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A multicenter, cross-sectional observational study (Italian GENder Differences in Awareness of Cardiovascular risk, IGENDA study) was carried out to evaluate the perception and knowledge of cardiovascular risk among Italian women. An anonymous questionnaire was completed by 4454 women (44.3 ± 14.1 years). The 70% of respondents correctly identified cardiovascular disease (CVD) as the leading cause of death. More than half of respondents quoted cancer as the greatest current and future health problem of women of same age. Sixty percent of interviewed women considered CVD as an almost exclusively male condition. Although respondents showed a good knowledge of the major cardiovascular risk factors, the presence of cardiovascular risk factors was not associated with higher odds of identifying CVD as the biggest cause of death. Less than 10% of respondents perceived themselves as being at high CVD risk, and the increased CVD risk perception was associated with ageing, higher frequency of cardiovascular risk factors and disease, and a poorer self-rated health status. The findings of this study highlight the low perception of cardiovascular risk in Italian women and suggest an urgent need to enhance knowledge and perception of CVD risk in women as a real health problem and not just as a as a life-threatening threat.

Background Heart failure with midrange ejection fraction (HFmrEF) represents a heterogeneous category where phenotype, as well as prognostic assessment, remains debated. The present study explores a specific HFmrEF subset, namely those who recovered from a reduced EF (rec-HFmrEF) and, particularly, it focuses on the possible additive prognostic role of cardiopulmonary exercise testing. Methods and Results We analyzed data from 4535 patients with HFrEF and 1176 patients with rec-HFmrEF from the Metabolic Exercise combined with Cardiac and Kidney Indexes database. The end point was cardiovascular death at 5 years. The median follow-up was 1343 days (25th–75th range 627–2403 days). Cardiovascular death occurred in 552 HFrEF and 61 rec-HFmrEF patients. The multivariate analysis confirmed an independent role of the MECKI score's variables in HFrEF (C-index = 0.744) whereas, in the rec-HFmrEF group, only age and peak oxygen uptake (pVO2) remained associated to the end point (C-index = 0.745). A peak oxygen uptake of ≤55% of predicted and a ventilatory efficiency of ≥31 resulted as the most accurate cut-off values in the outcome prediction. Conclusions: Present data support the cardiopulmonary exercise test and, particularly, the peak oxygen uptake, as a useful tool in the rec-HFmrEF prognostic assessment. A peak VO2 of ≤55% predicted and ventilatory efficiency of ≥31 might help to identify a high-risk rec-HFmrEF subgroup.

Aims Mineralocorticoid receptor antagonists (MRAs) have been demonstrated to improve outcomes in reduced ejection fraction heart failure (HFrEF) patients. However, MRAs added to conventional treatment may lead to worsening of renal function and hyperkalaemia. We investigated, in a population‐based analysis, the long‐term effects of MRA treatment in HFrEF patients. Methods and results We analysed data of 6046 patients included in the Metabolic Exercise Cardiac Kidney Index score dataset. Analysis was performed in patients treated (n = 3163) and not treated (n = 2883) with MRA. The study endpoint was a composite of cardiovascular death, urgent heart transplantation, or left ventricular assist device implantation. Ten years' survival was analysed through Kaplan–Meier, compared by log‐rank test and propensity score matching. At 10 years' follow‐up, the MRA‐untreated group had a significantly lower number of events than the MRA‐treated group (P

Aims The two main symptoms referred by chronic heart failure (HF) patients as the causes of exercise termination during maximal cardiopulmonary exercise testing (CPET) are muscular fatigue and dyspnoea. So far, a physiological explanation why some HF patients end exercise because of dyspnoea and others because of fatigue is not available. We assessed whether patients referring dyspnoea or muscular fatigue may be distinguished by different ventilator or haemodynamic behaviours during exercise. Methods and results We analysed exercise data of 170 consecutive HF patients with reduced left ventricular ejection fraction in stable clinical condition. All patients underwent maximal CPET and a second maximal CPET with measurement of cardiac output by inert gas rebreathing at peak exercise. Thirty‐eight (age 65.0 ± 11.1 years) and 132 (65.1 ± 11.4 years) patients terminated CPET because of dyspnoea and fatigue, respectively. Haemodynamic and cardiorespiratory parameters were the same in fatigue and dyspnoea patients. VO2 was 10.4 ± 3.2 and 10.5 ± 3.3 mL/min/kg at the anaerobic threshold and 15.5 ± 4.8 and 15.4 ± 4.3 at peak, in fatigue and dyspnoea patients, respectively. In fatigue and dyspnoea patients, peak heart rate was 110 ± 22 and 114 ± 22 beats/min, and VE/VCO2 and VO2/work relationship slopes were 31.2 ± 6.8 and 30.6 ± 8.2 and 10.6 ± 4.2 and 11.4 ± 5.5 L/min/W, respectively. Peak cardiac output was 6.68 ± 2.51 and 6.21 ± 2.55 L/min (P = NS for all). Conclusions In chronic HF patients in stable clinical condition, fatigue and dyspnoea as reasons of exercise termination do not highlight different ventilatory or haemodynamic patterns during effort.

Aims: Risk stratification in heart failure (HF) is crucial for clinical and therapeutic management. A multiparametric approach is the best method to stratify prognosis. In 2012, the Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score was proposed to assess the risk of cardiovascular mortality and urgent heart transplantation. The aim of the present study was to compare the prognostic accuracy of MECKI score to that of HF Survival Score (HFSS) and Seattle HF Model (SHFM) in a large, multicentre cohort of HF patients with reduced ejection fraction. Methods and results: We collected data on 6112 HF patients and compared the prognostic accuracy of MECKI score, HFSS, and SHFM at 2- and 4-year follow-up for the combined endpoint of cardiovascular death, urgent cardiac transplantation, or ventricular assist device implantation. Patients were followed up for a median of 3.67 years, and 931 cardiovascular deaths, 160 urgent heart transplantations, and 12 ventricular assist device implantations were recorded. At 2-year follow-up, the prognostic accuracy of MECKI score was significantly superior [area under the curve (AUC) 0.781] to that of SHFM (AUC 0.739) and HFSS (AUC 0.723), and this relationship was also confirmed at 4 years (AUC 0.764, 0.725, and 0.720, respectively). Conclusion: In this cohort, the prognostic accuracy of the MECKI score was superior to that of HFSS and SHFM at 2- and 4-year follow-up in HF patients in stable clinical condition. The MECKI score may be useful to improve resource allocation and patient outcome, but prospective evaluation is needed.

Aims: The use of β-blockers represents a milestone in the treatment of heart failure with reduced ejection fraction (HFrEF). Few studies have compared β-blockers in HFrEF, and there is little data on the effects of different doses. The present study aimed to investigate in a large database of HFrEF patients (MECKI score database) the association of β-blocker treatment with a composite outcome of cardiovascular death, urgent heart transplantation or left ventricular assist device implantation, addressing the role of β-selectivity and dosage regimens. Methods and results: In 5242 HFrEF patients, we investigated the role of: (i) β-blocker treatment vs. non-β-blocker treatment, (ii) β1-/β2-receptor-blockers vs. β1-selective blockers, and (iii) daily β-blocker dose. Patients were followed for 3.58 years, and 1101 events (18.3%) were observed; 4435 patients (86.8%) were on β-blockers, while 807 (13.2%) were not. At 5 years, β-blocker-patients showed a better outcome than non-β-blocker-subjects [hazard ratio (HR) 0.48, P < 0.0001], while also considering potential confounders. A comparable prognosis was observed at 5 years in the β1-/β2-receptor-blocker (n = 2219) vs. β1-selective group (n = 2216) (HR 0.95, P = ns). A better prognosis was observed in high-dose (>2 5 mg carvedilol equivalent daily dose, n = 1005) patients than in both medium dose (12.5–25 mg, n = 1431) and low dose (

Hypertension is a major risk factor for cardiovascular disease and outcomes in women, and antihypertensive therapy is not always successful in achieving control over the blood pressure (BP). Nonoptimal control of BP remains a crucial risk factor for cardiovascular mortality, and in women, it could be related to sex-specific factors. Historically, women have been under-represented in clinical trials; therefore, the benefits of clinical outcomes and the safety profiles of antihypertensive therapies have been studied less extensively in women. The reasons for the sex differences in BP levels are multifactorial, implying different roles of the sex hormones, the renin-angiotensin system, sympathetic activity, and arterial stiffness. A complete understanding of the pathophysiological features of these differences requires further investigation.Nevertheless, the prevalence of the use of antihypertensive agents is higher among middle-aged women than among men. Notably, in the United States, hypertensive women use more diuretics and angiotensin receptor blockers than men, whereas hypertensive men more often receive beta-blockers, calcium channel antagonists, or inhibitors of angiotensin-converting enzyme. To date, the explanations for these sex differences in the consumption of antihypertensive drugs remain unknown.

ObjectivesThe aim of this study was to determine the prevalence of right intraventricular dyssynchrony, its determinants and prognostic impact in idiopathic, heritable, and anorexigen-induced pulmonary arterial hypertension.BackgroundRight ventricular dyssynchrony has been described in pulmonary arterial hypertension, but no evidence is available on its prognostic impact and evolution after therapy.MethodsIn 83 consecutive therapy-naïve patients, right ventricular dyssynchrony was evaluated by 2-dimensional speckle-tracking echocardiography calculating the standard deviation of the times to peak-systolic strain for the 4 mid-basal right ventricular segments (RV-SD4). After baseline (World Health Organization [WHO] class, pulmonary hemodynamics, 6-min walk test [6MWT]), a second assessment was performed after 12 months or when clinical worsening occurred.ResultsPatients with right ventricular dyssynchrony (RV-SD4 >18 ms) had advanced WHO class, worse 6MWT, right ventricular remodeling, and hemodynamic profile compared with patients ≤18 ms. Determinants of dyssynchrony included pulmonary vascular resistance, QRS duration, and right ventricular end-diastolic area (r2 = 0.38; p

Echocardiography is the most commonly used imaging technique in current clinical cardiology practice and is usually performed using a monoplane approach. In recent years new matrix-array transducers have become available that allow the real-time simultaneous display of two or more echocardiographic scanning planes from the same acoustic window. This multiplane approach is particularly interesting as it may reduce, during the examination, the number of probe movements and consequently facilitate image acquisition. In some clinical applications, moreover, the multiplane approach improves both accuracy and reproducibility of echocardiography. This review evaluates the state of the art of multiplane echocardiography and discusses possible clinical applications, advantages and limitations of this technique.

Aortic valve stenosis is a common disease. Despite this, the diagnosis may often be missed; a significant proportion of patients are still identified at post-mortem examination, and 5% of operations are performed at end stage. Unrecognized aortic valve stenosis is an important cause of anesthetic mortality. One reason for failing to make a diagnosis is that the clinical signs can be difficult to interpret due to the confounding association with arterial hypertension, coronary artery disease and systemic arteriosclerosis, potentially blunting the effects of aortic valve stenosis on the circulation. Moreover, most patients with aortic valve stenosis have a long asymptomatic period and may not seek medical attention. In patients with severe, symptomatic, calcific aortic valve stenosis, aortic valve replacement is the only effective treatment; much evidence suggests that it should be offered to patients regardless of age, after appropriate clinical evaluation. Doppler echocardiography plays a pivotal role in confirming the diagnosis of aortic valve stenosis in assessing the severity of the disease and, ultimately, in giving prognostically relevant information. Moreover, echocardiography is suitable for monitoring of disease progression and left ventricular function in these patients, and is of fundamental support for clinical follow-up. Accurate noninvasive quantification of aortic valve stenosis is, however, a technically demanding and time-consuming procedure, with several potential pitfalls. Considering the frequency and importance of aortic valve stenosis, a comprehensive echocardiographic study should be offered and carefully performed in all patients with noteworthy murmurs and repeated regularly (at appropriate time intervals), together with clinical review, in patients in whom aortic valve stenosis has been diagnosed.

Doppler echocardiography is a fundamental instrument to understand heart damage during essential arterial hypertension. Left ventricular (LV) hypertrophy may also be conveniently studied in its morphological and functional aspects by ultrasound application. Echocardiography can also provide important morphological and functional information in hypertensive patients for therapeutic management and prognostic stratification. In recent years, echocardiography has been enriched by very refined techniques that are capable of studying the physiopathological intramyocardial phenomena: (i) tissue Doppler (which studies intramyocardial velocities and time intervals and allows the analysis of strain and strain rate); (ii) integrated backscatter (which analyzes variations of myocardial reflectivity in decibels); (iii) transthoracic Doppler derived coronary flow reserve (which quantifies the vasodilator response of coronary velocities to a hyperaemic stimulation); (iv) myocardial echo-contrast-echocardiography (which studies the kinetics of ultrasound contrast microbubbles at the intramyocardial level); and (v) real-time three-dimensional (3-D) echocardiography [which allows a more precise evaluation of left ventricular (LV) volumes and LV mass]. These new methodological approaches have recently been used in the hypertensive clinical setting to provide a deeper knowledge of the complex physiopathological and histopathological mechanisms underlying the modifications induced by arterial hypertension at the myocardial tissue level (myocytes, collagen, microcirculation). This review shows the advancement of high-tech ultrasound applied to hypertensive heart disease, pointing out limitations and incremental potentialities in comparison with conventional echocardiography.

In cardiology, ventricular function has extensively been studied, whereas atrial function received less attention. For such a reason atrial function is less known. The aim of this review was to summarize the role of atrial function and to explain how echocardiography and new echocardiographic-derived techniques may be of help to better study atrial function.

Background. Primary hyperparathyroidism (PHPT) is associated with high cardiovascular morbidity, and the role of calcium and parathyroid hormone is still controversial.Objective. To evaluate the prevalence and outcomes of metabolic syndrome, hypertension, and some cardiovascular alterations in asymptomatic PHPT, and specific changes after successful parathyroidectomy.Material and Methods. We examined 30 newly diagnosed PHPT patients (8 males, 22 females; mean age yrs), 30 patients with essential hypertension (EH) (9 males, 21 females; mean age ), and 30 normal subjects (NS) (9 males, 21 females: mean age ). All groups underwent evaluation with ambulatory monitoring blood pressure, echocardiography, and color-Doppler artery ultrasonography and were successively revaluated after one year from parathyroidectomy.Results. PHPT patients presented a higher prevalence of metabolic syndrome (38%) with respect to EH (28%). Prevalence of hypertension in PHPT was 81%, and 57% presented altered circadian rhythm of blood pressure, with respect to EH (35%) and NS (15%). PHPT showed an important myocardial and vascular remodelling. During follow-up in PHPT patients, we found significant reduction of prevalence of metabolic syndrome, blood pressure, and “non-dipping phenomenon.”Conclusions. Cardiovascular and metabolic alterations should be considered as added parameters in evaluation of patients with asymptomatic PHPT.

Objectives: Pulmonary arterial dilatation is considered a consequence of chronic pulmonary hypertension (PH), but despite its relatively common detection, its prevalence and prognostic impact have not yet been systematically investigated. The aim of the study was to investigate these factors in a relatively large cohort of severe PH patients. Methods: One hundred and forty-one consecutive patients diagnosed with PH were monitored for a mean of 957 days. Data including functional class, exercise capacity, invasive hemodynamics and pulmonary artery (PA) echo/CT scan measurement were performed and outcomes prospectively collected. Results: PA dilatation is a common feature, present in the 76.6% of cases in this cohort of severe PH patients. Survival at 1, 2 and 3 years was 83, 71 and 58%, respectively. On univariate analysis, the baseline variables associated with a poor outcome were related to pulmonary arterial hypertension associated with connective tissue disease (CDT-PAH), New York Heart Association (NYHA) functional class, 6-min walk test and right atrial pressure. On multivariate analysis only CDT-PAH and NYHA functional class remained independently associated with poor survival. Conclusions: PA dilatation is commonly detected in severe PH patients and is not associated with an increased risk of death.

A 44-year-old female with no past medical history was evaluated for hypertension. High blood pressure was recorded (160/100 mm Hg) and EKG showed sinus bradycardia and left anterior fascicular block. Physical examination was unremarkable. Transthoracic echocardiography showed normal systolic function and concentric left ventricular (LV) hypertrophy (14 mm); an incidental intramyocardial hyperechogenic mass (1×2 cm in diameter) located in the mid-inferior wall of the left ventricle was described (Fig. 1). The patient was referred for a cardiovascular magnetic resonance (CMR) for appropriate noninvasive evaluation and tissue characterization of the mass. CMR was performed with a 1.5-T scanner (Siemens Medical System). Fast-gradient-echo steady-state-free-precession (SSFP) sequence confirmed the echo findings of LV hypertrophy and normal global and regional LV function; an intramyocardial hypointense focal area in themid-inferior wall was identified in the cine sequences. The area appeared hypointense in T1-weighted images (Fig. 2, A and B) with a significant signal reduction on fat saturation T1-weighted sequence (Fig. 2, C andD). In the inversion-recovery sequence the lesion appeared hyperintense pre-contrast with no enhancement after contrast administration (Fig. 2, E and F). Based on CMR findings, intramyocardial cardiac lipoma was diagnosed. In fact, fat can be easily characterized with CMR due to the typical T1 relaxation time and suppression

Pulmonary arterial hypertension (PAH) is a clinical condition characterized by elevated vascular resistance, associated with a poor prognosis and usually diagnosed in late stage. Echocardiographic assessment of PAH includes early disease detection and functional heart evaluation, in order to introduce a more accurate surveillance at an early stage of the disease and to contribute to prognostic stratification of advanced disease. Detection involves pulmonary artery systolic pressure (PASP) estimation. There is no clear consensus on defining normal distribution, but a PASP of 36 mmHg has been widely assumed as a cut-off value for mild PAH, requiring a more aggressive surveillance to detect further progression. Functional heart evaluation requires an accurate characterization of morphologic and hemodynamic changes, secondary to PAH development, which involves description of dimensional parameters, ventricular interdependency, intracardiac flow patterns, and right ventricular systolic performance. A valid assessment of these issues results in a useful evaluation of cardiac function, supporting clinical context in defining heart failure condition.