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Abstract Arrhythmogenic cardiomyopathy (ACM) is a genetically determined heart muscle disease characterized by fibro-fatty myocardial replacement, clinically associated with malignant ventricular arrhythmias and sudden cardiac death. Originally described a disease with a prevalent right ventricular (RV) involvement, subsequently two other phenotypes have been recognized, such as the left dominant and the biventricular phenotypes, for which a recent International Expert consensus document provided upgrade diagnostic criteria (the 2020 “Padua Criteria”). In this novel workup for the diagnosis of the entire spectrum of phenotypic variants of ACM, including left ventricular (LV) variants, cardiac magnetic resonance (CMR) has emerged as the cardiac imaging technique of choice, due to its capability of detailed morpho-functional and tissue characterization evaluation of both RV and LV. In this review, the key role of CMR in the diagnosis of ACM is outlined, including the supplemental value for the characterization of the disease variants. An ACM-specific CMR study protocol, as well as strengths and weaknesses of each imaging technique, is also provided. Key Points • Arrhythmogenic cardiomyopathy includes three different phenotypes: dominant right, biventricular, and dominant left. • In 2020, diagnostic criteria have been updated and cardiac magnetic resonance has emerged as the cardiac imaging technique of choice. • This aim of this review is to provide an update of the current state of art regarding the use of CMR in ACM, with a particular focus on novel diagnostic criteria, CMR protocols, and prognostic significance of CMR findings in ACM.

Cerebrovascular accidents (CVAs) can complicate the follow-up of patients with acute myocardial infarction (AMI). Intracavitary blood stasis evaluation can be useful to stratify cardioembolic risk and optimize medical therapy. Cardiac magnetic resonance (CMR) imaging is increasingly used in AMI patients for prognostic purposes. Slow-flow artefact is common on T2-weighted images in presence of left ventricular (LV) blood stasis.In this observational retrospective study, all patients with AMI undergoing CMR in our hospital were included. T2-weighted images were used to assess the presence of LV blood stasis. Among the 209 patients enrolled (males 72%, mean age 61 ± 12 years), LV blood stasis was detected in 48 (23%) and was significantly more prevalent in patients with extensive anterior or antero-apical AMI, lower LV ejection fraction, greater infarct size and microvascular obstruction. During follow-up (54 months, IQR 41-70), 8 CVAs and 6 cardiovascular deaths occurred. LV blood stasis emerged as a significant risk factor for both endpoints (logRank p 0.001 and p = 0.008, respectively) and remained independent predictor of CVAs (HR 9.819, 95% CI 1.733-55.617, p = 0.010).LV blood stasis identified with CMR predicts the occurrence of CVAs in patients with AMI. These results may be helpful to personalize antithrombotic therapy for prevention strategies.

Aims We assessed the feasibility of cardiac magnetic resonance (CMR) and the role of myocardial strain in the diagnostic work-up of patients with acute myocardial infarction (AMI) and a clinical suspicion of cardiac rupture (CR). Methods and results Consecutive patients with AMI complicated by CR who underwent CMR were enrolled. Traditional and strain CMR findings were evaluated; new parameters indicating the relative wall stress between AMI and adjacent segments, named wall stress index (WSI) and WSI ratio, were analysed. A group of patients admitted for AMI without CR served as control. 19 patients (63% male, median age 73 years) met the inclusion criteria. Microvascular obstruction (MVO, P = 0.001) and pericardial enhancement (P < 0.001) were strongly associated with CR. Patients with clinical CR confirmed by CMR exhibited more frequently an intramyocardial haemorrhage than controls (P = 0.003). Patients with CR had lower 2D and 3D global radial strain (GRS) and global circumferential strain (in 2D mode P < 0.001; in 3D mode P = 0.001), as well as 3D global longitudinal strain (P < 0.001), than controls. The 2D circumferential WSI (P = 0.010), as well as the 2D and 3D circumferential (respectively, P < 0.001 and P = 0.042) and radial WSI ratio (respectively, P < 0.001 and P: 0.007), were higher in CR patients than controls. Conclusion CMR is a safe and useful imaging tool to achieve the definite diagnosis of CR and an accurate visualization of tissue abnormalities associated with CR. Strain analysis parameters can give insights into the pathophysiology of CR and may help to identify those patients with sub-acute CR.

INTRODUCTION mitral valve prolapse(MVP) is a common disease in women, causing chest pain and palpitation, due to structural and functional valve abnormality, sometime associated with gastro-esophageal-reflux-disease(GERD).This is a challenging clinical problem in clinical practice,requires targeted diagnostic assessment,to identify the underlying causes of the symptoms because treatment needs to be tailored,according to the causes themselves, to resolve the symptoms. Our aim is to assess the prevalence of GERD in a population of postmenopausal women affected by MVP and if there is any correlation between the two conditions. PATIENTS AND METHODS MVP diagnosis was performed by echocardiograpic examination,according to ASE(American-Society-Echocardiography) criteria. 289 consecutive MVP women,symptomatic for chest pain and palpitation,were included,250 consecutive women without MVP, symptomatic for chest pain and palpitation were control group(CG).GERD diagnosis was performed according to 2013 ACG(American-College-Gastroenterology) criteria,women affected by thyroid disorders, all heart disease, including mitral disease with moderate or severe mitral regurgitation,gastrointestinal diseases assessed by gastroscopy were excluded. RESULTS 31(11%) women were affected by GERD,among 289 with MVP, 11(4.4%) women were affected by GERD,among 250 on CG,Chi-squared 8.1,Odds ratio 2.7,c.i.95%,p

A 50-year-old female with a history of bileaflet mitral valve prolapse (MVP) was admitted to our Department for persistent palpitation. Physical examination revealed a mid-systolic click, followed by a mid-to-late apical systolic murmur. The electrocardiogram showed sinus rhythm with negative T-waves in inferior leads and repetitive polymorphic premature ventricular contractions (PVCs) with a right bundle branch block pattern and superior axis morphology suggestive of a possible origin from the posterior papillary muscle. The echocardiography confirmed normal ventricular ejection fraction, bileaflet MVP with moderate regurgitation, systolic curling and mitral annulus disjunction. Exercise stress testing demonstrated an increase of polymorphic PVCs during maximum effort. The cardiac magnetic resonance showed an underlying late gadolinium enhancement at the level of the papillary muscles and in the inferobasal region. After a multidisciplinary evaluation, a transvenous implatable cardioverter defibrillator (ICD) was implanted for primary prevention without clear indications deriving from current guidelines. After eleven years, the patients experienced two appropriate shocks due to polymorfic ventricular tachycardia while she was sleeping. Furthermore, the patient underwent successful mechanical transvenous lead extraction and ICD re-implantation for lead failure. During this hospitalization a subsequent echocardiography detected severe ventricular dilatation with moderate systolic disfunction. Conclusion Our report demonstrated that MVP represents potentially cause of life-threatening ventricular arrhythmias and tachycardia induced cardiomyopathy. Beta-blockers are often inadequate in order to reduce PVCs burden. We need more arrhytmic predictors to assestment of sudden cardiac death risk and evaluate ICD for primary prevention. Obtain left ventricular function recovery is difficult and it requires a multidisciplinary approach. It will be important in the future to better define the role will play cathether ablation and mitral valve repair or replacement to prevent malignant arrhytmias.

Background Arrhythmic mitral valve prolapse (MVP) is characterized by left ventricular (LV) fibrosis, due to an excessive myocardial stretch on the LV basal-mid inferolateral wall. Mitral annulus disjunction (MAD) and curling are common findings in arrhythmic MVP patients, thus representing the excessive traction of mitral apparatus on myocardium. Cardiac magnetic resonance (CMR) demonstrated to clearly identify these typical morpho-functional alterations, as well as LV fibrosis, in MVP patients. The involvement of right-sided annulus disease recently emerged as an interesting missing piece in the natural history of MVP patients. However, its role in a population of arrhythmic MVP patients in absence of significant mitral regurgitation (MR) has not been evaluated. Purpose The primary aim of the study was to evaluate the prevalence and the role of tricuspid annulus disjunction (TAD) in the arrhythmic MVP patients. Secondly, we evaluated the role of TAD in the prevalence and severity of the common morpho-functional alterations of MVP, MAD and curling. Methods Consecutive MVP patients with normal systolic function and without significant MR, referred for palpitations, were enrolled. Morpho-biventricular evaluations, including MAD and curling assessment, as well as LV fibrosis were evaluated using CMR. Results 66 patients met the inclusion criteria (29% male, median age 44 years). TAD was identified in 22 MVP patients (27% male, median age 52 years). No differences for ventricular arrhythmias (p: 0.459) between MVP patients without (n: 44) and with TAD (n: 22) were identified. MVP patients with TAD were older (52 vs 42 years, p: 0.009) and presented reduced biventricular end-diastolic volumes, despite normal, in comparison with those without TAD (left ventricle: 80.5 vs 93.5 ml/m2, p: 0.002; right ventricle: 72.5 vs 85.5 ml/m2, p: 0.018). MAD and curling were more common in patients without TAD (respectively, 25 vs 19, p:0.014 and 24 vs 20, p: 0.002) than in those with TAD. Conversely, MAD and curling are more severe in patients with TAD (respectively, 5.9 vs 4.7 mm and 4 vs 3 mm, both p: 0.034) than in those without TAD. No differences for LGE distribution were identified in the two groups (p: 0.062). Conclusion In arrhythmic MVP patients, presence of TAD was associated with a great severity of MAD and curling. So, despite uncommon, the contextual presence of TAD and MAD in arrhythmic MVP patients suggests a more severe biannular disease, characterized by an increased biventricular myocardial stretch. Conversely to MAD, TAD wasn't associated with ventricular arrhythmias. Thus, its role in ventricular arrhythmogenesis in MVP patients appeared limited.

A 42-year-old man went to the emergency room complaining about dyspnea and palpitations. He reported an episode of atrial fibrillation (AF) with symptoms of dizziness 8 years before. He had a family history of ischemic cardiopathy, his father has suffered from AF since a young age.Acute course: The ECG revealed AF at high ventricular frequency. The echocardiography demonstrated mild reduction of the left ventricular function (EF 45%) with diffuse hypokinesis, and mitral valve prolapse (MVP) with mild mitral regurgitation. The blood tests showed a troponin peak of 750 ng/L (n.v. 0–34 ng/L). The suspect was acute coronary syndrome. Thus, he was treated with dual antiplatet therapy and low doses of beta-blockers, and he underwent coronarography, which demonstrated no significant lesions. So, after a transesophageal echocardiography that excluded thrombosis, and a loading dose of amiodarone, a successful electrical cardioversion was performed. The discharge diagnosis was AF with mild left ventricular disfunction. Three months later: He came back to the emergency room because of suffering some days of progressive epigastric and retrosternal pain radiating to the shoulders. The ECG and the echocardiography were unchanged, the troponin-I values were 79 ng/L-74 ng/L. Therefore, he underwent cardiac magnetic resonance (CMR), which showed normal biventricular dimensions and function (LVEF 64%, LVEDV 80 ml/mq), MVP with mitral annular disjunction (MAD) and curling of the infero-lateral basal wall (Figure A). The native T1, T2 and ECV values were increased, and there was a wide left ventricular subepicardial late gadolinium enhancement (LGE). The conclusion was MVP and active myocarditis. Moreover, he underwent endomyocardial biopsy that revealed focal lymphocytic infiltration, PCRs for common cardiotropic viruses or bacteria were negative. Six months later: The basal ECG was characterized by low QRS voltages in limb leads (Figure B). The CMR revealed a wide left ventricular non-ischemic fibrosis with a ring-like pattern (Figure C). The 24-hours Holter ECG showed premature ventricular beats with a right bundle branch block/superior and inferior axis morphology (Figure D), in keeping with MVP. The next step was the genetic testing that resulted positive for a Filamin-C (FLNC) mutation associated with cardiomyopathy. The final diagnosis was “Hot-phase of Left Ventricular Arrhythmogenic Cardiomyopathy (ACM), MVP and paroxysmal AF”. Discussion: The ACM is a rare hereditary heart muscle disease, and the “hot phase” represents its uncommon clinical presentation. Mutations in FLNC gene could be involved in the pathogenesis of ACM. Moreover, there are few cases in literature about the correlation between FLNC mutations and MVP. FLNC mutation may be a cross-sectional substrate for both these pro-arrhythmic conditions.

Background Prognostic stratification of acute myocarditis (AM) presenting with normal left ventricular ejection fraction (LVEF) relies mostly on late gadolinium enhancement (LGE) characterization. Left ventricular peak global longitudinal strain (LV-GLS) measured by feature tracking analysis might improve prognostication of AM presenting with normal LVEF. Methods Data of patients undergoing cardiac magnetic resonance (CMR) for clinically suspected AM in seven European Centres (2013-2020) were retrospectively analysed. Patients with AM confirmed by CMR and LVEF >= 50% were included. LGE was visually characterized: localized versus. non-localized, subepicardial versus midwall. LV-GLS was measured by dedicated software. The primary outcome was the first occurrence of an adverse cardiovascular event (ACE) including cardiac death, life-threatening arrhythmias, development of heart failure or of LVEF Of 389 screened patients, 256 (66%) fulfilled inclusion criteria: median age 36 years, 71% males, median LVEF 60%, median LV-GLS -17.3%. CMR was performed at 4 days from hospitalization. At 27 months, 24 (9%) patients experienced >= 1 ACE (71% developed LVEF -20% or quartiles), non-localized and midwall LGE were associated with ACEs. Patients with LV-GLS = 50%, LV-GLS provides independent prognostic value over LGE characterization, improving risk stratification and representing a rationale for further studies of therapy in this cohort.

Multiple system atrophy (MSA) and Parkinson's disease (PD) may share overlapping features particularly at early disease stage, including sleep alterations, but have profoundly different prognoses. Certain sleep phenomena and disorders of motor control are more prevalent in multiple system atrophy, such as REM sleep behaviour disorder (RBD). We quantitatively tested whether pervasive muscle activity during sleep occurs in subjects with multiple system atrophy versus Parkinson's disease. Laboratory polysomnographic studies were performed in 50 consecutive subjects with Parkinson's disease and 26 age- and gender-matched subjects with multiple system atrophy at5 years from disease onset. The distributions of normalised electromyographic activity of submentalis, wrist extensor, and tibialis anterior muscles in different wake-sleep states during the night were analysed. Subjects with multiple system atrophy had significantly higher activity of submentalis, wrist extensor, and tibialis anterior muscles than subjects with Parkinson's disease during non-REM sleep, including separately in stages N1, N2, and N3, and during REM sleep, but not during nocturnal wakefulness. The activity of wrist extensor and tibialis anterior muscles during non-REM sleep and the activity of tibialis anterior muscles during REM sleep were also significantly higher in subjects with multiple system atrophy and RBD than in subjects with Parkinson's disease and RBD. In conclusion, with respect to Parkinson's disease, multiple system atrophy is characterised by a pervasive and diffuse muscle overactivity that involves axial and limb muscles and occurs not only during REM sleep, but also during non-REM sleep and between subjects with comorbid RBD.

Stridor treatment in multiple system atrophy (MSA) mainly comprises tracheostomy or continuous positive airway pressure (CPAP), but guidelines for the use of these treatments are lacking. The aim of the study was to evaluate the predictive value of stridor treatment in an MSA cohort.This is a retrospective and prospective monocentric cohort study including MSA patients evaluated at least once a year during the disease course. Stridor was video-polysomnography confirmed. The time of stridor treatment (CPAP or tracheostomy) and latency from stridor onset were collected. Survival and predictors of survival were calculated.A total of 182 (107 males, mean age at disease onset 57.3 ± 8.4 years) MSA patients were included in the study; 141 were deceased at the time of study. Of the total sample, 75 patients were diagnosed with stridor: 22 patients were treated with tracheostomy and 29 with CPAP, whilst 24 patients did not receive treatment. Treatment with tracheostomy showed longer survival compared with both treatment with CPAP or no treatment (incidence rate of death 12 vs. 21 vs. 23 per 100 person-years, respectively). Tracheostomy remained an independent factor associated with longer survival (hazard ratio 0.38, p = 0.029), also after adjustment for other confounders and latency for stridor treatment.This is the largest monocentric and long-term follow-up study comparing survival between tracheostomy and CPAP in MSA patients with stridor. Treatment with tracheostomy showed longer survival compared with both treatment with CPAP or no treatment. A careful multidisciplinary approach is required for the management of MSA patients with stridor.

Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion primarily due to cardiac dysfunction. This condition is the most common cause of death in patients affected by acute myocardial infarction (AMI). Despite early revascularization, prompt optimal medical therapy, and up-to-date mechanical circulatory supports, mortality of patients with CS remains high.The objective of this review is to summarize epidemiology, pathophysiology, and treatment options of CS in light of the new European Society of Cardiology (ESC) recommendations. The latest European guidelines on myocardial revascularization have reviewed the previous guidelines with respect to early multivessel revascularization and routine use of intra-aortic balloon pump (IABP) in patients with AMI-related CS.Most of the current evidences come partly from randomized trials, but mostly from observational registries because of the difficulty to test different treatments in this life-threatening clinical setting.Some of the latest studies highlight the potential crucial benefit of newly introduced mechanical circulatory support devices, although evidences are not sufficient to definitely assess the benefit/risk ratio of the different systems.Many questions remain unanswered in this field, and further trials are advocated to better elucidate the best medical, reperfusion, and circulatory support approaches aimed to improve the poor prognosis of patients with CS after AMI.

ObjectivesTo investigate (1) the prevalence of REM sleep behavior disorder (RBD) as mode of disease onset in a cohort of patients with multiple system atrophy (MSA) and (2) disease progression and prognosis in patients with MSA with RBD predating (pre-RBD) and following (post-RBD) disease onset.MethodsWe retrospectively identified all patients with a clinical diagnosis of MSA evaluated at least once a year during the disease course. Type of onset was defined by the first reported motor or autonomic symptom/sign related to MSA. The occurrence of symptoms/signs and milestone of disease progression, and their latency from disease onset, were collected. Survival data were calculated. RBD was confirmed by video-polysomnography.ResultsOf a total of 158 patients, pre-RBD represented the mode of disease onset in 27% of patients, preceding disease onset according to the international criteria with a median of 3 (2–5) years. Comparing pre-RBD and post-RBD patients, the first group showed an increased prevalence of autonomic onset of disease, a reduced prevalence of parkinsonism, an earlier onset of stridor, pyramidal signs, symptomatic orthostatic hypotension, urinary dysfunction, severe dysphagia, and wheelchair dependency. The risk of death was higher in patients with pre-RBD.ConclusionsIn our MSA cohort, RBD represented the most frequent mode of disease presentation. A more rapid progression of disease was observed in the pre-RBD group. These findings suggested a careful assessment of sleep disorders to early recognize RBD and a closer follow-up of autonomic dysfunction and stridor in patients with pre-RBD.

Arterial hypertension is a systemic condition characterized by elevated blood pressure in the vascular system. Despite the great effort of scientific community to sensitize population to the problem, enforcing the preventive and treatment measures, this condition continues to be responsible for a large portion of global mortality, as it represents one of the major modifiable risk factors of cardiovascular disease. The significant and substantial clinical implications of high blood pressure on cardiovascular morbidity and mortality are explained by the effect of hypertension on specific organs, particularly sensitive to the effects of changes in blood pressure, resulting cardiac remodeling, cerebrovascular disease, renal failure, atherosclerotic vascular disease, and retinopathy, hence the term "target organ damage". The aim of this review is to give an overview of several noninvasive tools useful in the detection of organ damage related to arterial hypertension.

Aims Prognostic stratification of acute myocarditis (AM) presenting with normal left ventricular (LV) ejection fraction (EF) relies mostly on late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) imaging. In this specific AM population, LV peak global longitudinal strain (LV-GLS) measured by feature tracking (FT) analysis might provide further prognostic information. Methods and results Data of patients undergoing CMR for clinically suspected AM in seven European Centres, between January 2013 and August 2020, were retrospectively analysed. Those patients fulfilling CMR Lake Louise Criteria (LLC) for the diagnosis of AM and presenting with normal LVEF (≥50%) were included. Patients presenting with heart failure (HF) or significant arrhythmic events, LVEF -20% or quartiles), diffuse and mid-wall LGE were associated with a significantly higher rate of ACEs. LV-GLS remained independently associated with ACEs after adjustment for diffuse or mid-wall LGE as covariate at bivariable analysis. Conclusions In AM with LVEF ≥50%, LV-GLS provides independent prognostic value over LGE, improving risk stratification and providing a rationale for further studies of therapy in this cohort. 100 Figure

Aims The most frequent cause of death among patients affected by rheumatoid arthritis (RA) is heart failure, its high prevalence is independent by cardiovascular risk factors. An early diagnosis of heart failure risk may be done assessing left ventricular diastolic dysfunction (LVDD) by Doppler echocardiography. Our study aimed to estimate the LV diastolic function in RA patients. Methods and results We enrolled 207 consecutive postmenopausal women (PMW) with normal electrocardiography, physical examination, and confirmed diagnosis of RA for over a year and 200 PMW free from RA as control group (CG). All women underwent to M-mode, two-dimensional Doppler echocardiography. Seventy-two women were affected by LVDD among 207 women with RA (34.8%), 46 among 200 women on CG (23%), Chi-squared 6.8, odds ratio 1.8, confidence interval (CI) 95%, P Conclusions We assess that PMW affected by RA have a significantly high incidence of LV diastolic dysfunction without clinical evidence of heart disease, the incidence is even higher if they are hypertensive, so we recommend a Doppler echocardiography examination for all women with a diagnosis of RA.

Aims Arrhythmic mitral valve prolapse (MVP) is characterized by left ventricular (LV) fibrosis in the basal inferolateral wall and papillary muscles. We hypothesized that LV fibrosis are driven by excessive mechanical forces acting on myocardial susceptible cells, representing the last step in the MVP-induced myocardial stretch process. We evaluated the LV myocardial deformation, using strain assessed with cardiac magnetic resonance (CMR), in arrhythmic MVP patients with normal LV ejection fraction (LVEF) and absent/trivial mitral regurgitation (MR) and its correlation with the presence of LV fibrosis, detected by late gadolinium enhancement (LGE) in post-contrast CMR images. Methods and results We enrolled consecutive arrhythmic MVP patients with normal LVEF and no/trivial MR. Sixty-nine (39 female; median age: 40 years) patients without MVP, arrhythmias or cardiovascular history served as control group. All patients underwent CMR for identification of LGE and evaluation of LV myocardial deformation. A total of 66 patients were enrolled (47 female; median age: 44 years). In the overall MVP population, LGE was present in 41 patients (62.1%). MVP patients without LGE (25 patients, 37.9%) presented a higher global radial (median: 42.19 vs. 33; P Conclusions Arrhythmic MVP patients with normal LV systolic function and absent/trivial MR presented an abnormal myocardial deformation pattern. The reduced strain in BPL wall of MVP patients without LGE could be considered as an early marker of MVP-induced myocardial stress, that could promote, time by time, LV fibrosis and arrhythmias in MVP patients.

Background Coronary atherosclerosis is a frequent complication of type 2 diabetes mellitus (DM2). Considering the contiguity with the vascular wall, perivascular adipose tissue (PVAT) could play a crucial role in the pathogenic microenvironment of atherosclerosis. The PVAT attenuation index (p-FAI) is a non-invasive marker that reveals the change in peri-coronary adipose tissue (PCAT). High values of p-FAI are associated with increased cardiovascular mortality and poor prognosis. Emerging as an indication, contributor to, and therapeutic target for atherosclerosis, PCAT warrants further investigation in DM2. Purpose We aimed to characterize the association of PCAT by p-FAI and DM2, and to compare coronary inflammation in DM2 versus non DM2 patients with coronary artery disease (CAD), and versus healthy controls. Methods 15 consecutive DM2 patients (9 male, age 63±10 years) without symptoms/signs of cardiovascular disease were included in the study and compared to 8 non DM2 patients with CAD and 13 healthy volunteers without cardiovascular diseases, matched for age and sex. All patients and controls underwent coronary computed tomography angiography (CCTA) for the evaluation of coronary arteries and p-FAI. All scans were performed using a 320-slice multidetector computed tomography (Toshiba Aquilion) and a prospective ECG-triggered sequential acquisition. p-FAI analysis was performed using a dedicated workstation (Aquarius iNtuition Edition version 4.4.13. P3; TeraRecon Inc., Foster City, CA, USA). The proximal 40-mm segment of the right coronary artery (RCA) was identified and the inner and the outer wall were automatically traced, excluding the 10 mm from the ostium. The adipose tissue localized within a radial distance from the outer wall equal to a medium diameter of the RCA was evaluated. Voxel histograms of CT attenuation were traced and included between −190 to −30 HU within the PCAT volume. p-FAI was calculated as the median CT attenuation value of PCAT of the proximal 40-mm segment of the RCA (Figure 1). Results CAD was present in 10 DM2 patients (5 males, aged 63.1±10.5 years); in 5 DM2 patients (4 males, aged 63±11 years) epicardial coronary arteries were normal. p-FAI was higher in DM2 patients than in healthy controls (p=0.004). The presence of CAD did not impact on p-FAI in DM2 patients, presenting a comparable value (p=0.37). p-FAI was higher in DM2 patients with CAD than in non DM2 patients with CAD (p=0.04). Moreover, p-FAI was higher in DM2 patients without CAD than in non DM2 patients with CAD (p=0.002, Figure 2). Finally, p-FAI was not different in non DM2 patients with CAD compared to healthy controls (p=0.65), suggesting the limited role of CAD in the progression of peri-coronary inflammation when compared to DM2. Conclusions Coronary inflammation evaluated by p-FAI measurement was higher in DM2 patients, also without CAD. Therefore, our results suggest that DM2 is a determinant of coronary inflammation stronger than CAD. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Introduction Multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII) are two modalities of treating type 1 diabetes mellitus (T1DM). The benefits of CSII on long-term metabolic control and outcomes compared to those of MDI are still debated. We investigated both vascular function and myocardial performance in T1DM adolescents on MDI or CSII treatment. Methods One hundred twenty-three T1DM subjects (mean age 14.16±2.55 years), 63 on MDI regimen, 60 on CSII, and 57 controls were enrolled. Anthropometric and biochemical characteristics were evaluated. Ultrasound assessments of carotid intima-media thickness (cIMT), flow-mediated dilatation of brachial artery, anteroposterior diameter of the infrarenal abdominal aorta (APAO), and transthoracic echocardiography were performed. Results T1DM subjects on the CSII regimen showed better glycemic control than those on MDI, expressed as glycated haemoglobin (HbA1c). c-IMT and APAO were higher in MDI than CSII patients (0.61±0.11 mm vs. 0.56±0.07 mm, p=0.04; 13.61±3.29 mm vs. 11.65±1.84 mm, p=0.01, respectively). Left and right Tei index and left E/e’ ratio were higher in MDI than CSII subjects (0.82±0.40 vs. 0.52±0.19, p=0.002; 0.86±0.41 vs. 0.64±0.1, p=0.02; 5.89±2.0 vs. 4.73±1.59, p=0.02, respectively). Multiple regression analyses showed that glucose level, HbA1c and diabetes onset were significantly related to vascular and echocardiographic parameters in MDI and CSII patients. Conclusions CSII regimen in T1DM adolescents improves glycemic control and seems to ameliorate endothelial function and global myocardial performance as compared to MDI therapy.

Background: The aim of this study was to assess the role of cardiac and vascular parameters as all-cause mortality determinants in patients suffering from gynecological cancers. Methods: This was an observational, prospective, non-randomized, and non-controlled study. Forty-seven consecutive patients (mean age: 58 ± 13 years) were enrolled after cancer staging. All patients underwent evaluation of vascular (common carotid intima-media thickness (mean C-IMT), flow-mediated dilation of the brachial artery (FMD), and antero-posterior diameter of the infrarenal abdominal aorta (APAO)) and cardiac function and morphology before cancer-related interventions. A 6-year follow-up was carried out to assess the overall survival of the whole population. Results: Twenty patients (42%) died by the time of the 6-year follow-up. The brachial artery FMD values were higher in the survivors than the non-survivors (9.71 ± 3.53% vs. 6.13 ± 2.62%, p &lt, 0.001), as well as the LVEF (60.8 ± 3.0% vs. 57.8 ± 4.4%, p = 0.009). There were no differences in the mean C-IMT, APAO, and other echocardiographic parameters. ROC curve analysis identified a baseline LVEF &lt, 57% and FMD value &lt, 5.8% as the best cut-offs. Kaplan–Meier evaluation showed that the LVEF, tricuspid annular plane systolic excursion, and FMD were the best predictors of all-cause mortality, although only the LVEF and FMD were confirmed in multivariate Cox regression analysis. Conclusions: The LVEF and brachial artery FMD are independent prognostic determinants in patients with gynecological cancers.

Funding Acknowledgements Type of funding sources: None. Background Left ventricular thrombosis (LVT) is a possible complication following myocardial infarction (MI). Besides infarct size, risk factors for LVT include ST-elevated MI (STEMI), anterior and apical location, reduced left ventricular ejection fraction (LVEF) and the presence of microvascular obstruction. Echocardiography quantified myocardial strain has been associated with LVT following MI. Recently, global longitudinal strain, calculated with feature tracking (FT) - CMR, emerged as an independent predictor of major cardiovascular events following MI. Anyway, the relationship between abnormalities on FT-CMR and LVT following MI is still unexplored. Aim of our study is to investigate the possible association between abnormal strain on FT-CMR and LVT following apical STEMI. Methods We performed a retrospective analysis including all patients with a previous apical STEMI, who underwent CMR at our Institute between August 2013 and October 2020. Patients with ongoing anticoagulant therapy were excluded. Differences in global and segmental strain on CMR between patients with and without LVT were tested in a propensity-matched sample, using LVEF, age, gender, time from MI diagnosis and number of LV segments with transmural late gadolinium enhancement (LGE) as covariates to assign propensity score. Furthermore, difference in terms of apical to global radial strain percentual deviation (AGD), calculated as [(Global Radial Strain – Apical Radial Strain)/Global Radial Strain] * 100, was tested. Results Of 356 patients with apical STEMI undergoing CMR at our center, 37 (10.4%) were diagnosed with LVT. After performing a propensity score matching, we obtained a sample of 36 pairs, with a mean age of 65 (SD 11) years, and a median EF of 35% (IQR 27-42); 59 (82%) of them were male. A significant difference in terms of apical radial strain was found between the two groups, with a median strain of 10.75 (IQR 6.8–16.5) in patients without LVT compared to a value of 5.25 (IQR 2.7–9-6) in patients with LVT (p = 0.007). No differences were found in terms of global longitudinal, radial and circumferential strain (p = 0.19, p= 0.2 and p= 0.49 respectively) and segmental circumferential and longitudinal strain. When considering the AGD parameter, a significant difference was found between the two groups, with a median deviation of 12% (IQR -20; +48) in patients without LVT and 51% (IQR +47; +75) in patients with LVT (p= 0.0003). Furthermore, an AGD value of 26% was found to be the most accurate in terms of sensitivity and specificity applying a Receiver Operating Characteristic (ROC) curve analysis (AUC 0.74; CI 0.62-0.85). Conclusions Among patients with transmural MI involving LV apex, reduced apical radial strain on FT-CMR is associated with the presence of LV thrombosis. Furthermore, among patients developing LV thrombi, a greater apical radial strain deviation from the global one was found, with a threshold value of 26% at ROC curve analysis.

Funding Acknowledgements Type of funding sources: None. Background. Arrhythmic mitral valve prolapse (MVP) is characterized by left ventricular (LV) fibrosis in the basal inferolateral wall and papillary muscles. We hypothesized that LV fibrosis are driven by excessive mechanical forces acting on myocardial susceptible cells, representing the last step in the MVP-induced myocardial stretch process. Purpose. We aimed to evaluate the LV myocardial deformation, using strain assessed with cardiac magnetic resonance (CMR), in arrhythmic MVP patients with normal LV ejection fraction (LVEF) and absent/trivial mitral regurgitation (MR) and its correlation with the presence of LV fibrosis, detected by late gadolinium enhancement (LGE) in post-contrast CMR images. Methods. We enrolled consecutive arrhythmic MVP patients with normal LVEF and no/trivial MR. Sixty-nine (39 female; median age: 40 years) patients without MVP, arrhythmias or cardiovascular history served as control group. All patients underwent CMR for identification of LGE and evaluation of LV myocardial deformation. Results. A total of 66 patients were enrolled (47 female; median age: 44 years). In the overall MVP population, LGE was present in 41 patients (62.1%). MVP patients without LGE (25 patients, 37.9%) presented a higher global radial (median: 42.19 vs 33; p

Background Inflammatory bowel diseases (IBD) may be complicated by extraintestinal manifestations (EIM). Both conditions may be implicated in the overall increase of cardiovascular (CV) risk profile of the patients. The study aimed to assess CV risk in IBD patients with EIMs in relation to the stages of both diseases. Methods A total of 70 (38 men, mean age 51.7±12.4 years) patients with IBD and 22 controls (12 men, mean age 49.2±13.6 years) were enrolled. All patients and controls were screened for extraintestinal manifestations and underwent physical and anthropometric examinations, standard laboratory investigations, ultrasound evaluation of carotid arteries and flow-mediated vasodilatation (FMD). Patients were divided into four groups in relation to their active or remission stage of disease: 1. IBD+ EIM+; 2. IBD+ EIM-; 3. IBD- EIM+; 4. IBD- EIM-. Results The groups were homogenous according to their clinical characteristics. Patients with both IBD and EIM in active phase showed significantly lower values in FMD than controls (p=0.024). Carotid intima-media thickness values (cIMT) were similar among groups. Patients with active phases of IBD and/or EIM showed statistically significant lower values in FMD measurements (p=0.0008 and p=0.0011, respectively). Multivariate regression did not reveal any independent predictors for FMD values. Conclusions The active phase of IBD or EIM or both may promote endothelial dysfunction in patients, thus increasing their CV risk profile. Patients in remission phase showed endothelial function similar at controls.

Introduction: The neuroanatomical substrate of stridor associated with Multiple System Atrophy (MSA) remains unclear. We evaluated stridor-related gray matter (GM) changes in MSA. Methods: 36 MSA patients underwent standardized nocturnal video-polysomnography and brain MRI. Differences in GM density between MSA patients with and without stridor and a sample of 22 matched healthy controls were evaluated with Voxel Based Morphometry protocol supplemented by a specific tool (SUIT) for analysing infratentorial structures. Results: Stridor was confirmed in 14 patients (10 MSA-cerebellar variant; 10 M; mean ± SD age = 61.6 ± 8.9years; disease duration = 5.2 ± 2.9years) and absent in 22 (11 MSA-cerebellar variant; 18 M; age = 61.4 ± 9.9years; disease duration = 4.8 ± 3.4years). Compared to MSA without stridor, patients with stridor showed higher GM density in the cerebellum (p < 0.05, corrected for the MSA-cerebellar variant and uncorrected when considering both MSA-variants) and lower in the striatum (p < 0.05, uncorrected). Conclusions: This preliminary study has demonstrated for the first time in MSA stridor-related GM changes in striatal and cerebellar regions. Abnormalities in these regions were previously reported in dystonic disorders affecting laryngeal muscles, suggesting the hypothesis that stridor pathophysiology is dystonia-related. These results need however to be confirmed in a larger sample of patients.

A significant change of platelet number may be a risk factor for atherosclerotic cardiovascular disease. The aim of this study was to investigate the association between platelet number and early signs of atherosclerosis, evaluated by carotid intima-media thickness (c-IMT), in a apparently healthy population mainly represented by obese subjects.As many as 961 subjects, 686 women and 275 men, aged between 18 and 74 years, were enrolled in the study. Of these, 54 individuals (5.6% of all subjects) were normal weight, 259 individuals (27.0% of all subjects) were overweight, and 648 individuals (67.4% of all subjects) were obese. Waist circumference (WC) and blood glucose, insulin, total cholesterol, high and low density lipoprotein cholesterol, triglycerides and platelet count were also detected in all subjects, who underwent carotid echo color doppler ultrasound to measure c-IMT. c-IMT was significantly and positively associated to age (r = 0.204, P 0.0001), fasting glucose (r = 0.073, P 0.0240), total cholesterol (r = 0.096, P = 0.0031), and systolic and diastolic blood pressure (r = 0.140, P 0.0001 and r = 0.119, P 0.0003 respectively); c-IMT was significantly and negatively correlated with platelet count (r = -0.165, P 0.0001). Only age (P 0.0001) and systolic blood pressure (P = 0.0393), positively, and platelet number (P 0.0001), negatively, were significantly and independently associated to c-IMT in a final multiple regression analysis.Lower platelet number represented an independent determinant of c-IMT in a population, mainly represented by obese patients. These results suggest that a decrease of platelet number may well be an early defensive mechanism in subjects developing the thickening of carotid artery.

Prospective cohort study. To analyze the circadian rhythm and state-dependent modulation of core body temperature (Tcore) in individuals with spinal cord injury (SCI) under controlled environmental conditions. Institute of the Neurological Sciences of Bologna, Italy. We assessed 48-h rectal Tcore and sleep–wake cycle by means of video-polygraphic recording in five cervical SCI (cSCI), seven thoracic SCI (tSCI), and seven healthy controls under controlled environmental conditions. cSCI showed higher night-time Tcore values with reduced nocturnal decrease, higher MESOR and earlier acrophase compared with tSCI and controls (p

Background: Coronary microvascular dysfunction (CMD) is usually evaluated measuring coronary flow velocity reserve (CFVR). A more comprehensive analysis of CFVR including additional consideration of the associated logical companion-CFVR, where hyperemic diastolic coronary flow velocity may act as surrogate, was applied in this study to elucidate the mechanism of CMD in psoriasis. Methods and results: Coronary flow velocity reserve was analysed using transthoracic echocardiographs of 127 psoriasis patients (age 36 ± 8 years; 104 males) and of 52 sex- and age-matched healthy controls. CFVR determination was repeated in the patient subgroup (n = 78) receiving anti-inflammatory therapy. Baseline and hyperemic microvascular resistance (MR) were calculated. CMD was defined as CFVR ≤ 2.5. Four endotypes of CMD were identified referring to concordant or discordant impairments of hyperemic flow or CFVR. We evaluated the companion-CFVR, as derived from the quadratic mean of hyperemic and diastolic flow velocity at rest. Coronary flow parameters, including CFVR (p = 0.01), were different among the two endotypes having CFVR > 2.5. Specifically, all 11 (14%) patients with CFVR deterioration despite therapy, belonged to endotype 1, and had higher baseline and hyperemic MR (p

The introduction of high-sensitivity cardiac troponin allowed identifying a proportion of subjects with chest pain and electrocardiographic changes suggestive of myocardial infarction showing &lt, 50% coronary artery stenosis. PFAI is a coronary CT marker proved to predict outcome in ischemic heart disease. Based on CMR findings, patients were divided into myocarditis (n = 15), MINOCA (n = 14) and TTS (n = 9) groups. The aim was to estimate the value of pFAI in these groups compared to 12 controls. To evaluate the coronary inflammation “time course,” 20 patients underwent CMR and coronary CT scan within 8 days from the onset, the others within 60 days. There were higher values of pFAI in myocarditis (−86.45 HU), MINOCA (−84.63 HU) and TTS (−84.79 HU) compared to controls (−96.02 HU, p = 0.0077). Among patients who underwent CT within 8 days from onset, the MINOCA had a significantly higher pFAI value (−76.91 HU) compared to the control group (−96.02 HU, p = 0.0001). In the group that underwent CT later than 8 days, elevated pFAI values persisted only in the myocarditis and TTS groups, and there was no difference between MINOCA and controls. Our study shows that in patients with a diagnosis of MINOCA, there is acute coronary inflammation, which is more evident within one week from the acute event but tends to disappear with time.

The need for anticoagulation in patients with atrial fibrillation (AF) is fundamental to prevent thromboembolic events. Direct oral anticoagulants (DOACs) recently demonstrated to be superior, or at least equal, to Warfarin in reducing the risk for stroke/systemic embolism and preventing major bleeding and intracranial hemorrhages. The AF population often suffers from chronic kidney disease (CKD). Indeed, the relationship between AF and renal function is bidirectional: AF can trigger kidney failure, while kidney impairment can promote alterations able to enhance AF. Therefore, there are concerns regarding prescriptions of anticoagulants to patients with AF and CKD. The worsening in kidney function can be effectively due to anticoagulants administration. Warfarin has been recognized to promote acute kidney injury in case of excessive anticoagulation levels. Nevertheless, further mechanisms can induce the chronic worsening of renal function, thus leading to terminal kidney failure as observed in post-hoc analysis from registration trials and dedicated observational studies. By contrast, DOACs seem to protect kidneys from injuries more efficiently than Warfarin, although they still continue to play a role in promoting some kidney lesions. However, the exact mechanisms remain unknown. This narrative review aimed to discuss the influence of oral anticoagulants on renal impairment as well as to overview potential pathophysiological mechanisms related to this clinical complication.

Background According to expert opinion, orthostatic hypotension (OH) associated to a change in heart rate (ΔHR) less than 15 bpm suggests neurogenic OH (NOH). Recently, the ratio between HR and systolic blood pressure changes at 3 min of tilt test (ΔHR/ΔSBP) has been proposed as a better index than the ΔHR cut-off of 17 bpm. Our aim was to validate these indexes based on HR in an independent cohort of patients who performed cardiovascular reflex tests according to standardized procedures at our Institution. Methods We applied the HR indexes to all cardiovascular reflex tests that fulfilled the following criteria: (1) presence of classical OH at tilt test, (2) reliable Valsalva manoeuvre (VM), (3) absence of heart disease. We classified OH according to VM (absence of overshoot = NOH), and verified how many were correctly identified by ΔHR/ΔSBP (≤0.49 neurogenic) and ΔHR (≤17 and ≤15 neurogenic). Results We identified 369 tests with OH. Based on VM, 335 were NOH. The ΔHR/ΔSBP ≤ 0.49 identified NOH with a sensitivity of 91% and a specificity of 59%, the ΔHR ≤ 17 bpm with 88% sensitivity and 38% specificity, and the ΔHR ≤ 15 bpm with 84% sensitivity and 50% specificity. Conclusion In our cohort, the ΔHR/ΔSBP ratio had a good sensitivity but a limited specificity to identify NOH. This easily applicable test may represent a valuable screening tool in a clinical setting to identify patients who need further detailed autonomic testing to confirm the neurogenic origin of OH.

Inflammatory bowel diseases have been recognized as predisposing factors to atherosclerosis and thrombotic events, involving both the venous and the arterial circulatory systems. We report the case of a 70-year-old man who presented with ST elevation myocardial infarction during the active phase of ulcerative colitis (UC). Because of the ongoing hematochezia, after successful revascularization of the culprit vessel, the patient was medicated with Clopidogrel, in place of one of the more powerful new oral P2Y12 inhibitors that currently represent the gold standard therapy. Few days later a second elective percutaneous coronary intervention (PCI) on a non-culprit vessel ensued in a life-threatening early massive stent thrombosis involving the left main. During and after emergency PCI antiplatelet therapy was upgraded to Abciximab and Ticagrelor; this therapy proved successful in handling the massive stent thrombosis in the absence of severe bleeding complications. This case is unique and paradigmatic of the complex management of patients with coexisting active UC and acute coronary syndromes; it demonstrates as in this setting the balance between hemorrhagic and ischemic risk is labile and tricky to assess.

Background ST2 receptor (suppression of tumorigenity) has been described as receptor for the interleukin 33 (IL-33), a member of the IL-1 family of cytokines. This receptor is associated in various way to coronary artery disease, all-causes mortality and cardiovascular mortality. It's role in the pathogenesis of atherosclerosis is not well-defined yet. Purpose The present study was designed to assess the relationship between serum level of sST2, a decoy receptor, and immunohistochemicalespression of ST2L in atherosclerotic plaques of formalin fixed paraffin-embedded internal carotid arteries of patients underwent endarterectomy, accepted the predictive value of ST2 in atherosclerosis. Methods The study involved 76 cases (31 symptomatic= 41%, 45 asymptomatic= 59%), age range from 47 to 86 years old, underwent endarterectomy for the treatment of internal carotid stenosis in our vascular surgery of polyclinic, all procedures performed by the same physician. Patients were divided into three groups, depending on the presence of ST2Ltransmembrane receptor on the carotid plaque after immunoistochemical evaluation (group low presence of ST2L= 0–1+; moderate presence of ST2= 2+; high presence of ST2= 3+). Serum level of sST2 were defined through the use of an ELISA-kit, specific for ST2 and ready-to-use. Results There was a relationship between ST2L and sST2 values: if considering sST2 mean and median value referring to specific subgroup (low, moderate and high), this is lower if the group (i.e. ST2L presence on the atherosclerotic plaque) is higher, and vice-versa. This shows an inverse relationship between this two parameters. Moreover, using Pearson correlation coefficient, all the three sub-group show a strong correlation to the leukocytes value (low=0.658, moderate= 0.434, high= 0.358). Conclusions The ST2L immunohistochemical expression was for the first time investigated in a large number of human carotid atherosclerotic plaques. The inverse relationship between ST2L and sST2 supports the pathogenetic hypothesis that ST2L/IL33 axis could drive the mechanism of plaque development and eventually rupture. Correlation with leukocytes provides a further strong evidence confirming inflammatory pathogenesis of atherosclerosis, but most of all leukocytes' high value could be associated to a greater plaque instability. Acknowledgement/Funding None

This study aimed to quantify 24 h body core temperature (BcT°) and sleep-wake cycle rhythm alterations in craniopharyngioma (CP) patients and to identify markers related to the postsurgical outcomes. Ten consecutive CP patients underwent neuroradiological, endocrinological and ophthalmological evaluations, 24 h BcT° and sleep-wake cycle recordings before and after endoscopic endonasal surgery. The sample included four women and six men. Nocturnal sleep efficiency was pathologically reduced in eight patients before surgery. Seven out of ten patients presented one to three daytime naps. 24 h BcT° rhythm was pathological in six out of ten cases. Post-surgery sleep efficiency normalized in four out of eight patients, whereas nine out of ten patients presented with two to six longer daytime naps. Diurnal naps were mainly present in patients showing pre-operative involvement of the third ventricle floor. 24 h BcT° remained pathological in only one out of six cases, returned to normal in two and improved in three. 24 h BcT° rhythm improved more in papillary CPs than in adamantomatous CPs. Our data confirmed that both CP and surgery frequently disrupt the sleep-wake cycle and BcT° rhythms. Tumour location and histotype may be related to a worse postsurgical outcome. Therefore, in-depth investigation including circadian monitoring is crucial for surgical outcome.

Introduction The primary endpoint of this study was to determine the prevalence of coronary artery disease (CAD) and coronary artery calcium score (CACS) using coronary computed tomography angiography (CCTA) among patients with polyvascular atherosclerosis (PVA). Secondary endpoints were to evaluate the prevalence of cardiovascular risk factors and determine the predictors of PVA. Methods The presence of atherosclerotic disease was assessed using ultrasonographic vascular examination in 515 asymptomatic patients. All patients with presence of stenosis over 50% and moderate-to-severe cardiovascular risk profile underwent CCTA to identify atherosclerotic coronary disease. Results Among 515 participants, 143 patients had no evidence of atherosclerotic plaque. Of the 372 patients with atherosclerotic plaque, 184 patients had single-vessel disease, 111 patients had double-vessel disease and 77 patients had triple-vessel disease; among these patients, those who also presented with stenosis > 50% underwent CCTA. Coronary stenosis categories included: normal (6.4%); haemodynamically insignificant (34.6%); intermediate (28.7%); significant (26.6%); and total artery occlusion (3.7%). Based on the coronary vessel involved, the patients were categorised as having single- (41.0%), double- (42.0%) or triple- (17.0%) coronary disease. CACS was significantly higher in patients with double- or triple-vessel disease when compared to those with single-vessel disease. Conclusion Our study confirmed not only the high sensitivity of CCTA for highlighting CAD, but also its negative predictive value for excluding the presence of coronary stenosis or ischaemia. We found good correlation between PVA and CACS, and were able to confirm the risk factors for PVA.

Cardiovascular diseases represent a major health problem, being one of the leading causes of morbidity and mortality worldwide. Therefore, in this scenario, cardiovascular prevention plays an essential role although it is difficult to establish when promoting and implementing preventive strategies. However, there is growing evidence that prevention should start even before birth, during pregnancy, aiming to avoid the onset of cardiovascular risk factors, since events that occur early in life have a great impact on the cardiovascular risk profile of an adult. The two pillars of this early preventive strategy are nutrition and physical exercise, together with prevention of cardio-metabolic diseases during pregnancy. This review attempts to gather the growing evidence of the benefits of antenatal, perinatal and primordial prevention, discussing also the possibility to reverse or to mitigate the cardiovascular profile developed in the initial stages of life. This could pave the way for future research, investigating the optimal time and duration of these preventing measures, their duration and maintenance in adulthood, and the most effective interventions according to the different age and guiding in the next years, the best clinical practice and the political strategies to cope with cardiovascular disease.

Primary prevention of cardiovascular events in older adults is a relevant problem, due to lack of evidence for safe and efficacious therapy, its costs and elderly quality of life, Italy’s aging population is constantly increasing, so cardiovascular disease (CVD) primary prevention in the elderly is a prime objective. Life expectancy has dramatically increased over the last 2 decades, the proportion of individuals aged 80 years and older has grown rapidly in Europe and the United States, but cost / effective ratio of CVD prevention through risk factors control is debated. It is therefore important to implement cardiovascular risk factors estimation in the elderly to maximize the quality of life of patients and to lengthen their healthy life expectancy, choosing the better treatment for each patient sharing the choice with himself when it is possible, always remembering that elderly patients often have multiple co-morbidities that require a high number of concurrent medications; this may increase the risk for drug-drug interactions, thereby reducing the potential benefits of CVD prevention therapy. Nevertheless, CVD is not an inevitable concomitant of aging. Sometimes, autopsy in the elderly reveals atheroma-free coronary arteries, a normal-sized heart and unscarred valves. All primary prevention strategy decisions should consider estimated life expectancy and overall function and not just the cardiovascular event risks, magnitude and time to benefit or harm, potentially altered adverse effect profiles, and informed patient preferences. CVD primary prevention needs to be more implemented in the elderly, this might contribute to improve health status and quality of life in this growing population if correctly performed.