Comparative diagnostic accuracy of transcranial Doppler and contrast-enhanced transthoracic echocardiography for the diagnosis of patent foramen ovale and atrial septal defect.

BACKGROUND: Recognition of right-to-left shunt is crucial in the work-up of patients with suspected patent foramen ovale (PFO) or atrial septal defect (ASD). While transesophageal echocardiography (TEE) remains the gold standard diagnostic tool for the anatomic assessment of PFO/ASD, transcranial Doppler (TCD) and contrast-enhanced transthoracic echocardiogram (CE-TTE) hold the promise of providing minimally invasive yet accurate clinical details. Their comparative accuracy remains however debated. METHODS: We conducted a retrospective observational study leveraging our extensive institutional experience with systematic TCD and CE-TTE in patients with suspected PFO/ASD. Several measures of diagnostic test accuracy were computed, with point estimates and 95% confidence intervals, when applicable. RESULTS: A total of 1358 patients were included, with age 48±14 years and 772 (58%) women. Tests were performed for diagnostic purposes in 797 (58.6%) and during follow-up in 740 (54.5%). A PFO was eventually diagnosed in 1038 (77.9%) patients, and an ASD in 60 (4.5%). Agreement between TCD and CE-TTE occurred in 1309 (85.2%) cases, with TCD yielding worse findings than CE-TTE in 91 (5.9%) patients, and vice versa in 137 (8.9%), yielding a Cohen kappa of 78.6% (95% CI: 76.3-81.1%) and a highly significant P value at McNemar test (P<0.001). After dichotomization, and using TCD as benchmark, CE-TTE yielded sensitivity 96.9%, specificity 95.1%, area under the curve 92.1%, and P=0.249. Similar findings were obtained when focusing only on diagnostic tests or follow-up ones (Cohen kappa respectively 74.0% [70.2-77.1%], P<0.001 and 80.3% [76.4-84.3%], P<0.001). Notably, Valsalva was necessary to disclose the presence of shunt during TCD in 487 (31.7%) patients and during CE-TTE in 482 (31.4%) cases. Finally, performance of TCD and CE-TTE in a subset of patients eventually undergoing TTE was quite similar. CONCLUSIONS: The diagnostic accuracy of CE-TTE appears favorable, and this imaging test may identify patients who may be missed if only TCD is used to screen patients with suspected PFO/ASD. Accordingly, CE-TTE is recommended as an adjunct diagnostic modality for all patients with a high pre-test probability of PFO/ASD and right-to-left shunt.

Preventing COVID-19 in assisted living facilities: An impossible task pending vaccination roll out.

Here, we aimed to describe the clinical outcomes of the residents of a long-term care facility during its closure to visitors and suppliers in response to the first COVID-19 pandemic from February 23 to June 22, 2020, and the results of the facility-wide SARS-CoV-2 testing of residents and staff in June 2020 before its partially reopening. Seventy-four residents and 53 members of staff were included in the present study. The staff underwent nasopharyngeal swab tests for SARS-CoV-2, and both the staff and residents underwent serological tests to detect IgG antibodies against SARS-CoV-2. The results of all of the tests were negative. Conversely, 94% of residents and 38% members of the staff were tested positive to the nasopharyngeal swab tests during the second COVID-19 pandemic wave (data collected from November 1 to November 30, 2020). Our experience suggests that, in the presence of a life-threatening pandemic such as SARS-CoV-2 infection, the prompt use of restrictive procedures can prevent the spread and progression of disease in assisted living facilities in the short term but may fail in the long term, especially when the prevalence of the COVID-19 greatly increased outside the facility enhancing the risk of import the disease from outside. SARS-CoV-2 vaccination of residents and staff members would contribute to control/limit the prevalence and the spread of the virus.

Factors Associated with ICU Admission following Blunt Chest Trauma.

Background. Blunt chest wall trauma accounts for over 10% of all trauma patients presenting to emergency departments worldwide. When the injury is not as severe, deciding which blunt chest wall trauma patients require a higher level of clinical input can be difficult. We hypothesized that patient factors, injury patterns, analgesia, postural condition, and positive airway pressure influence outcomes. Methods. The study population consisted of patients hospitalized with at least 3 rib fractures (RF) and at least one pulmonary contusion and/or at least one pneumothorax lower than 2 cm. Results. A total of 140 patients were retrospectively analyzed. Ten patients (7.1%) were admitted to intensive care unit (ICU) within the first 72 hours, because of deterioration of the clinical conditions and gas exchange with worsening of chest X-ray/thoracic ultrasound/chest computed tomography. On univariable analysis and multivariable analysis, obliged orthopnea (p = 0.0018) and the severity of trauma score (p < 0.0002) were associated with admission to ICU. Conclusions. Obliged orthopnea was an independent predictor of ICU admission among patients incurring non-life-threatening blunt chest wall trauma. The main therapeutic approach associated with improved outcome is the prevention of pulmonary infections due to reduced tidal volume, namely, upright postural condition and positive airway pressure.

The effect of aldosterone-antagonist therapy on aortic elastic properties in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: Many studies proved the prognostic importance of aortic stiffness as an independent predictor of cardiovascular morbidity and all-cause mortality. The decrease of arterial compliance has a high prevalence in patients with heart failure and affects both hemodynamics and prognosis. Aortic stiffness is partially caused by excessive activation of the renin-angiotensin-aldosterone system. Spironolactone, a mineralcorticoid receptor antagonist (MRA), has been shown to decrease aortic stiffness and fibrosis in experimental models. However, there are few studies that describe the effects of MRA on aortic stiffness in patients with nonischemic dilated cardiomyopathy. AIMS: To evaluate the effect of spironolactone on aortic stiffness in patients with nonischemic dilated cardiomyopathy. MATERIALS AND METHODS: We randomized (1 : 1) 102 patients with nonischemic dilated cardiomyopathy with New York Heart Association class I-II to receive spironolactone 25 mg/day (up to 100 mg/day) or placebo, in addition to recommended therapy. Aortic stiffness index, aortic strain, aortic distensibility and aortic dimensions were assessed at baseline and after 6 months. All measures were obtained with echocardiography M-mode at 3 cm above the aortic valve on parasternal long axis view and simultaneous brachial arterial pressure with sphygmomanometer. RESULTS: Ascending aorta diameters, aortic stiffness index, aortic distensibility and aortic strain were similar at randomization in the two groups. After 6 months of therapy in the treated group, we found a reduction of aortic stiffness index (7.2 ±â€Š3.5 versus 9.6 ±â€Š4.8 mmHg; P = 0.03) and an increase of aortic distensibility (3.77 ±â€Š1.0 versus 2.92 ±â€Š0.55 mmHg; P = 0.01) and systolic aortic strain (10.0 ±â€Š5.0 versus 8.0% ±â€Š2.1%; P = 0.01). There were no difference in systolic arterial pressure, diastolic arterial pressure and differential pressure in the two groups. CONCLUSION: Therapy with spironolactone is effective in reducing aortic stiffness in patients with nonischemic dilated cardiomyopathy. This effect could improve hemodynamics supporting the use of MRAs in patients with low New York Heart Association class (I-II).

Noninvasive assessment of endothelial function: the classic methods and the new peripheral arterial tonometry.

The combination of risk stratification by assessment of conventional risk factors for cardiovascular disease (CVD) with not only a morphological assessment of vascular damage (such as carotid ultrasound examination) but also vascular function tests may be a useful strategy for the management of CVD and its related risk factors. Endothelial dysfunction is present in a great variety of pathological conditions: it is considered the first alteration of vascular function in atherosclerosis and one of the phenomena involved in the progression of heart failure. Assessing endothelial function with noninvasive methods could have a central role for evaluation of treatment, prognostic stratification, and pharmacological studies in CVD. In this review, we focus on noninvasive techniques that have recently become available to assess endothelial function and express the possible clinical role in different clinical settings.

[New pharmacological approaches to ischemic heart disease]. / Nuovi approcci farmacologici nella cardiopatia ischemica.

Major steps have been made in the treatment of ischemic heart disease from the discovery of nitrates as antianginal medication to the techniques of percutaneous angioplasty. This incredible therapeutic progress has resulted in a reduced incidence of ischemic heart disease and related mortality and morbidity. However, statistical and epidemiological data indicate that in ischemic heart disease, despite the achievement of great success, there is a necessity for a further step toward treatment, considering the fact that the characteristics of this population are changing (increased prevalence of subendocardial infarction compared with classic transmural infarction, especially in the elderly population). Furthermore, the need for alternative therapeutic approaches to traditional ones is recognized. Ranolazine is a selective inhibitor of Na channels that prevents pathological extension of late Na current developing in the ischemic myocardial cell. This current is responsible for calcium overload, with consequent impairment of diastolic relaxation. Ranolazine reduces Na overload induced by calcium and improves diastolic relaxation and coronary subendocardial flow, without affecting hemodynamic parameters such as blood pressure, heart rate, or inotropic state of the heart, avoiding undesirable side effects. Efficacy of ranolazine has been evaluated in several trials, using clinical and instrumental endpoints (MARISA and CARISA) or, more recently, using endpoints such as mortality and reinfarction (ERICA and MERLIN-TIMI 36). Ivabradine acts through the inhibition of late Na current (also known as If), which controls the spontaneous diastolic depolarization of sinus node cells. The partial inhibition of these channels reduces the frequency of sinus node action potential initiation, resulting in decreased heart rate without effects on contractility, atrio-ventricular conduction, or repolarization. The BEAUTIFUL trial has tested whether the effect of ivabradine in lowering heart rate is able to reduce mortality and cardiovascular morbidity in patients with coronary artery disease and left ventricular systolic dysfunction. The most significant results were obtained in the subgroup of patients with life-limiting exertional angina. In this group, ivabradine significantly reduced the primary endpoint, a composite of cardiovascular death, hospitalization for fatal and nonfatal acute myocardial infarction (AMI) or heart failure, by 24%, and hospitalizations for AMI by 42%. In the subgroup of patients with baseline heart rate >70 bpm, hospitalizations for AMI and revascularization were reduced by 73% and 59%, respectively.

Biological drugs: classic adverse effects and new clinical evidences.

The last 20 years was characterized by great improvements in the efficacy and tolerability of anticancer therapies. Most of these changes are related to the introduction of targeted drugs, which presents a better activity on the biology of cancer and less toxicity. Nevertheless, the initial enthusiasm was cooled by the emerging evidences of cardiac side effects. The aim of this review is to describe the actual knowledge about the possible cardiotoxicity of targeted drugs. The most important need is the detection of early cardiotoxicity and the evidence of subtle myocardial dysfunction that allows to begin a protective therapy. In our review we analyzed the non invasive imaging techniques to early predict myocardial dysfunction. Echocardiography seems to be the ideal method for her availability, safety and clinical usefulness, in particular the new echocardiographic techniques like speckle tracking.

[Indications for statin therapy in patients with acute coronary syndrome of ischemic origin]. / Indicazione alla terapia con statine nel paziente con sindrome coronarica acuta ad eziologia ischemica.

Recent evidence has increasingly demonstrated that statins, besides reducing cholesterol levels, are as effective as other therapeutic approaches in the treatment of patients with acute coronary syndromes. Appropriate control of cardiovascular risk factors accounts for 44% of the overall reduction in mortality. The decrease in plasma cholesterol concentrations, however, remains the most effective therapeutic target, leading to a -24% reduction of total mortality. Statins have proved to be effective within the first few weeks after an acute coronary event. As a consequence, their use is recommended by current guidelines (class IB) in patients with non-ST-elevation myocardial infarction. Data from recent trials suggest that early statin therapy is a reasonable option for patients with ST-elevation myocardial infarction (class IA recommendation).