Concetta Di Nora

Prevalence and prognostic impact of non-cardiac co-morbidities in heart failure outpatients with preserved and reduced ejection fraction: a community-based study: Prognostic impact of non-cardiac co-morbidities in HF outpatients

To assess adverse outcomes attributable to non‐cardiac co‐morbidities and to compare their effects by left ventricular ejection fraction (LVEF) group [LVEF <50% (heart failure with reduced ejection fraction, HFrEF), LVEF ≥50% (heart failure with preserved ejection fraction, HFpEF)] in a contemporary, unselected chronic heart failure population.

Prognostic value of cardiopulmonary exercise testing in Idiopathic Dilated Cardiomyopathy

BACKGROUND Although cardiopulmonary exercise testing (CPET) is considered as an important tool in risk stratification of patients with heart failure (HF), prognostic data in the specific setting of Idiopathic Dilated Cardiomyopathy (iDCM) are still undetermined. The aim of the study was to test the prognostic value of CPET in a large cohort of iDCM patients. METHODS AND RESULTS We analyzed 381 iDCM patients who consecutively performed CPET. The study end-point was a composite of cardiovascular death/urgent heart transplantation (CVD/HTx). In the overall population the average values of peak oxygen consumption (peak VO2/kg) and percent-predicted peak VO2 (peak VO2%) were 17.1±5.1ml/kg/min and 59±15%, respectively. Mean VE/VCO2 slope was 29.8±6.1. During a median follow-up of 47months (interquartile range 23-84), 83 patients experienced CVD/HTx. Peak VO2% (Area Under the Curve [AUC] 0.74; 95% CI 0.71-0.85, p<0.001) and VE/VCO2 slope (AUC 0.78; 95% CI 0.74-0.84, p<0.001) were more accurate in predicting CVD/HTx compared to peak VO2/kg (AUC 0.60; 95% CI 0.54-0.68, p=0.003) (p<0.001 for both comparisons). The most accurate threshold values for outcome prediction in our iDCM cohort were <60% for peak VO2% and >29 for VE/VCO2 slope. At multivariable analysis peak VO2% and VE/VCO2 slope were the strongest predictors of CVD/HTx, either as continuous and categorical variables, whereas peak VO2/kg was not independently related with prognosis. CONCLUSION In a large population of iDCM patients peak VO2% and VE/VCO2 slope emerged as the strongest prognostic CPET variables. Prospective studies will be necessary to confirm these data.

Prognostic role of cardiac calcifications in primary prevention: A powerful marker of adverse outcome highly dependent on underlying cardiac rhythm

BACKGROUND Increasing evidence exists regarding calcium detected in aortic cusps and/or mitral annulus (AOC_MAC) at transthoracic echocardiogram as a predictor of cardiovascular (CV) events and mortality. PURPOSE To verify whether AOC_MAC has a prognostic role in the setting of primary prevention independently of the presence of atrial fibrillation (AF). METHODS All subjects consecutively referred from January 2011 to October 2014 to the Cardiovascular Centre for CV risk assessment in primary prevention were selected. AOC_MAC was assessed by transthoracic echocardiography. Primary study endpoint was a composite of CV hospitalizations/all-cause death. RESULTS The 1389 study patients were 70 years old, 43% males, 24% had diabetes mellitus, 75% arterial hypertension, 56% dyslipidaemia. Of all, 997 (72%) were in sinus rhythm (SR), 392 (28%) in AF. Patients with AF were older and more frequently males, with larger atria than SR subjects. During a median follow-up of 32 months, 165 patients (12%) were hospitalized for CV cause, 68 (5%) died. The primary endpoint occurred more frequently in patients with than without AOC_MAC (18% vs 11%, p < 0.001). AF patients showed higher event-rate compared with patients in SR (20% vs 10%, respectively; p < 0.01). AOC_MAC emerged as an independent prognosticator of primary endpoint in SR patients (HR 1.74 [1.07-2.82], p = 0.02), together with increasing age and left ventricular hypertrophy, while AOC_MAC had no prognostic relevance in AF patients. CONCLUSIONS In subjects with multiple CV risk factors assessed in primary prevention, the presence of AF nullifies the prognostic power of AOC_MAC, on the contrary robustly confirmed in SR patients.

Obesity, Cardiac Remodeling, and Metabolic Profile: Validation of a New Simple Index beyond Body Mass Index

Aim: The body mass index (BMI), the most used anthropometric index of obesity, has an important limitation, not taking into consideration the distribution of body fat. We developed a new simple index: the waist-corrected BMI (wBMI), calculated as waist circumference (WC) × BMI. The study aim was to assess the role of wBMI, compared to BMI, WC, and Waist-to-Height Ratio (WHtR) in predicting abnormal cardiac geometry, insulin resistance, increased arterial stiffness, and dyslipidemia. Methods: This was a cross-sectional study that included 805 patients referred to our Department of Preventive Cardiology for risk factors evaluation and treatment. Eleven echographic and laboratory parameters were determined, and receiver operating characteristic (ROC) curves were derived. Areas under ROC curves (AUC) were used to assess the accuracy of the four indexes to identify unfavorable characteristics. Results: There were 29% overweight, 59% obese, and 77% hypertensive patients. Of 11 echographic and laboratory parameters, wBMI, BMI, WHtR, and WC had the largest AUC for identifying 3, 1, 6, and 1 parameters, respectively, but with overlapping 95% confidence intervals. wBMI had the largest AUC for increased arterial stiffness and insulin resistance; also, it was superior to BMI for increased left atrial volume, relative wall thickness, and triglyceride level. Conclusions: In a large population with a high prevalence of obesity and hypertension, all four indexes were associated with unfavorable characteristics. wBMI has the theoretical advantage of taking into account simultaneously the global fat mass and distribution and might be useful for a better cardiovascular risk assessment.

New classification of geometric ventricular patterns in severe aortic stenosis: Could it be clinically useful?

In severe aortic stenosis, different left ventricle (LV) remodeling patterns as a response to pressure overload have distinct hemodynamic profiles, cardiac function, and outcomes. The most common classification considers LV relative wall thickness and LV mass index to create 4 different groups. A new classification including also end‐diastolic volume index has been recently proposed.

Left ventricular function and exercise performance in idiopathic dilated cardiomyopathy: role of tissue Doppler imaging

Background To examine the relationship between left ventricular (LV) function evaluated at echocardiography and exercise performance in idiopathic dilated cardiomyopathy (IDCM) patients. Methods and results We enrolled 76 consecutive IDCM patients in sinus rhythm, undergoing cardiopulmonary exercise testing and echocardiography [49 ± 13 years old; LV ejection fraction 31 ± 7%, LV end-diastolic volume 96 ± 31 ml/m2; peak oxygen consumption (peak VO2/kg) 18 ± 5.6 ml/kg/min]. Linear regression analysis revealed that peak systolic velocity (S′) (r = 0.46; P < 0.001) and E/E′ (r = −0.43; P < 0.001), two tissue Doppler imaging derived parameters, were related to peak VO2/kg, whereas ejection fraction and mitral inflow variables were not. Considering the 69 patients (90%) without diastolic restrictive pattern (a well known index of severe diastolic dysfunction), multivariate regression analysis showed that age, E/E′ and S′ were the only independent variables related to peak VO2/kg. Similarly, age and E/E′ were confirmed as independent parameters for the prediction of ventilation/carbon dioxide production slope in the whole population. Conclusion In IDCM patients, cardiopulmonary exercise performance variables were strongly related to E/E′ and S′.

Systolic blood pressure target in systemic arterial hypertension: Is lower ever better? Results from a community-based Caucasian cohort

BACKGROUND Extensive evidence exists about the prognostic role of systolic blood pressure (SBP) reduction ≤140mmHg. Recently, the SPRINT trial successfully tested the strategy of lowering SBP<120mmHg in patients with arterial hypertension (AH). AIM To assess whether the SPRINT results are reproducible in a real world community population. METHODS Cross-sectional, population-based study analyzing data of 24,537 Caucasian people with AH from the Trieste Observatory of CV disease, 2010 to 2015. We selected and divided 2306 subjects with AH according to the SPRINT trial criteria; similarly, SPRINT clinical outcomes were considered. RESULTS Study patients median age was 75±8years, two third male, one third had ischemic heart disease. They were older, with lower body mass index, higher SBP and Framingham CV risk score than the SPRINT patients. Three-hundred-sixty-eight patients (16%) had SBP<120mmHg. During 48 [36-60] months of follow-up, 751 patients (32%) experienced a major adverse cardiac event (MACE). The SBP <120mmHg group had higher incidence of MACE, CV deaths and all-cause death than SBP≥120mmHg group (37% vs 31%; 10% vs 4%; 19% vs 10%, all p<0.05). The condition of SBP<120mmHg was an independent predictor of MACE in multivariate Cox analysis together with older age, male gender, higher Charlson score. CONCLUSIONS In our experience, the SBP<120mmHg condition is associated with worse clinical outcomes, suggesting the SPRINT results are not reproducible tout court in Caucasian community populations. These differences should be taken as a warning against aggressive reducing of SBP<120mmHg.

A Large Ostium Secundum Atrial Septal Defect in an 88-Year-Old Asymptomatic Woman

version and poster were presented at the 98th Annual Meeting of the Endocrine Society, April 3, 2016, Boston, Massachusetts. Conflict of Interest: None. Author Contributions: Wong, Wang: study concept and design, acquisition of subjects and data, analysis and interpretation of data, preparation of manuscript. Sponsor’s Role: N/A.

Genetics: Genotype/Phenotype Correlations in Cardiomyopathies

Cardiomyopathies (CMP) are defined as disorders of the heart muscle unexplained by coronary artery disease, hypertension, valvular disease, or congenital heart disease. All forms of CMP can be caused by genetic and nongenetic mechanisms. Whereas differences exist in the classification schema, CMP have historically been broken down into several major phenotypic categories: hypertrophic, dilated, arrhythmogenic, and restrictive. Phenotype overlap is common and increases the challenge in diagnostic accuracy. Some genetic and nongenetic subtypes can be identified using a step-by-step strategy, including history, physical examination, electrocardiography, echocardiography, laboratory, and a CMP-focused approach to interpreting cardiac and noncardiac investigations, not only in the patient but also in the familial history. Genetic testing is most informative if directed to a specific diagnosis suspected on the basis of the clinical assessment, and it is becoming an important tool for a personalized medical approach to CMP.

Arrhythmogenic Right Ventricular Cardiomyopathy: Clinical Assessment and Differential Diagnosis

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiovascular disorder leading to life-threatening ventricular arrhythmias, progressive biventricular dysfunction, and heart failure. Sudden death can be the unique feature of the disease. Genetic studies indicate that ARVC should be considered a disease of desmosome dysfunction. Diagnosis remains a clinical challenge mainly in its early stages and in patients with minimal imaging structural abnormalities. ARVC shares some common features with other cardiac diseases, such as RV outflow tract ventricular tachycardia, Brugada syndrome, dilated cardiomyopathy, and myocarditis, due to arrhythmic expressivity and biventricular involvement. Diagnosis is based on major and minor criteria listed in the Revised Task Force Criteria.