J.L. Zamorano

ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).

Authors/Task Force Members: Kenneth Dickstein (Chairperson) (Norway)*, Alain Cohen-Solal (France), Gerasimos Filippatos (Greece), John J.V. McMurray (UK), Piotr Ponikowski (Poland), Philip Alexander Poole-Wilson (UK), Anna Strömberg (Sweden), Dirk J. van Veldhuisen (The Netherlands), Dan Atar (Norway), Arno W. Hoes (The Netherlands), Andre Keren (Israel), Alexandre Mebazaa (France), Markku Nieminen (Finland), Silvia Giuliana Priori (Italy), Karl Swedberg (Sweden)

Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC).

Non-thrombotic PE does not represent a distinct clinical syndrome. It may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult. With the exception of severe air and fat embolism, the haemodynamic consequences of non-thrombotic emboli are usually mild. Treatment is mostly supportive but may differ according to the type of embolic material and clinical severity.

Recommendations for transoesophageal echocardiography: update 2010

Transoesophageal echocardiography (TOE) is a standard and indispensable technique in clinical practice. The present recommendations represent an update and extension of the recommendations published in 2001 by the Working Group on Echocardiography of the European Society of Cardiology. New developments covered include technical advances such as 3D transoesophageal echo as well as developing applications such as transoesophageal echo in aortic valve repair and in valvular interventions, as well as a full section on perioperative TOE.

Stress echocardiography expert consensus statement-executive summary: european association of echocardiography (a registrated branch of the ESC).

Stress echocardiography is the combination of echocardiography with a physical, pharmacological, or electrical stress. The diagnostic endpoint for the detection of myocardial ischaemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy to radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the possibility of performing coronary flow reserve evaluation of the left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage of the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence on the operators training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of non-invasive diagnosis of coronary artery disease. In 1935, Tennant and Wiggers1 demonstrated that coronary occlusion immediately resulted in instantaneous abnormality of wall motion. A large body of evidence2–5 recognized for the first time that transient dys-synergy was an early, sensitive, specific marker of transient ischaemia, clearly more accurate than ECG changes and pain. In European clinical practice,6–10 stress echo has been embedded in the legal and cultural framework of existing European laws and medical imaging referral guidelines. The …

Isovolumic Contraction Time by Pulsed-Wave Doppler Tissue Imaging in Aortic Stenosis

BACKGROUND Doppler Tissue Imaging (DTI) has been evaluated in ischaemic heart disease and some cardiomyopathies. In patients with aortic stenosis (AS), left ventricular contraction is slowered. This study aimed to evaluate the possible role of the measurement of isovolumic contraction time (ICT) by DTI in the evaluation of AS severity. METHODS The study population constitutes 30 patients: 15 with AS (nine severe and six non-severe) and 15 control subjects. All of them had normal systolic function, sinus rhythm, and absence of ischaemic heart disease of conduction abnormalities. ICT was defined as the time from the onset of the QRS complex to the beginning of the DTI systolic wave. The correlation between ICT and aortic area obtained by continuity equation, as well as the diagnostic value of ICT in the identification of severe AS were studied. RESULTS ICT was significantly increased in patients with severe AS (98+/-27 versus 65+/-21 ms, p=0.024). There was a significant correlation between ICT and aortic area (r=-0.56; p=0.035). The receiver operator characteristic curve of ICT in the identification of severe AS yielded an area under the curve of 0.852 (95% confidence interval: 0.665-1.0). The two best cut-points were >73 ms (88% sensitivity, 77% specificity) and >85 ms (78% sensitivity, 83% specificity). A value of >41 ms had a 100% sensitivity, but only a 17% specificity, and >91 ms showed a 100% specificity, but only a 44% sensitivity. CONCLUSIONS ICT measured by pulsed-wave DTI is increased in patients with aortic stenosis.

Three-Dimensional Echocardiographic Assessment of Left Atrial Size and Function and the Normal Range of Asynchrony in Healthy Individuals

Left atrial size and function are very important prognostic factors. Our aim was to evaluate left atrial size, function and mechanical synchrony using three-dimensional echocardiography in order to establish normal reference values. The study involved 63 healthy individuals enrolled at two hospitals. All underwent two-dimensional and three-dimensional echocardiography. Mechanical asynchrony was assessed by determining the standard deviation of the time each left atrial segment took to reach the minimum volume during atrial systole, normalized by the RR interval. The mean value for this normalized standard deviation was 15.4+/-10.9. In conclusion, it is possible to analyze left atrial asynchrony, size and function using three-dimensional echocardiography.

Myocardial contrast echocardiography in coronary artery disease

Myocardial contrast echocardiography (MCE) allows the assessment of myocardial perfusion by imaging the coronary microcirculation. The development of new contrast agents and new diagnostic tools far assessing myocardial perfusion by means of MCE has led to a new field of applications far patients suffering from ischemic heart disease. Several studies have shown that MCE is a feasible and accurate method to evaluate patients with: a) acute coronary syndromes: MCE is useful before the epicardial reperfusion to delineate the area at risk and to assess the collateral-derived myocardial blood flow, and after the epicardial reperfusion to detect the non-reflow phenomenon; b) chronic coronary syndromes: MCE allows the detection of significant coronary stenosis by means of stress methods and methods without any stress; c) myocardial viability and hibernating myocardium: MCE helps to predict functional recovery of akinetic segments. In these settings, MCE is not only useful as a diagnostic tool but also provides prognostic information. MCE is a technique in constant development. Among the latest advances we note the development of transesophageal probes with second-harmonic image that allows assessment of myocardial perfusion in a more accurate way. This technique should introduce MCE into new clinical fields, especially the evaluation of myocardial perfusion during cardiac operations. Another recent development is in parametric imaging techniques. These consist in obtaining time curves for all the pixels in the image instead of working only with a few separate regions of interest. A parameter scan is computed far any pixel showing their value as a color overlay in the parametric image. Summarizing, we can say that MCE is crossing from the experimental laboratory to the daily clinical practice far the evaluation of ischemic heart disease. MCE provides an interesting tool that offers the potential of a complete evaluation of patients with chronic coronary artery disease. This includes both diagnostic and prognostic evaluation.

Cardio-Oncology Services: rationale, organization, and implementation

AIMS Anticancer therapies have extended the lives of millions of patients with malignancies, but for some this benefit is tempered by adverse cardiovascular (CV) effects. Cardiotoxicity may occur early or late after treatment initiation or termination. The extent of this cardiotoxicity is variable, depending on the type of drug used, combination with other drugs, mediastinal radiotherapy, the presence of CV risk factors, and comorbidities. A recent position paper from the European Society of Cardiology addressed the management of CV monitoring and management of patients treated for cancer. METHODS AND RESULTS The current document is focused on the basis of the Cardio-Oncology (C-O) Services, presenting their rationale, organization, and implementation. C-O Services address the spectrum of prevention, detection, monitoring, and treatment of cancer patients at risk of cardiotoxicity and/or with concomitant CV diseases. These services require a multidisciplinary approach, with the aims of promoting CV health and facilitating the most effective cancer therapy. CONCLUSION The expected growing volume of patients with cancer at risk of developing/worsening CV disease, the advent of new technological opportunities to refine diagnosis, and the necessity of early recognition of cancer therapy-related toxicity mandate an integrative multidisciplinary approach and care in a specialized environment. This document from the ESC Cardio-Oncology council proposes the grounds for creating C-O Services in Europe based on expert opinion.

Myocardial perfusion in real-time using power modulation: In vivo evidence for microcirculatory damage after acute myocardial infarction

BACKGROUND AND OBJECTIVES In addition to the myocardium, the microvasculature may be also damaged in acute myocardial infarction. The aim was to evaluate the capability of myocardial contrast echocardiography in the detection of microvasculature damage after myocardial infarction. PATIENTS AND METHODS Twelve patients with recent acute myocardial infarction and five control subjects with normal coronary arteries and without history of myocardial infarction were studied. Myocardial contrast echocardiography with power modulation was performed, and quantitative data were measured off-line. Power modulation uses a combination of low (0.1) and high (1.7) mechanical indexes, allowing a real-time evaluation of myocardial perfusion. Contrast agent was administered as a 3-min bolus. The quantitative analysis was performed off-line by a different blinded investigator. The refilling velocity was calculated as the difference between the peak myocardial refilling value and the value at 1 s after the impulse divided by the time from the first second after the impulse to the peak refilling value. RESULTS Eighty-one myocardial segments (75%) were analysed qualitatively and quantitatively in AMI patients, and 18 (60%) in control subjects (P=NS). The peak refilling intensity was not significantly different in patients and control subjects (6.62+/-5.85 vs. 7.53+/-4.06 dB, respectively). However, time to peak refilling intensity was significantly longer (5.25+/-1.57 vs. 4.00+/-0.53, P=0.004) and the velocity of refilling was significantly lower (2.74+/-5.34 vs. 6.58+/-8.02, P=0.028) in patients with myocardial infarction. CONCLUSION There is microvasculature damage after myocardial infarction that is reflected as a delayed velocity of refilling in myocardial contrast echocardiography.

State of play and future direction with NOACs: An expert consensus

Atrial fibrillation (AF) and venous thromboembolism (VTE) are cardiovascular conditions significant in contemporary practice. In both, the use of anticoagulation with vitamin K antagonists (VKAs) has been traditionally used to prevent adverse events. However, VKA therapy is associated with challenges relating to dose maintenance, the need to monitor anticoagulation, and bleeding risks. The non-vitamin K oral anticoagulants (NOACs) are becoming accepted as a clear alternative to VKA therapy for both AF and VTE management. The aim of this paper was to review contemporary evidence on the safety of NOACs in both conditions. A comprehensive literature review was conducted to explore key safety issues and expert consensus was achieved from eight professionals specialised in AF and VTE care. Consensus-based statements were formulated where available evidence was weak or contradictory. The expert statements in this paper form a key overview of the safety of NOACs compared with VKA therapy, and the comparative safety of different NOACs. It is apparent that a detailed patient work-up is required in order to identify and manage individual risk factors for bleeding and thrombosis prior to NOAC therapy. Additional measures, such as dose reductions, may also be used to maintain the safety of NOACs in practice.