Liver involvement in presence of heart disease and heart involvement in presence of liver disease: a conundrum.

Data from literature show a cross-talk between the heart and liver during diseases which primarily involve one of the two organs, but data regarding this relationship are scant. Aim of this study was to investigate this relationship. In this narrative review we critically explored the most recent literature on this topic using PubMed and Medline and examining the most recent studies about liver involvement in heart failure and heart involvement in course of liver disease. Patients with acute and chronic heart failure and those who undergo heart transplatation (HT) manifest various signs of liver damage with a rate of incidence which is higher in candidates for left ventricular assist device. In presence of cardiogenic shock a very marked hepatocellular necrosis may occur while in the setting of chronic heart failure congestive hepatopathy and-or the so-called cardiac cirrhosis are observed. On the other side in presence of chronic liver disease and in case of liver transplantation (LT) heart functions may be altered and cirrhotic cardiomyopathy, which is a syndrome characterized by systolic, diastolic and electrophysiological abnormalities may occur. In this review we have analyzed the relationship between heart and liver disease, even in case of LT and HT. Furthermore we have underscored the effects of chronic alcoholism and of systemic disorders such as hemochromatosis and amyloidosis on both heart and liver.

Right ventricle: current knowledge of echocardiographic evaluation of this "forgotten" chamber.

In the past the right ventricle (RV) has been traditionally regarded as a simple conduit between the venous system and the pulmonary circulation and it has aroused little interest in both clinical and echocardiographic cardiologists to such an extent that it has been defined as the "forgotten chamber." Subsequently it was clearly shown that the right heart (RH) plays an important physiologic role in cardiac activity, and that congenital or acquired alterations in its structure and function have an important prognostic value. Aim of this review is to shed the light on the echocardiographic approach to this cardiac chamber. In this narrative review we critically explored the most recent literature on this topic using PubMed and Medline and examining the most recent guidelines on the echocardiographic approach to the RV. Echocardiographic approach to RV presents some technical difficulties, which stem from the position of the RV inside the thorax and around the LV and from its particular anatomy, which precludes geometric assumptions. However, RV may now be evaluated quantitatively and qualitatively in many ways, and some new methods can partially overcome some of the limits imposed by its complex anatomy, thereby yielding a quantitative evaluation. Furthermore, due to the wide range of pathologies which may involve the RV a disease-oriented approach should be considered in the echocardiographic investigation of right heart disease.

Speckle-tracking echocardiography: state of art and its applications.

Echocardiographic evaluation of left ventricular ejection fraction (LVEF) provides important information regarding both myocardial function and prognosis. This parameter presents various limitations and does not allow early detection of myocardial dysfunction. LVEF may be related to hemodynamic load, geometric assumptions, to image quality, and it does not reflect myocardial contractility. It has been hypothesized that speckle tracking echocardiography (STE) may allow overcoming such limits. STE through the measurement of strain and strain rate, which detect myocardial deformation, allows earlier identification of myocardial dysfunction in different settings both in presence of systolic and diastolic dysfunction, helps to predict left ventricular remodeling after acute myocardial infarction (AMI), and helps to decide the timing of surgery in asymptomatic severe valvular heart disease which is still a problematic issue. Increasingly interest regards the role of STE for the assessment of cardiomyopathies, myocarditis, and pulmonary hypertension. STE may be applied to the evaluation of systolic and diastolic dysfunction. STE is useful in all conditions in which cardiac dysfunction is not still overt, but a subclinical involvement is undoubtedly present such as in presence of cardiovascular risk factors and in cardio-oncology at earlier stages. It has been confirmed its role in predicting left ventricular remodeling after AMI which represents an important prognostic datum and in deciding the timing of surgery in asymptomatic valvular diseases. STE is an important tool to detect myocardial impairment even at earlier stages. 3DSTE and layer-specific strain represent promising fields of clinical application of STE.

May standard basal echocardiogram allow to obtain predictors of asymptomatic cardiac dysfunction in alcoholics?

BACKGROUND: Long-lasting heavy alcohol intake has been progressively recognized as a leading cause of nonischemic dilated cardiomyopathy, involving 10% of all people who use alcohol. It is of huge importance to identify the earliest markers of this dysfunction and it is known that the newest echocardiographic techniques such as speckle tracking may allow to do it. In this study we investigated if standard basal echocardiogram features allow to obtain predictors of asymptomatic cardiac dysfunction in alcoholics. METHODS: A population of 80 consecutive asymptomatic alcoholics was enrolled. None presented history, signs or symptoms of cardiovascular disease. All of them underwent a conventional transthoracic monobidimensional and doppler echocardiography. RESULTS: Our cohort did not present echocardiographic findings of increased left ventricular sizes, mass or relative wall thickness. Hence, a significant rate of systolic dysfunction was not found. Furthermore, statistical analysis displayed an inverse relationship between alcohol consumption and systolic pulmonary arterial pressure as well as between alcohol abuse and left atrium enlargement. This may be explained by a potential vasodilator mechanism occurring in the earliest stages of alcohol intake. On the contrary, a positive correlation with the E/A ratio was found, and this might be ascribed to state of high cardiac output determined by alcohol abuse. There were modes sex-related differences. CONCLUSIONS: This study has demonstrated that standard echocardiography may allow to predict cardiac dysfunction in asymptomatic alcoholics, and sex-related differences may be identified in this regard. These data need to be confirmed by further studies involving larger population.

Cutaneous effects of antihypertensive drugs.

INTRODUCTION: Treatment with antihypertensive drugs may be associated with different dermatological adverse reactions. EVIDENCE ACQUISITION: We systematically reviewed the literature available on the MEDLINE (PubMED) databases, up to July 2018. We searched for the terms "calcium-channel blockers" or "angiotensin-converting enzyme inhibitors" or "angiotensin II receptors blockers" or "diuretics" or "beta blockers" AND "dermatological effects" or "skin disease." EVIDENCE SYNTHESIS: The most important cutaneous events occurring during treatment with calcium-channel blockers are represented by pedal edema and photosensitivity with consequent increased risk of skin cancer. Moreover, other adverse reactions are eczematous and psoriasiform dermatitis, subacute cutaneous lupus erythematosus, and rarely toxic epidermal necrolysis. In patients taking angiotensin-converting enzyme inhibitors or angiotensin II receptors blockers, angioedema, psoriasis and pemphigus can be exacerbated. Furthermore, some authors associated the use of these medications with the onset of skin neoplasms. As for diuretics, the most relevant cutaneous reactions are represented by subacute cutaneous lupus erythematosus and leukocytoclastic vasculitis. Photosensitivity is another important event related to diuretics use. Eventually, itching is often related to the use of thiazides, particularly in elderly patients. With regards to beta blockers, we should remember a significant association with psoriasis, lichen planus, subacute cutaneous lupus erythematosus, and an increased risk of skin cancer. CONCLUSIONS: During antihypertensive treatment, several dermatological reactions may occur. Clinicians should inform their patients of the increased risk of cutaneous lesions associated with the use of these drugs, and perform periodic examination of the skin.

Predictors of cardiovascular outcome and rehospitalization in elderly patients with heart failure.

BACKGROUND: Heart failure (HF) is a major public health problem and represents the only cardiac disease continuing to increase in prevalence, in particular among elderly patients. The frequent rehospitalizations have a negative impact on quality of life of patients with HF, constituting a substantial cost for patients and the health system. The aim of this review was to look into biochemical, echocardiographic and socioeconomical parameters as predictors of clinical outcomes and rehospitalizations. METHODS: This narrative review is based on the material searched for and obtained via PubMed from January 2000 up to March 2018. The search terms we used were as follows: "elderly, heart failure, cardiovascular" in combination with "biomarker, echocardiography and hospitalization." RESULTS: This review analyses the potential predictive role of biochemical and echocardiographic and socioeconomical parameters on clinical outcomes (particularly cardiovascular) and hospital readmissions in patients with chronic HF. We focused on risk stratification of elderly patients with HF, who constitute a category of frail subjects at higher risk for readmission to hospital. CONCLUSIONS: In elderly subjects with chronic HF, the risk stratification could benefit of a multiparametric approach combining biochemical, echocardiographic, demographic and socioeconomical parameters, thus ensuring a better quality of life and at the same time a better allocation of financial resources.

Cardiac involvement in cutaneous sarcoidosis.

Sarcoidosis is a chronic multisystem disease that usually has a good prognosis but in some cases, especially when cardiac involvement occurs, the outcome is fatal. Cardiac sarcoidosis is insidious to diagnose because it is usually asymptomatic and when clinically apparent, it may have a wide variety of manifestations. The aim of this study was to investigate the possible cardiac involvement in cutaneous sarcoidosis patients. Diagnosis of cutaneous sarcoidosis was confirmed by skin biopsy, laboratory tests and radiological findings in 13 Caucasian patients. To evaluate cardiac damage, electrocardiography, echocardiography, and contrast-enhanced cardiac magnetic resonance were performed. Magnetic resonance identified cardiac sarcoidosis only in one of the cutaneous sarcoidosis patients. We suggest investigating cardiac involvement in patients with cutaneous sarcoidosis, albeit asymptomatic, since cardiac lesions are frequently associated with a poorer prognosis.

Biophysical aspects and novel treatments of atrial fibrillation.

INTRODUCTION: Atrial fibrillation (AF) is a cardiac arrhythmia caused by various mechanisms, such as multiple re-entering wavelets, high frequency activity, and rotor sources. EVIDENCE ACQUISITION: This narrative review was based on papers found on PubMed and MEDLINE up to May 2016. The search terms were "atrial fibrillation" in combination with "catheter ablation, pathophysiology, antiarrhythmic drugs". EVIDENCE SYNTHESIS: Antiarrhythmic drugs are the cornerstone of therapy in AF, but their efficacy and safety might have to be improved. In case of failure of pharmacologic therapies, other treatments can be considered. A better understanding of the important role of the pulmonary veins has led to new approaches, such as ablation procedures, which were initially only surgical, while percutaneous options were later added. However, these strategies may present various technical complications also when performed by skilled operators. A promising field of investigation is the genetics of AF, as highlighted by studies on the role of micro-RNA. CONCLUSIONS: Relevant improvement on the knowledge of the electrophysiological basis of genesis and maintenance of AF has been done in order to treat a very common arrhythmia, but further studies, as those in the genetics field, can open new challenging therapeutic horizons.

The left ventricle as a mechanical engine: from Leonardo da Vinci to the echocardiographic assessment of peak power output-to-left ventricular mass.

The interpretation of the heart as a mechanical engine dates back to the teachings of Leonardo da Vinci, who was the first to apply the laws of mechanics to the function of the heart. Similar to any mechanical engine, whose performance is proportional to the power generated with respect to weight, the left ventricle can be viewed as a power generator whose performance can be related to left ventricular mass. Stress echocardiography may provide valuable information on the relationship between cardiac performance and recruited left ventricular mass that may be used in distinguishing between adaptive and maladaptive left ventricular remodeling. Peak power output-to-mass, obtained during exercise or pharmacological stress echocardiography, is a measure that reflects the number of watts that are developed by 100 g of left ventricular mass under maximal stimulation. Power output-to-mass may be calculated as left ventricular power output per 100 g of left ventricular mass: 100× left ventricular power output divided by left ventricular mass (W/100 g). A simplified formula to calculate power output-to-mass is as follows: 0.222 × cardiac output (l/min) × mean blood pressure (mmHg)/left ventricular mass (g). When the integrity of myocardial structure is compromised, a mismatch becomes apparent between maximal cardiac power output and left ventricular mass; when this occurs, a reduction of the peak power output-to-mass index is observed.