). Responders had significant left-ventricular (LV) reverse remodeling (LV end-diastolic volume = 240 ± 90 mL vs. 217 ± 89 mL, p < 0.001) and higher LV ejection fraction (26 ± 5.8% vs. 35 ± 8.7%, p < 0.001). Conclusions: HRRI computation during routine ET is useful for the evaluation of responsiveness to CRT.

Toll-like receptor 4 (TLR4) expression is correlated with T2* iron deposition in response to doxorubicin treatment: cardiotoxicity risk assessment.

Although doxorubicin (Dox) is an effective antitumor antibiotic in the anthracycline class, it often induces the undesirable side effect of cardiomyopathy leading to congestive heart failure, which limits its clinical use. The primary goal of this study is to evaluate a reliable translational method for Dox-induced cardiotoxicity (CTX) screening, aiming to identify a high-risk population and to discover new strategies to predict and investigate this phenomenon. Early identification of the presence of iron deposits and genetic and environmental triggers that predispose individuals to increased risk of Dox-induced CTX (e.g., overexpression of Toll-like receptor 4 (TLR4)) will enable the early implementation of countermeasure therapy, which will improve the patient's chance of survival. Our cohort consisted of 25 consecutive patients with pathologically confirmed cancer undergoing Dox chemotherapy and 12 control patients. The following parameters were measured: serum TLR4 (baseline), serum transferrin (baseline and 6-week follow-up) and iron deposition (baseline and 6-week follow-up). The average number of gene expression units was 0.121 for TLR4 (range 0.051-0.801). We subsequently correlated serum TLR4 levels in our cohort with myocardial iron overload using the cardiac magnetic resonance (CMR) T2* technique, the ventricular function (% ejection fraction, %EF) and serum transferrin levels. There is a strong negative linear relationship between serum TLR4 and CMR T2* values (r = - 0.9106, ****P < 0.0001). There is also a linear correlation (either positive or negative) with EF and transferrin; no established relationship related to the sex of the patients was found. Patients with elevated serum TLR4 at baseline also exhibited an increase in serum transferrin levels and Dox-induced left ventricular dysfunction with a decreased EF (< 50%); this phenomenon was observed in 7 of 25 patients (28%) at the 6-week follow-up. There were no significant differences or correlations based on sex. We concluded that there is a direct relationship between Dox-induced CTX (indicated by elevated serum TLR4) and the times (ms) for T2* (decreases in which correspond to immediate and rapid iron overload).

Exercise test is essential in LV-only fusion CRT pacing without right ventricle lead.

Purpose: Left ventricle (LV)-only pacing is non-inferior to biventricular pacing but permanent fusion pacing is needed to ensure cardiac resynchronization therapy (CRT) responsiveness. The role of systematic exercise testing (ET) in these patients has not been established. This study was designed to assess clinical and therapeutic implications (device programming/drugs) of systematic ET in patients requiring fusion-pacing CRT without an right ventricle (RV) lead. Methods: Consecutive patients with a right atrium/LV-only dual-chamber (DDD) pacing system were included. Prospective data were obtained: device interrogation, ET, and echocardiography at every 6-month follow-up visit. CRT assessment during ET included maximal heart rate, beat-to-beat echocardiography analysis of LV fusion pacing, LV loss of capture, and improvement in exercise capacity. If LV loss of capture or unsatisfactory LV fusion pacing occurred, reprogramming was individualized for each patient and ET redone. Results: A total of 55 patients (29 male) aged 62±11 years were included. During follow-up (39±18 months), a total of 235 ETs were performed, with mean exercise load 6.4±1.3 metabolic equivalents of task (118±35 W, maximal heart rate 119±17 beats/min). Twenty patients (36%) had inadequate pacing or loss of LV capture during ET, due to exceeding the maximum tracking rate (11%), chronotropic incompetence (7%), and LV pacing outside the fusion-pacing band (18%), caused by physiological shortening of the PR interval or exagerated LV preexcitation during maximum exercise. Post-ET CRT-device optimization included reprogramming of rate-adaptive atrioventricular interval (total decrease 23±8 ms), individualized programming of maximum tracking rate, or rate-response function. Drug optimization was performed in 32% of patients, and ET redone in 36%. Conclusion: In one of three ETs, an intervention in device and medication optimization was done to ensure a better outcome. Routine ET should be a standard approach to maximize fusion-pacing CRT response during follow-up.

Current Perspectives in Facilitated Angioplasty.

BACKGROUND: Ischemic heart disease represents the most important cause of mortality worldwide, and the management of patients with ST-elevation myocardial infarction (STEMI) still remains a great challenge. For a great number of patients who do not have immediate access to primary percutaneous coronary intervention (PCI), facilitated angioplasty may be a reasonable therapeutic option. AREAS OF UNCERTAINTY: The goal of reperfusion therapy is achieving repermeabilization of the infarct-related artery. However, the restoration of normal epicardial flow is not always followed by microvascular tissue perfusion and the presence of myocardial blush. Early studies assessing the benefits of facilitated angioplasty over primary PCI encountered disappointing results, with an increased number of bleeding complications. The invasive strategy following fibrinolysis mainly consists in angiography and PCI of the infarct-related artery between 2 and 24 hours after successful fibrinolysis or rescue PCI in failed fibrinolysis, hemodynamic, electrical instability, or worsening ischemia. Currently, a strategy of routine early angiography after fibrinolysis is recommended, taking into account studies that have demonstrated a reduced rate of reinfarction and recurrent ischemia, without an increased risk of stroke or major bleeding complications. THERAPEUTIC ADVANCES: After evaluating 1892 patients with STEMI within 3 hours after the onset of symptoms and revealing, beyond clear benefit of fibrinolysis, an increased risk of bleeding complications, the STREAM trial was the one that led to halving the tenecteplase dose for patients aged >75 years. A safety profile of adjusted-dose fibrinolytic therapy in elderly patients with STEMI will be further investigated by the ongoing STREAM-2 trial. CONCLUSIONS: With the current increased burden of acute coronary syndromes and the lack of immediate primary PCI facilities for all patients with STEMI, facilitated angioplasty seems a feasible therapeutic option. Another benefit of facilitated angioplasty may be represented by a major contribution of thrombolytic therapy in re-establishing microvascular myocardial blood flow.

Therapeutic Advances in Emergency Cardiology: A Focus on Acute Myocarditis.

BACKGROUND: Myocarditis, defined as an inflammation of the myocardium, is an important cause of dilated cardiomyopathy and congestive heart failure. Unfortunately, its diagnosis and etiology is often challenging in clinical practice, and thus, improving diagnosis and therapeutic approach of this cardiac pathology is a matter of great interest. AREAS OF UNCERTAINTY: The etiology of the disease may be represented by not only infectious agents, usually with viral determination, but also autoimmune and systemic diseases or drugs. Regarding diagnostic techniques, endomyocardial biopsy remains the gold standard; but beyond histological findings, an important step in achieving an accurate diagnosis was represented by the use immunohistochemical criteria and noninvasive diagnostic tests such as cardiac magnetic resonance imaging. DATA SOURCES: We reviewed current data on the current diagnosis and therapeutic approach of acute myocarditis. THERAPEUTIC ADVANCES: In addition to the standard heart failure therapy, some specific therapeutic options are available in selected cases. Viral myocarditis with persistent inflammation and viral clearance may be responsive to immunosuppressive therapy with azathioprine and cortisone or to immunoadsorption technique. Also, some chronic viral myocardial infections may benefit from 6 months of interferon-ß therapy. CONCLUSIONS: The diagnosis of acute myocarditis still remains a great challenge, despite advances related to new diagnostic procedures. Endomyocardial biopsy, an invasive diagnostic tool that is not always usually available in clinical practice, still remains the standard diagnostic technique. Due to the potential evolution of acute myocarditis, identifying new parameters that may allow an early selection of patients with great risk of evolution toward myocardial fibrosis and dilated cardiomyopathy may be a field of great interest for future studies.

Reduced ejection fraction heart failure - new data from multicenter studies and national registries regarding general and elderly populations: hopes and disappointments.

The evaluation of patients diagnosed with impaired systolic function heart failure represents a great challenge, in both the general and elderly population. We consider that elderly patients are the most severely affected by this disease that represents the final impact of cardiovascular disease continuum. Cardiovascular diseases are associated with serious morbidity and mortality, and considerable health care costs related to diagnosis and treatment. In this report we discuss some controversies regarding methods of heart failure evaluation as well as therapeutic steps and devices, including: reparatory therapeutic steps and initiation of therapy with loop diuretics, inconsistent dose titration for angiotensin-converting enzyme inhibitors/angiotensin receptor blocker and beta blockers, as well as novel therapies, such as angiotensin receptor neprilysin inhibitor and treatments that directly improve cardiomyocyte function. We conclude that, beyond technical progress, which is raising the cost of therapy for patients with heart failure, more careful monitoring of patient progress through clinical and paraclinical control visits, both at medical facilities and at home, would have greater impact and be more cost-effective. Physical therapy and promoting emotional and psychological wellbeing, to maintain a positive state of mind, contribute substantially to the quality of life and life expectancy, and are most important in elderly people who are most affected by dramatic reductions in wellbeing. Unfortunately, for many patients with severe impairment of left ventricular ejection fraction, these goals and therapeutic procedures are often lacking in current health care systems.

Romanian Registry of Hypertrophic Cardiomyopathy - overview of general characteristics and therapeutic choices at a national level.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) is a disease with increased left ventricular (LV) wall thickness not solely explained by abnormal loading conditions, with great heterogeneity regarding clinical expression and prognosis. The aim of the present study was to collect data on HCM patients from different centres across the country, in order to assess the general characteristics and therapeutic choices in this population. METHODS: Between December 2014 and April 2017, 210 patients from 11 Romanian Cardiology centres were enrolled in the National Registry of HCM. All patients had to fulfil the diagnosis criteria for HCM according to the European Society of Cardiology guidelines. Clinical, electrocardiographic, imaging and therapeutic characteristics were included in a predesigned online file. RESULTS: Median age at enrolment was 55 ± 15 years with male predominance (60%). 43.6% of the patients had obstructive HCM, 50% non-obstructive HCM, while 6.4% had an apical pattern. Maximal wall thickness was 20.3 ± 4.8 mm (limits 15-37 mm) while LV ejection fraction was 60 ± 8%. Heart failure symptoms dominated the clinical picture, mainly NYHA functional class II (51.4%). Most frequent arrhythmias were atrial fibrillation (28.1%) and non-sustained ventricular tachycardia (19.9%). Mean sudden cardiac death risk score (SCD-RS) was 3.0 ± 2.3%, with 10.4% of the patients with high risk of SCD. However, only 5.7% received an ICD. Patients were mainly treated with beta-blockers (72.9%), diuretics (28.1%) and oral anticoagulants (28.6%). Invasive treatment of LVOT obstruction was performed in a small number of patients: 22 received myomectomy and 13 septal ablation. Cardiac magnetic resonance was reported in only 14 patients (6.6%). CONCLUSIONS: The Romanian registry of HCM illustrates patient characteristics at a national level as well as the gaps in management which need improvement - accessibility to high-end diagnostic tests and invasive methods of treatment.

Risk stratification in patients with heart failure: the value of considering both global longitudinal left ventricular strain and mechanical dispersion.

In previous studies, mechanical dispersion (MD) predicted ventricular arrhythmias independently of left ventricular ejection fraction (LVEF). Moreover, the combination of MD and global longitudinal strain (GLS) increased the prediction of arrhythmic events. We investigated the prognostic value of a new 2-dimensional strain index, GLS/MD, in patients with heart failure (HF). We analyzed 340 consecutive HF outpatients in sinus rhythm. Echocardiography was performed at 1.6 ± 0.4 months after hospital discharge. The end point included sudden cardiac death, ventricular fibrillation, and sustained ventricular tachycardia (SCD/VA). During the follow-up period (36 ± 9 months), SCD/VA occurred in 48 patients (14.1%). A multivariate Cox regression analysis, which included LVEF, early diastolic transmitral / mitral annular velocity ratio (E/E'), GLS, MD, and GLS/MD in the model, revealed that GLS/MD was the best independent predictor of SCD/VA (HR = 3.22, 95% confidence interval = 1.72-6.15, p = 0.03). Separate inclusion of LVEF, systolic mitral annular velocity, E/E', GLS, and MD together with GLS/MD showed that GLS/MD remained the best predictor of SCD/VA (each p < 0.05). The optimal GLS/MD cutoff value to predict SCA/VA was -0.20%/ms (80% sensitivity, 76% specificity). Irrespective of LVEF, free survival was significantly better in patients with GLS/MD ≤ -0.2%/ms (log-rank test, p < 0.001). In conclusion, GLS/MD may improve cardiovascular risk stratification in subjects with HF.