Antonio Parente

Assessment of cardiac sympathetic activity by MIBG imaging in patients with heart failure: a clinical appraisal

Cardiac sympathetic activity can be assessed by 123I-labelled meta-iodobenzylguanidine (MIBG) scintigraphy. Abnormalities of sympathetic cardiac activity have been shown in patients with heart failure, resulting in reduced MIBG uptake. Abnormal MIBG uptake predicts cardiac death, arrhythmias and all-cause mortality in patients with heart failure with a prognostic power incremental to that of conventional risk markers, and may identify patients at low risk of arrhythmias despite current guideline indications for implantable cardioverter defibrillator or patients at high risk for arrhythmias not fulfilling implantable cardioverter defibrillator indications. Prospective outcome studies are needed to assess whether MIBG imaging will have an impact on the mortality and morbidity of patients with heart failure.

Prognostic role of myocardial single photon emission computed tomography in the elderly

The increase in average life expectancy will move the burden of coronary artery disease (CAD) to older patients. Myocardial perfusion imaging by single photon emission computed tomography (SPECT) has been extensively validated for diagnosis and prognostic evaluation in large population series. Yet, its use is usually limited in elderly patients in whom, despite increased absolute cardiovascular risk, diagnostic and therapeutic work-up is often underperformed. American College of Cardiology/American Heart Association guidelines recommend exercise ECG testing as the initial noninvasive method for assessment of CAD in patients with a normal or near-normal resting ECG, regardless of age. However, a considerable proportion of elderly patients is unable to reach an adequate workload during the exercise test and the majority of those undergoing for standard exercise treadmill score are classified as intermediate risk. In elderly patients, SPECT imaging may provide valuable diagnostic and prognostic information for clinical management. In particular, normal or near normal SPECT identifies elderly patients at low risk of major adverse cardiac events at the short-term follow-up.

Ischemic cardiovascular involvement in psoriasis: A systematic review

Epidemiologic studies demonstrate that psoriasis is associated with shorter life expectancy, most frequently attributable to cardiovascular (CV) events. Although increased prevalence and incidence of CV risk factors for atherosclerosis have been reported in psoriatic patients, psoriasis likely plays an independent role in the increased cardiovascular risk, presumably linked to the chronic systemic inflammatory state. Consistently, preliminary investigations suggest that anti-inflammatory therapies may improve early subclinical vascular alterations and reduce cardiovascular morbidity and mortality. This review will focus on ischemic CV involvement in psoriatic patients, summarizing the prevalence and incidence of CV risk factors and CV events, as well as evidence on mechanisms of premature atherosclerosis and on effects of systemic anti-inflammatory therapies on CV risk profile. We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and evaluated the quality of studies comparing drug treatments using Detsky score. Our review documented that psoriatic patients are at increased CV risk, related to raised prevalence and incidence of CV risk factor and to inflammatory status. However, available literature lacks of studies that establish appropriate targets for CV risk factors and assess the clinical value of screening for subclinical organ damage and the impact of disease-modifying therapies on CV risk profile in psoriatic patients. Awareness of raised CV risk in psoriatic patients should foster further research aimed at elucidating these aspects.

Ischemic heart disease in systemic inflammatory diseases. An appraisal

Systemic inflammatory diseases are inflammatory syndromes that are associated with increased cardiovascular morbidity and mortality. The link between inflammatory and cardiovascular diseases can be attributed to coexistence of classical risk factors and of inflammatory mechanisms activated in systemic inflammatory diseases and involving the immune system. Yet, clinical implications of these findings are not entirely clear and deeper knowledge and awareness of cardiac involvement in inflammatory diseases are necessary. The aims of this review are to summarize cardiac involvement in systemic inflammatory diseases and to identify areas where evidence is currently lacking that deserve further investigation in the future.

Efficacy and safety of prolonged dual antiplatelet therapy: a meta-analysis of 15 randomized trials enrolling 85 265 patients

AIMS The optimal duration of dual antiplatelet therapy (DAPT) in patients with ischaemic cardiovascular (CV) disease is still debated. Previous meta-analyses reported conflicting results about prolonged DAPT on mortality and major CV events. Aim of this study was to assess the effects of prolonged vs. no/short-term DAPT on myocardial infarction (MI), stroke, bleeding, and mortality. METHODS AND RESULTS Trial inclusion criteria were: randomization to prolonged duration vs. no/short DAPT; reporting of at least one outcome among overall and CV death, MI, stroke, major non-fatal, fatal, and intracranial bleeding. Fifteen randomized studies including 85 265 patients were included. Prolonged DAPT, compared with no or short DAPT, significantly reduced MI (RR: 0.785, 95% CI: 0.729-0.845, P < 0.001) and stroke (RR: 0.851, 95% CI: 0.754-0.959, P = 0.008), but had no effect on overall (RR: 0.989, 95% CI: 0.921-1.061, P = 0.751) or CV (RR: 0.951, 95% CI: 0.872-1.037, P = 0.258) mortality. Prolonged DAPT significantly increased major non-fatal (RR: 1.690, CI: 1.322-2.159, P < 0.001), but not intracranial or fatal bleeding (RR: 1.236, CI: 0.899-1.698, P = 0.192, RR: 1.069, CI: 0.760-1.503, P = 0.703; respectively). The effects of DAPT were similar to those reported in the overall analysis in patients with stable CV disease, whereas in those with unstable CV disease only the significant reduction of stroke was not confirmed. Dual antiplatelet therapy prolonged beyond 1 year significantly reduced MI but not stroke, all-cause, or CV death. It significantly increased the risk of major non-fatal bleeding, with no difference in intracranial and fatal bleeding. CONCLUSION Prolonged DAPT significantly reduced ischaemic CV events but not mortality. Even if a significant increase of major non-fatal bleeding was detected, no increased risks of intracranial and fatal bleeding were observed.

N-terminal pro-b-type natriuretic peptide and left atrial function in patients with congestive heart failure and severely reduced ejection fraction.

AIMS Amino-terminal portion of pro-B-type natriuretic peptide (NT-pro-BNP) is a valuable diagnostic and prognostic marker in congestive heart failure (CHF). In CHF patients, elevation of natriuretic peptide levels correlate with decreased left ventricular (LV) ejection fraction (EF) and increased left atrial (LA) volumes, but a correlation with LA function that is a determinant of haemodynamic and clinical status in CHF with independent prognostic value has never been investigated. Aim of this study was to evaluate the relationship between cardiac neurohormonal activation and LA function in patients with CHF due to dilated cardiomyopathy. METHODS AND RESULTS One hundred and one patients (86% males; mean age, 64 ± 11 years) with dilated ischaemic or non-ischaemic cardiomyopathy, LV EF ≤45% (mean LV EF, 33 ± 8%), and New York Heart Association class II-IV underwent transthoracic echocardiography to evaluate LA fractional active and total emptying from M- and B-Mode images, and, on the same day, venous blood sample collection to dose NT-pro-BNP. By univariate analyses, NT-pro-BNP significantly correlated to age, LA dimensions, LA function indexes, EF, and functional class. At multivariate analysis, LV EF and M- or B-Mode indexes of LA function were the only independent predictors of NT-pro-BNP values. A NT-pro-BNP cut-off of 1480 pg/mL identified LA dysfunction with 89% specificity and 54% sensitivity. CONCLUSION In CHF patients with severely impaired systolic function, NT-pro-BNP levels reflect LA and LV dysfunction. These data should prompt studies to investigate the relationship between changes of LA function and NT-pro-BNP levels and their clinical value as prognostic and therapeutic targets in CHF.

Reduction of C-reactive protein is not associated with reduced cardiovascular risk and mortality in patients treated with statins. A meta-analysis of 22 randomized trials

BACKGROUND The association between C-reactive protein (CRP) levels and risk of cardiovascular (CV) events has been reported in several studies. However, it is unclear whether a reduction in CRP is associated with a reduction in risk of clinical events. Therefore we sought to investigate, in a meta-regression analysis of randomized studies enrolling patients treated by statins, whether changes in CRP are associated with changes in risk of CV events or overall survival. METHODS Randomized trials enrolling patients treated by statins, reporting CRP at baseline and at end of follow-up, CV events [myocardial infarction (MI) and stroke], CV and all-cause mortality were selected. RESULTS Twenty-two trials enrolling 54,213 participants were included in the analysis. Meta-analysis showed that active treatment significantly reduced risk of all-cause death by 8%, myocardial infarction by 11%, stroke by 10.3% and the composite outcome (including CV death, MI and stroke) by 8%, whereas risks of CV mortality was not significantly reduced. Meta-regression analysis revealed that reduction in CRP levels was significantly associated only with the reduction of MI, whereas no relationship was identified between changes in CRP and risk of stroke, CV and all-cause mortality, and the composite outcome. CONCLUSIONS These findings demonstrate that statin-induced changes in CRP do not correlate with major CV events apart from the risk of MI nor with overall survival in high-risk patients. These data suggest that although CRP may be a surrogate marker for coronary risk, it should not be used for predicting the effectiveness of statin therapy.

Sleep-disordered breathing, impaired cardiac adrenergic innervation and prognosis in heart failure.

Objective Unfavourable effects of sleep-disordered breathing (SDB) in heart failure (HF) are mainly mediated by impaired sympathetic activity. Few data are available on SDB and cardiac adrenergic impairment evaluated at myocardial level. The aim of the study was to assess the relationship between SDB, cardiac sympathetic innervation assessed by 123I-metaiodobenzylguanidine (123I-MIBG) imaging and prognosis in HF. Methods Observational, prospective study enrolling patients with HF and reduced systolic function. Patients underwent nocturnal cardiorespiratory monitoring to assess SDB presence by apnoea/hypopnoea index (AHI), and 123I-MIBG imaging to calculate heart-to-mediastinum (H/M) ratios and washout rate. Patients were prospectively followed for 29±18 months for the combined endpoint of cardiovascular death and HF hospitalisation. Results Ninety-four patients (66.1±9.8 years; left ventricular ejection fraction 32±7%) were enrolled; 72 (77%) showed SDB and, compared with non-SDB, significantly reduced early (1.67±0.22 vs 1.77±0.13; p=0.019) and late H/M ratios (1.50±0.22 vs 1.61±0.23; p=0.038). Dividing patients into two groups according to SDB severity, patients with a moderate–severe disturbance (AHI >15; n=43) showed significantly worse survival for the composite study outcome (log-rank test, p=0.001) with respect to patients with mild or no disorder (AHI ≤15; n=51). Adding SDB variables to the already known prognostic role of 123I-MIBG imaging, we observed a worse survival in patients with both SDB and H/M impairment. Conclusions Patients with systolic HF and SDB show more impaired cardiac adrenergic innervation assessed by 123I-MIBG imaging, and more adverse prognosis compared with HF patients without SDB.

Vitamin D deficiency and clinical outcome in patients with chronic heart failure: A review

AIM The aim of this review was to summarize evidence on the role of Vitamin D deficiency in heart failure (HF), from pathophysiological mechanisms to clinical effects of Vitamin D supplementation. DATA SYNTHESIS Chronic HF secondary to left ventricular (LV) systolic dysfunction is a growing health problem, still associated with poor clinical outcome. In recent years, experimental and epidemiological evidence focused on the role of Vitamin D in HF. Cross sectional studies demonstrated that prevalence of HF is increased in patients with Vitamin D deficiency or parathyroid hormone (PTH) plasma level increase, whereas longitudinal studies showed enhanced risk of developing new HF in patients with Vitamin D deficiency. In addition, in patients with established HF, low plasma levels of Vitamin D are associated with worsening clinical outcome. Yet, clinical studies did not definitively demonstrate a benefit of Vitamin D supplementation for preventing HF or ameliorating clinical outcome in patients with established HF. CONCLUSIONS Despite convincing experimental and epidemiological data, treatment with Vitamin D supplementation did not show clear evidence of benefit for preventing HF or influencing its clinical course. Ongoing clinical studies will hopefully shed lights on the effects of Vitamin D supplementation on clinical endpoints along the spectrum of HF.

Effects of novel oral anticoagulants on left atrial and left atrial appendage thrombi: an appraisal

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and predisposes to an increased risk of thromboembolic events. Patients affected by AF exhibit an increased risk of stroke compared with those in sinus rhythm, with the most common location of thrombi in the left atrial appendage. Until 2009, warfarin and other vitamin K antagonists were the only class of oral anticoagulants available. More recently, dabigatran, rivaroxaban, apixaban, and edoxaban have been approved by regulatory authorities for prevention of stroke in patients with non-valvular AF. Few data are available about the efficacy of novel oral anticoagulants for the treatment of left atrial and left atrial appendage thrombosis. Aim of this review is to summarize available evidence regarding the effectiveness of novel oral anticoagulants on left atrial appendage thrombosis.