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Background: Use of echocardiography (echo) has exponentially increased in recent decades. Concerned about this scientific society developed appropriate use criteria (AUC). Clinical management still suffers geographical variations, and no objective data are available about echo AUC in developing countries. We aimed to evaluate (1) the appropriateness of referrals and (2) their relation to changes in clinical decision management. Methods: Prospective analysis of referrals from January to December 2014. Appropriateness and endpoints analyzed in different time points from medical archives. Endpoints: (1) change in the diagnosis, (2) indication for another method to complete the diagnosis, (3) change in clinical treatment, (4) indication for a treatment intervention, or (5) no change in management. Descriptive statistical analysis, Fisher's or chi‐square tests, and Cox regression used as appropriate (significance if P < .05). Results: One thousand one hundred referrals were analyzed (55.5 ± 16.1 years, 44.6% male). 80.5% of referrals were appropriate (A), 11.2% “Rarely Appropriate” (RA), and 8.3% “May Be Appropriate” (MBA). Proportion of (A) did not differ between modalities (TTE‐80.5% vs TEE‐87.7% vs STR‐81.2%, P = .67). (A) referrals were more related to clinical decision than (RA)+(MBA) (38.9% [A] vs 15% [RA]+[MBA], P < .001). The most frequent clinical indications of (RA) and (MBA) TTE were reevaluation of ventricular function without clinical change (AUC 10 and 11) and search of infectious endocarditis when low clinical probability (53). Conclusions: In a developing country, appropriateness of echo was similar to the United States and Europe. However, a significant proportion of referrals were still (RA) or (MBA), with no effect in clinical management. Controlling referrals 10, 11, and 53 can optimize echo use in developing countries. [ABSTRACT FROM AUTHOR]

Background: Two‐dimensional speckle tracking evaluation (2D‐STE) is a useful tool to evaluate the complexity of atrial function by the analysis of the different phases of atrial deformation and by the combination with Doppler measurements of diastolic function. Aim of the study: To evaluate the role of the left atrial (LA) strain parameters to predict worsening chronic heart failure (CHF). Methods: We enrolled outpatients affected by CHF referred to our heart failure unit. Each patient underwent a medical visit, an electrocardiogram (ECG), and an echocardiographic examination. LA function was assessed by 2D‐STE. The three phases of LA strain, that is, the reservoir (LAr), the conduit (LAcd), and the contraction (LAct)—were evaluated. Moreover, the ratio between E and LAr (E/LAr) and those between LAr and septal (LAr/Ees), lateral (LAr/Eel), and septal‐lateral (LAr/Eem) E/e' were measured. During follow‐up, the events related to worsening of heart failure were evaluated. Results: Two hundred eleven patients were enrolled. During a mean follow‐up of 14 ± 7 months, 37 patients showed at least one event related to heart failure worsening. At univariate Cox regression analysis, LAr, LAcd, LAct, E/LAr, LAr/Ees, LAr/Eel, and LAr/Eem were all associated with events related to heart failure worsening, but at multivariate regression analyses, only LAr (Hazard Ratio, HR:.95; 95% Confidence Interval, CI:.92–.99; p:.031), LAct (HR: 1.06; 95% CI: 1.01–1.12; p:.027), E/LAr (HR: 1.10; 95%CI: 1.0–1.16; p <.001), LAr/Ees (HR:.57; 95% CI:.37–.87; p:.010), and LAr/Eem (HR:.71; 95% CI:.53–.96; p:.026) remained significantly associated with the events. Finally, in a predictive model including the other relevant echocardiographic parameters LAr < 18%, LAct > −10.0%, LAr/Ees < 1.28, and E/LAr > 3.70 were associated with a statistically significant overall net reclassification improvement. Conclusions: In CHF patients, the measure of the LA reservoir and contraction by 2D‐STE is independently associated with heart failure worsening, but the accuracy in predicting the events is even greater when the reservoir is combined with the Doppler measures of diastolic function. [ABSTRACT FROM AUTHOR]

Background: Myocarditis have variable clinical presentation, evolution and prognosis. Aim of our study was to evaluate the value of speckle tracking echocardiography and cardiac magnetic resonance (CMR) in the short‐term prediction of supraventricular arrhythmias (SVA) in patients with acute myocarditis. Methods: Seventy patients (mean age 31±14 years old) with acute myocarditis and preserved left ventricular ejection fraction (LVEF) were enrolled. Longitudinal systolic strain (LS) of the left ventricle (LV), mechanical dispersion (MD) and CMR with quantitative measurement of delayed enhancement (DE) were performed in a subset of 43 patients. Logistic regression and ROC analysis were used to identify predictors of SVA Results: Only LS measured at sup‐epicardial, mid‐wall and sub‐endocardial level of the apical 4‐chamber view was significantly lower in patients with SVA, while MD was marginally prolonged in this setting. A value of LS > ‐ 16.1% measured at LV mid‐wall in the apical 4‐chamber view (ROC‐AUC.75, Sensitivity 63%, Specificity 85%) was the most accurate measure to identify patients with SVA. DE mass was also helpful with a ROC‐AUC.76; a DE‐Mass > 18.9 gr. had a Sensitivity 63% and a Specificity 77%, to identify patients at risk of SVA. Conclusions: Both DE mass and LS were associated with higher risk of SVA in patients with acute myocarditis and preserved LVEF. However, LS measured at the mid‐wall level and limited to LV segments included in the apical 4‐chamber view was the most accurate measure and did not show interaction with DE mass. [ABSTRACT FROM AUTHOR]

Aims: Aortic stenosis (AS) grading by 2D‐transthoracic echocardiography (2D‐TTE) aortic valve area (AVA) calculation is limited by left ventricular outflow tract (LVOT) area underestimation. The combination of Doppler parameters with 3D LVOT area obtained by multidetector computed tomography (MDCT) can improve AS grading, reconciling discordant 2D‐TTE findings. This study aimed to systematically evaluate the role of 3D‐transesophageal echocardiography (3D‐TEE) in AS grading using MDCT as reference standard. Methods and results: 288 patients (81 ± 6.3 years, 52.4% female) with symptomatic AS underwent 2D‐TTE, 3D‐TEE, and MDCT for transcatheter aortic valve implantation. Doppler parameters were combined with 3D LVOT areas measured by manual and semi‐automated software 3D‐TEE and by MDCT to calculate AVA, reassessing AS severity. Both 3D‐TEE modalities demonstrated good correlation with MDCT, with excellent intra‐observer and inter‐observer variability. Compared to MDCT, 3D‐TEE measurements significantly underestimated AVA (PANOVA <.0001), although the difference was clinically acceptable. Compared to 2D‐TTE, 3D‐TEE manual and semi‐automated software reclassified severe AS in 21.9% and 25.2% of cases, respectively (P <.0001), overcame grading parameters discordance in more than 40% of cases in patients with low‐gradient AS (P <.0001) and reduced the proportion of low‐flow states in nearly 75% of cases when combined to stroke volume index assessment (P <.0001). 3D‐TEE imaging modalities showed a reduction in the proportion of patients with low‐gradient and pathological AVA as defined by 2D‐TTE, and improved AVA and mean pressure gradient agreement with current guidelines cutoff values. Conclusion: 3D‐TEE AVA calculation is a reliable tool for AS grading with excellent reproducibility and good correlation with MDCT measurements. [ABSTRACT FROM AUTHOR]

Introduction Ranolazine reduces the Na-dependent calcium overload via inhibition of the late sodium current, improving diastolic tone and oxygen handling during myocardial ischemia. In patients with angina, evidence of myocardial ischemia, but no obstructive coronary artery disease ( CAD), abnormal coronary autoregulation plays a key role. Transthoracic Doppler-derived coronary flow reserve ( CFR) is an index of coronary arterial reactivity and decreases in both microvascular dysfunction and coronary artery stenosis. The aim of this study was to assess the effect of ranolazine on CFR in this group of patient. Methods Fifty-eight (39M, 19F) patients with angina and evidence of myocardial ischemia, but no obstructive CAD, were enrolled in a double-blind, placebo-controlled trial. Participants were assigned to ranolazine (29) or placebo (29) for 8 weeks (up to 500 mg twice a day). CFR was determined as the ratio of hyperemic, induced by intravenous dypiridamole administration, to baseline diastolic coronary flow velocity. CFR was assessed before and after 8-week therapy. Results CFR was successfully performed in all patients. There were no significant differences in baseline characteristics and CFR between ranolazine and placebo group. After 8 weeks CFR significantly increased in ranolazine group (2.54 ± 0.44 vs. 1.91 ± 0.31; P = 0.005) but not in placebo group (1.99 ± 0.32 vs. 1.94 ± 0.29; P = ns). No patient dropped out during 8 weeks therapy. Side effects were similar in both groups. Conclusions Ranolazine is able to improve CFR in these patients. This is probably due to improvement in abnormal coronary autoregulation, both reducing baseline diastolic coronary flow velocity and increasing hyperemic diastolic coronary flow velocity. [ABSTRACT FROM AUTHOR]