Elisabetta Pirozzi

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.

Expert Review on the Prognostic Role of Echocardiography after Acute Myocardial Infarction

&NA; Acute myocardial infarction (AMI) remains a leading cause of morbidity and mortality worldwide, placing a major economic and resource burden on public health systems. During hospitalization, all AMI patients should be evaluated with transthoracic echocardiography, a noninvasive, low‐cost, and easily available bedside imaging tool that allows the detection of myocardial walls involved in the ischemic process, damage extent, functional consequences, and mechanical complications. Moreover, and more importantly, transthoracic echocardiography can provide information on short‐ and long‐term outcomes after AMI. The purpose of this review is to clarify the role of standard and advanced echocardiographic parameters for an early identification of patients at high risk for developing adverse events and mortality after AMI. Standard echocardiography (in particular left ventricular ejection fraction, wall motion score index, and diastolic measurements including E velocity deceleration time and E/e′ ratio) proposes powerful parameters for risk stratification after AMI. Advanced echocardiographic technologies, in particular speckle‐tracking–derived longitudinal strain, coronary flow velocity reserve, and myocardial contrast echocardiography (contrast defect index), can provide additional prognostic value beyond standard techniques. Therefore, echocardiography plays a fundamental role in predicting short‐ and long‐term prognosis, and a more accurate risk stratification of patients may be useful to drive therapy and follow‐up after AMI. Accordingly, a comprehensive echocardiography‐based algorithm would be welcome for an early stratification of cardiovascular risk in patients experiencing AMI. Graphical abstract Figure. No caption available. HighlightsThe general role of echocardiography in acute myocardial infarction is recognized.The prognostic role of standard echocardiography involves all of the ultrasound techniques such as M‐mode, two‐dimensional, and Doppler.The prognostic role of advanced technologies involves speckle‐tracking echocardiography, myocardial contrast echocardiography, coronary flow reserve, and real‐time three‐dimensional echocardiography.An echocardiographic prognosticator should consider ejection fraction, mitral regurgitation grading, E velocity deceleration time, E/e′, left atrial volume index, left and right ventricular global longitudinal strain, and pulmonary arterial systolic pressure.

Implantable cardioverter defibrillator to prevent sudden cardiac death in a patient with systemic sclerosis: A clinical case

Ventricular arrhythmias are frequent in patients with systemic sclerosis and may result in sudden cardiac death. We report the case of a patient with systemic sclerosis and recent syncopes in whom induction of unstable sustained ventricular tachycardia of 2 different morphologies accompanied by syncopal event was demonstrated at the electrophysiological study. He was then implanted a 3rd generation implantable cardioverter defibrillator and remained thereafter asymptomatic. We suggest that aggressive testing is warranted in systemic sclerosis patients with suspected malignant arrhythmias to identify candidates for defibrillator implantation and prevent sudden deaths.

Clinical applications of MIBG SPECT in chronic heart failure

Heart failure is characterized by several abnormalities of sympathetic cardiac activity that can be assessed by 123I metaiodobenzylguanidine single photon emission computed tomography (MIBG SPECT). This technique may be useful in the clinical management of heart failure patients. Abnormal MIBG uptake has been demonstrated to be a predictor of death and arrhythmic events in heart failure patients with a prognostic power incremental to that of conventional risk markers; it may also be useful to identify patients at low risk of arrhythmias despite current guideline indications for an implantable cardioverter-defibrillator (ICD) or patients at high risk for arrhythmias not fulfilling ICD indications. This review will focus on the clinical applications of MIBG SPECT in chronic heart failure, on the basis of the most recent evidence.

Heart rate during exercise: mechanisms, behavior, and therapeutic and prognostic implications in heart failure patients with reduced ejection fraction

Exercise intolerance is a typical manifestation of patients affected by heart failure with reduced ejection fraction (HFrEF); however, the relationship among functional capacity, mortality, and exercise-induced heart rate response during exercise remains unclear in either sinus rhythm or atrial fibrillation subjects. Heart rate increase during incremental load exercise has a typical pattern in normal subjects, whereas it is commonly compromised in HFrEF patients, mainly due to the imbalance of the autonomic nervous system. In the present review, we aim to describe the behavior of heart rate during exercise in normal subjects and in HFrEF patients in sinus rhythm and atrial fibrillation, understanding and explaining the mechanism leading to a different exercise performance and functional limitation. Moreover, the role of chronotropic incompetence and the need of standardizing the cutoff criteria are also discussed in order to clarify the clinical importance, the prognostic relevance, and the potential therapeutic implications of this condition. Looking into the relative contribution and interaction of heart rate response during exercise might represent an important issue to guide individualized therapeutic interventions and prognostic assessment in HFrEF patients.

Dalla ricerca di base alla pratica clinica: nuove prospettive terapeutiche nello scompenso cardiaco

Despite significant advances in pharmacological and clinical treatment, heart failure remains a leading cause of morbidity and mortality worldwide. G-protein coupled receptors are a wide superfamily of plasma membrane receptors which represent an important target of heart failure drug therapy. Since heart failure is characterized by the overactivity of different neurohormones, such as catecholamines and angiotensin II, responsible for several detrimental effects on the cardiovascular system, over the last decade therapeutic strategies targeting beta-adrenergic and angiotensin receptors have been developed. Despite the introduction of successful drug classes, such as beta-adrenergic receptor blockers, angiotensin-converting enzyme inhibitors and sartans, heart failure still poses an enormous challenge, thus indicating the urgent need to develop innovative treatments that might counteract mechanisms involved in heart failure onset and progression. It is now established that a single receptor, activated by the same agonist, can elicit several different signaling pathways often resulting in opposite cellular responses, some beneficial and some detrimental. However, drugs currently used in heart failure target receptors on their extracellular domain by competing with the endogenous agonists. Thus, they can inhibit non-specifically all the receptor-related signaling pathways including those with beneficial activity whose blockade would not be desirable in heart failure. These observations stress the need for the generation of new therapeutic molecules able to target specific signaling pathways which might result in innovative therapies for cardiovascular disease.

Dalla ricerca di base alla pratica clinica

Despite significant advances in pharmacological and clinical treatment, heart failure remains a leading cause of morbidity and mortality worldwide. G-protein coupled receptors are a wide superfamily of plasma membrane receptors which represent an important target of heart failure drug therapy. Since heart failure is characterized by the overactivity of different neurohormones, such as catecholamines and angiotensin II, responsible for several detrimental effects on the cardiovascular system, over the last decade therapeutic strategies targeting beta-adrenergic and angiotensin receptors have been developed. Despite the introduction of successful drug classes, such as beta-adrenergic receptor blockers, angiotensin-converting enzyme inhibitors and sartans, heart failure still poses an enormous challenge, thus indicating the urgent need to develop innovative treatments that might counteract mechanisms involved in heart failure onset and progression. It is now established that a single receptor, activated by the same agonist, can elicit several different signaling pathways often resulting in opposite cellular responses, some beneficial and some detrimental. However, drugs currently used in heart failure target receptors on their extracellular domain by competing with the endogenous agonists. Thus, they can inhibit non-specifically all the receptor-related signaling pathways including those with beneficial activity whose blockade would not be desirable in heart failure. These observations stress the need for the generation of new therapeutic molecules able to target specific signaling pathways which might result in innovative therapies for cardiovascular disease.