Search

Idiopathic pulmonary fibrosis (IPF) is a specific form of chronic, progressive, fibrosing interstitial pneumonia of unknown cause that leads to respiratory failure and death within few years of diagnosis. Pulmonary hypertension (PH) is a common complication in IPF, where it is strongly associated with increased morbidity and mortality. Patients with IPF and PH have particularly poor prognosis, despite current best medical therapies and the anti-fibrotic therapy with pirfenidone or nintedanib. The aim of our study was to assess the clinical and prognostic impact of PH in patients affected by IPF, already treated with pirfenidone or nintedanib. Seventy-four consecutive outpatients with a diagnosis of IPF, in therapy with pirfenidone or nintedanib, were prospectively enrolled in the study. All patients underwent pulmonary and cardiology assessment by clinical exam, spirometry, DLCO test, chest CT, 6MWT and echocardiography performed by a cardiologist experienced in PH in an ambulatory setting under resting conditions. GAP index has been determinate for all patients. During follow-up, all patients were evaluated every 6 months, or less if necessary. Data about mortality were then collected in a 3-year follow-up. Of the seventy-four patients enrolled, 38 were treated with pirfenidone and 36 with nintedanib. The two groups were comparable for age, gender, FVC, DLCO and PAPS. The patients were also divided in four groups, based on presence of mild/moderate/severe PH by echocardiography at baseline. Significant differences were found for DLCO and the GAP index. Severity of PH was significantly associated with a reduction of DLCO and with an increased GAP index. Survival was directly correlated with 6MWT (R = 0.48), DLCO (R = 0.29, p

Purpose The use of sodium-glucose-cotransporter-type-2 inhibitors (SGLT2i) was associated in previous studies with an improved vascular function in non-human experimental models. We therefore sought to evaluate possible changes in endothelial function assessed by flow-mediated dilation (FMD) in patients with chronic heart failure (CHF) and type-2 diabetes mellitus (T2DM), switching from other oral hypoglycemic agents to SGLT2i in an observational study. Methods Twenty-two consecutive outpatients with CHF and T2DM were enrolled after switching to SGLT2i therapy, and compared with 23 consecutive controls from the same registry comparable for principal clinical characteristics. In all patients, endothelial function was assessed by FMD at baseline and after 3 months of follow-up. Results Three months of therapy with SGLT2i were associated with a statistically significant improvement in endothelial function (19.0 ± 5.7% vs 8.5 ± 4.1%, p p Conclusions Switch to SGLT2i in patients with CHF and T2DM was associated in an observational non-randomized study with an improved endothelial function.

For decades, cardiologists have largely underestimated the role of the right heart in heart failure due to left heart disease. Nowadays, the importance of evaluating right ventricular (RV) structure and function in left heart failure is well documented and this concept has been emphasized in the most recent heart failure guidelines. However, several relevant questions remain unanswered such as the following: (a) which imaging technique (standard or 3D echocardiography or strain imaging or cardiac magnetic resonance) and, more, which parameters should be used to grade the severity of RV dysfunction? (b) do less widespread and less applied diagnostic tools such as cardiopulmonary stress testing and bioelectrical impedance analysis play a role in this field? (c) are there specific biochemical aspects of RV failure? (d) why notion of pathophysiology of heart and lung interaction are so well appreciated at an academic level but are not applied in the clinical setting? The present review has been prepared by the Heart Failure (HF) working group of the Italian Society of Cardiology and its main objective is to improve our understanding on RV dysfunction in heart failure.

Despite recent advances in chronic heart failure (HF) therapy, the prognosis of HF patients remains poor, with high rates of HF rehospitalizations and death in the early months after discharge. This emphasizes the need for incorporating novel HF drugs, beyond the current approach (that of modulating the neurohumoral response). Recently, new antidiabetic oral medications (sodium-glucose cotransporter 2 inhibitors (SGLT2i)) have been shown to improve prognosis in diabetic patients with previous cardiovascular (CV) events or high CV risk profile. Data from DAPA-HF study showed that dapaglifozin is associated with a significant reduction in mortality and HF hospitalization as compared with placebo regardless of diabetes status. Recently, results from EMPEROR-Reduced HF trial were consistent with DAPA-HF trial findings, showing significant beneficial effect associated with empagliflozin use in a high-risk HF population with markedly reduced ejection fraction. Results from the HF with preserved ejection fraction trials using these same agents are eagerly awaited. This review summarizes the evidence for the use of gliflozins in HF treatment.

Despite relative frequency of delirium in elderly hospitalized heart failure patients, skills and expertise in managing such complication are usually poor for physicians and nurses facing this clinical condition. International guidelines on heart failure do not provide detailed indication for such clinical condition, and evidence on this topic is limited. A multi-disciplinary approach (cardiologists, internists, geriatricians, psychologists, and psychiatrists) is often required; this review will therefore focus on diagnosis and clinical management of delirium in heart failure patients from a multidisciplinary point of view.

Patients with advanced heart failure have poor prognosis despite traditional pharmacological therapies. The early identification of these subjects would allow them to be addressed on time in dedicated centers to select patients eligible for heart transplantation or ventricular assistance. In this article we will report the current management of these patients based on latest international guidelines, underlining some critical aspects, with reference to future perspectives.

Takotsubo syndrome (TTS) can be induced by a large variety of physical/emotional triggers; several cases, however, are related to either an overt or occult malignancy, as shown in retrospective studies and case reports. The aim of this study was therefore to evaluate the clinical outcome of patients with TTS and cancer in a meta-analysis study. In June 2018, a Pubmed systematic research was conducted for studies assessing outcome in patients with TTS and cancer. We assessed Mantel-Haenszel pooled estimates of risk ratios (RRs) and 95% confidence intervals (CIs) for adverse events at follow-up. After paper retrieval, four studies were included in the meta-analysis, with a total of 123,563 patients. The prevalence of current or previous malignancy among patients admitted with TTS was 6.7% (8258 patients). When compared to control patients, patients with cancer showed an increased risk of clinical events (RR 3.24, 95% CI 3.04–3.45, p

Heart failure (HF) is the end result of many different cardiac and non-cardiac abnormalities leading to a complex clinical entity. In this view, the use of biomarkers in HF should be deeply reconsidered; indeed, the same biomarker may carry a different significance in patients with preserved or reduced EF. The aim of this review is to reconsider the role of biomarkers in HF, based on the different clinical characteristics of this syndrome. The role of cardiac and non-cardiac biomarkers will be reviewed with respect of the different clinical manifestations of this syndrome.

Background Few works have evaluated the effect of statins on left ventricular dysfunction in patients with chronic heart failure (CHF), by using tissue Doppler imaging (TDI). We therefore aimed to investigate whether atorvastatin treatment may influence prognosis and myocardial performance evaluated by TDI in subjects with CHF. Methods Five hundred thirty-two consecutive CHF outpatients enrolled in a local registry, the Daunia Heart Failure Registry, were prospectively analysed. 195 patients with CHF and left ventricular ejection fraction (LVEF) ≤40 %, either in treatment with atorvastatin (N: 114) or without statins (N: 81), underwent TDI examination. Adverse events were evaluated during follow-up. Results The atorvastatin group showed a lower incidence of adverse events (cardiac death: 0 % vs 7 %, p

The cardiopulmonary exercise test (CPX) is an affordable tool for risk prediction in patients with chronic heart failure (CHF). We aimed to determine the role of CPX parameters in predicting the risk of incidence of sustained ventricular arrhythmias (SVA) in CHF.Sixty-one consecutive patients with CHF enrolled in the Daunia Heart Failure Registry underwent CPX and were followed for 327 ± 247 days. Clinical follow-up was performed every month and anticipated in case of re-hospitalisation for cardiac disease. Incidence of SVA was evaluated by direct clinical examination (ECG, ambulatory ECG).Patients with episodes of SVA (N 14) showed lower values of pVO2 and PetCO2, and higher values of VE/VCO2, VE/VCO2 slope, and VE%. After correction for age, gender, diabetes, ischaemic heart disease and left ventricular ejection fraction, peak VO2 (hazard ratio (HR) 0.68, 95 % confidence interval (CI) 0.51-0.91, p 0.05), VE% (HR 1.38, 95 % CI 1.04-1.84, p 0.05), VE/VCO2 (HR 1.38, 95 % CI 1.04-1.82, p 0.05), VE/VCO2 slope (HR 1.77, 95 % CI 1.31-2.39, p 0.01), PetCO2 (HR 0.66, 95 % CI 0.50-0.88, p 0.01) were found as predictors of SVA. At Kaplan-Meier analysis, lower event-free rates were found in subjects with peak VO2 values below median (log rank p 0.05), values of VE/VCO2 above mean (p 0.05), higher VE/VCO2 slope tertiles (p0.05), and values of PetCO2 below median (p 0.05).CPX provides prognostic independent information for risk of SVA in subjects with CHF.

We report the case of a woman who presented with ST elevation and episodes of chest pain, mimicking an acute myocardial infarction. At coronary angiography no sign of coronary stenosis was found and ECG anomalies were related to asymmetric left ventricular hypertrophy and aortic stenosis.

The prognosis of Tako-Tsubo syndrome (TTS) is believed to be favorable. In most of the cases, there is a complete recovery of left ventricular (LV) function and of symptoms, but previous cases have been described with low-output syndrome, deaths within the first 24 h from acute heart failure, and some deaths due to LV free wall rupture. We describe a case of a patient with TTS who died after right ventricular (RV) free wall rupture. Furthermore, this report suggests that cardiac magnetic resonance imaging with echocardiography might be a useful integrated imaging diagnostic tool for the diagnosis of TTS, ruling out acute coronary syndrome.

Aim To investigate correlations between plasmatic concentrations of acute phase proteins (APPs) and left ventricular systolic function during the early phase of acute myocardial infarction. Methods Plasmatic concentrations of alpha-1-anti-trypsin (A1AT), alpha 1 glyco-protein (A1GP), haptoglobin (HG), caeruloplasmin (CP) and C-reactive protein (CRP) were evaluated in 123 patients with ST elevation acute myocardial infarction (STEMI) within 12 h after onset of chest pain. Systolic function was assessed with bi-dimensional echography and incidence of in-hospital adverse events was compared to APPs levels. Results A1AT, A1GP, HG and CP showed a statistically significant correlation with admission CRP concentrations (P < 0.001). Left ventricular ejection fraction inversely correlated with plasmatic concentrations of A1GP, A1AT, CP and HG. Incidence of acute heart failure correlated with values of APPs and, in a stepwise analysis, CP values were the most significant markers of acute heart failure. Conclusions Systolic dysfunction in STEMI patients seems to be associated with an inflammatory response featured by a rise in plasmatic concentration of APPs; increase in APPs concentrations seems to own a short-term prognostic relevance.

Most patients with pulmonary arterial hypertension (PAH) in combination therapy suffer from depression or live alone, in absence of any at home assistance or caregiver; so, their compliance in the case of therapy with continuous infusion with epoprostenol, is actually limited. An alternative therapeutic approach for the treatment of severe PAH is therefore needed. Ivabradine, a selective inhibitor of the sinus node If channels, may be of help in improving the hemodynamics of patients with PAH and higher sinus rates. We therefore sought to verify the safety and feasibility of ivabradine and high-dose sildenafil in such patients, who often refuse continuous infusion with prostanoids.

We report the case of a 79-year-old woman with transient left ventricular systolic dysfunction with apical ballooning (tako-tsubo like syndrome, TTS) showing an alternative newly reported "onion" shape. The patient was also characterized by atrial fibrillation and marked spontaneous echo-contrast: possible precipitating role for these conditions in TTS are discussed.

We read with great interest the review by Scholzel et al. [1], about chronic thromboembolic pulmonary hypertension (CTEPH), and especially, the sections on pathophysiology, risk factors and diagnostic work-up. However, we would like a further comment about congenital abnormalities causing hypercoagulability in these subjects. In fact, in our experience [2, 3], we have observed CTEPH patients with methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism or combined deficiency of proteins C and S. Can we consider these abnormalities as predisposing factors for CTEPH? Should thrombophilia screening be performed in subjects with suspect PAH? Could these abnormalities play a role in recurrent pulmonary hypertension after pulmonary endarterectomy?

A 41-year-old man, with a history of non-ischaemic dilated cardiomyopathy (DCM) and an automatic implantable cardioverter defibrillator (AICD), was admitted to our Department for worsening of heart failure. During the hospitalisation, his clinical status worsened with severe hypotension and dyspnoea. Transthoracic (Fig. 1) and transoesophageal echocardiography (Fig. 2), showed a mobile thrombus in the right atrium (RA), attached to the permanent transvenous lead. A chest CT was performed and it was indicative of massive pulmonary embolism. Anticoagulation therapy was performed and the patient's clinical status improved. Fig. 1 Transthoracic echocardiography: detail of the right atrium (RA) with thrombus (T) adherent to lead Fig. 2 Transoesophageal echocardiography: detail of the right atrium (RA) with thrombus (T) adherent to lead. The mass is shown better than with transthoracic examination Thrombotic complications after implantation of pacemaker (PM) or AICDs regard essentially the veins involved in the introduction of the catheters [1]. Rarely thrombi in RA and/or pulmonary embolism secondary to permanent cardiac pacing are reported [2, 3]. This case shows that worsening of symptoms of cardiac failure, in patients with DCM and AICD, could sometimes be caused by pulmonary embolism due to an intracardiac device.

We read with great interest the article by Fassio et al. [1] which provided a detailed review on Kounis syndrome (allergic acute coronary syndrome). The authors approached the issue both from the cardiologist’s and the allergist’s view. Authors report that initial descriptions of Kounis syndrome were focused on patients with ‘‘angiographycally’’ normal coronary arteries and acute release of allergic mediators (histamine or leukotrienes); the prognosis of these patients is good, with the left ventricular function normalizing over 3 days to several weeks [2]. However, we recently reported a case (a 70-year-old woman) of transient apical ballooning (Tako-Tsubo syndrome) [3], with mild ST-elevation in anterior leads and increased troponin-I levels [1.09 ng/ml (n.v. \ 0.03)], triggered by administration of antibiotics (cephalosporin) in a patient with history of asthma and allergy. Tako-Tsubo syndrome is characterized by acute onset of chest symptoms, ECG changes with elevated cardiac markers mimicking acute myocardial infarction, left ventricular wall motion abnormalities in the apical region with preserved function of base, and normal coronary arteries [4]. Those affected are typically older women presenting after a stressful trigger, either emotional or physical. According to authors’ opinion, could there be a link between Kounis syndrome’s variant with ‘‘angiographycally’’ normal coronary arteries and Tako-Tsubo syndrome triggered by administration of drugs in patient with history of asthma and allergy?

Dear Sir, We read with interest the article by Hoendermis [1] concerning an update on pulmonary arterial hypertension (PAH). This paper pays particular attention to the diagnosis and treatment of PAH; however, we would like to highlight the role of stress echocardiography to detect pulmonary vascular disease (PVD) prior to a rise of pulmonary arterial pressure (PAP) at rest. In fact, stress echocardiography has been successfully used on relatives of patients with idiopathic and familial PAH in a large multicentre study [2] and in patients with systemic sclerosis [3, 4]. It seems to be a useful tool to detect PVD early, but it requires further validation because of the lack of standardisation in the exercise protocol and because the cut-off value of PAP as in these cases has not been established; neither, to our knowledge, has the influence of age, gender, and body mass index on PAP been clearly defined. Stress echocardiography, despite MRI and CT, is more available and less expensive, and it might give more information on the functionality. However, today, it is not yet recommended as a routine method for the early detection of PVD, but we do hope that future research would fill the existing gaps and allow an extended use.