Maria Maiello

Endothelial Function in Pre-diabetes, Diabetes and Diabetic Cardiomyopathy: A Review

Diabetes mellitus worsens cardiovascular risk profile of affected individuals. Its worldwide increasing prevalence and its negative influences on vascular walls morphology and function are able to induce the expression of several morbidities which worsen the clinical conditions of the patients getting them running towards a reduced survival curve. nAlthough overt diabetes increases the mortality rate of individuals due to its pathogenesis, poor information are in literature about the role of pre-diabetes and family history of diabetes mellitus in the outcome of general population. nThis emphasizes the importance of early detection of vascular impairment in subjects at risk of developing diabetes. nThe identification of early stages of atherosclerotic diseases in diabetic persons is a fundamental step in the risk stratification protocols followed-up by physicians in order to have a complete overview about the clinical status of such individuals. Common carotid intima-media thickness, flow-mediated vasodilatation, pulse wave velocity are instrumental tools able to detect the early impairment in cardiovascular system and stratify cardiovascular risk of individuals. nThe aim of this review is to get a general perspective on the complex relationship between cardiovascular diseases onset, pre-diabetes and family history of diabetes. Furthermore, it points out the influence of diabetes on heart function till the expression of the so-called diabetic cardiomyopathy.

Cardiovascular health in migrants: current status and issues for prevention. A collaborative multidisciplinary task force report.

Objectives To review information on cardiovascular health and migration, to stress the attention of researchers that much needs to be done in the collection of sound data in Italy and to allow policy makers identifying this issue as an important public health concern. Background In Italy, the rate of immigrants in the total number of residents increased from 2.5% in 1990 to 7.4% in 2010, and currently exceeds 10% in regions such as Lombardia, Emilia Romagna and Toscana. Methods A consensus statement was developed by approaching relevant Italian national scientific societies involved in cardiovascular prevention. Task force members were identified by the president and/or the boards of each relevant scientific society or working group, as appropriate. To obtain a widespread consensus, drafts were merged and distributed to the scientific societies for local evaluation and revision by as many experts as possible. The ensuing final draft was finally approved by scientific societies. Results In several western European countries, the prevalence of hypertension, diabetes, chronic kidney disease, obesity and metabolic syndrome was found to be higher among immigrants than in the native population. Although migrants are often initially healthier than non-migrant populations in their host countries, genetic factors, and changing environments with lifestyle changes, social exclusion and insufficient medical control may expose them to health challenges. Cultural reasons may also hamper both the dissemination of prevention strategies and migrant communication with healthcare providers. However, great diversity exists across and within different groups of migrants, making generalizations very difficult and many countries do not collect registry or survey data for migrants health. Conclusions In the present economic context, the European Union is placing great attention to improve data collection for migrant health and to support the implementation of specific prevention policies aimed at limiting the future burden of cardiovascular and renal disease, and the consequent load for health systems. Wider initiatives on the topic are awaited in Italy.

An Update on hypertensive emergencies and urgencies

Severe acute arterial hypertension is usually defined as ‘hypertensive crisis’, although ‘hypertensive emergencies’ or ‘hypertensive urgencies’, as suggested by the Joint National Committee and the European Society of Hypertension, have completely different diagnostic and therapeutic approaches. The prevalence and demographics of hypertensive emergencies and urgencies have changed over the last four decades, but hypertensive emergencies and urgencies are still associated with significant morbidity and mortality. Different scientific societies have repeatedly produced up-to-date guidelines; however, the treatment of hypertensive emergencies and urgencies is still inappropriate, with potential clinical implications. This review focuses on hypertensive emergencies and urgencies management and treatment, as suggested by recent data.

Left ventricular diastolic function in hypertension: methodological considerations and clinical implications.

The assessment of left ventricular (LV) diastolic function should be an integral part of a routine examination of hypertensive patient; indeed when LV diastolic function is impaired, it is possible to have heart failure even with preserved LV ejection fraction. Left ventricular diastolic dysfunction (LVDD) occurs frequently and is associated to heart disease. Doppler echocardiography is the best tool for early LVDD diagnosis. Hypertension affects LV relaxation and when left ventricular hypertrophy (LVH) occurs, it decreases compliance too, so it is important to calculate Doppler echocardiography parameters, for diastolic function evaluation, in all hypertensive patients. The purpose of our review was to discuss about the strong relationship between LVDD and hypertension, and their relationship with LV systolic function. Furthermore, we aimed to assess the relationship between the arterial stiffness and LV structure and function in hypertensive patients.

Ventricular-vascular coupling in hypertension: methodological considerations and clinical implications.

The present review is addressed to analyse the complex interplay between left ventricle and arterial tree in hypertension. The different methodological approaches to the analysis of ventricular–vascular coupling in the time and frequency domain are discussed. Moreover, the role of hypertension-related changes of arterial structure and function (stiffness and wave reflection) on arterial load and how ventricular–vascular coupling modulates the process of left ventricular adaptation to hypertension are analysed. The different interplay between vascular bed and left ventricle emerges as the pathophysiological basis for the development of the multiple patterns of ventricular structural adaptation in hypertension and provides a pathway for the interpretation of systolic and diastolic functional abnormalities observed in hypertensive patients. Targeting the therapeutic approach to improve ventricular–vascular coupling may have relevant impact on reversing left ventricular hypertrophy and improving systolic and diastolic dysfunction.

Is Echo‐Determined Left Ventricular Geometry Associated with Ventricular Filling and Midwall Shortening in Hypertensive Ventricular Hypertrophy?

Background: The correlation between left ventricular (LV) geometry, mass, diastolic function, and midwall fractional shortening (MFS) in hypertensive patients with left ventricular hypertrophy (LVH) is not well established owing to limited diffusion of MFS evaluation. The aim of the study was to evaluate this correlation in 1887 consecutive hypertensive patients, all affected by LVH (mean age 66 years, 924 males), with LV ejection fraction (LVEF) >45% for early detection of ventricular dysfunction rather than LVEF and diastolic function impairment. Methods and Results: All patients underwent M‐B mode echocardiography and PW‐Doppler evaluation. LV geometry and mass were compared with Doppler‐determined mitral flow and tissue velocities. LV geometry was eccentric (E) for 1018 subjects (53.9%) and concentric (C) for 869 (46.1%). There was no difference concerning LV diastolic dysfunction (P: n.s.) between 576 (30.6%) of the ELVH and 368 (19.4%) of the CLVH patients. The following parameters showed significant statistical differences: LV MFS impairment (P < 0.01) between 86 (4.6%) of the ELVH and 177 (9.4%) of the CLVH patients. LV MFS impairment rate was higher in 171 patients without LV diastolic dysfunction (9.1%), than in 92 patients affected (4.9%, P < 0.02). In CLVH patients, a higher prevalence of LV MFS impairment was observed in 143 without LV diastolic dysfunction (7.6%), than in 34 patients affected (1.8%, P < 0.01). In ELVH patients, a lower prevalence of LV MFS impairment was observed in 28 without diastolic dysfunction (1.5%), than in 58 patients affected (3.1%, P < 0,03). Conclusion: Midwall LV impairment, an independent predictor of cardiac death and morbidity in hypertensive patients, can allow early identification of patients with LV dysfunction even when LVEF or assessment of diastolic function are normal. LV MFS impairment rate is higher in CLVH patients, and even higher when considering only those CLVH patients with no diastolic dysfunction. These results suggest that the ventricular dysfunction with normal LVEF is not always due to diastolic dysfunction, but often to systolic dysfunction as assessed by MFS impairment, an important early sign of ventricular dysfunction in hypertensive patients, even when diastolic function is normal.

Mediterranean diet impact on cardiovascular diseases: A narrative review

&NA; Cardiovascular disease (CVD) accounts for more than 17 million deaths per year worldwide. It has been estimated that the influence of lifestyle on CVD mortality amounts to 13.7% for smoking, 13.2% for poor diet, and 12% for inactive lifestyle. These results deeply impact both the healthy status of individuals and their skills in working. The impact of CVD on productivity loss accounts for the 24% in total costs for CVD management. Mediterranean diet (MedD) can positively impact on natural history of CVD. It is characterized by a relatively high consumption of inexpensive and genuine food such as cereals, vegetables, legumes, nuts, fish, fresh fruits, and olive oil as the principal source of fat, low meat consumption and low-to-moderate consumption of milk, dairy products, and wine. Its effects on cardiovascular health are related to the significant improvements in arterial stiffness. Peripheral artery disease, coronary artery disease, and chronic heart failure are all positively influenced by the MedD. Furthermore, MedD lowers the risk of sudden cardiac death due to arrhythmias. The present narrative review aims to analyze the effects of MedD on CVD.

The controversial relationship between exercise and atrial fibrillation: Clinical studies and pathophysiological mechanisms

Atrial fibrillation is the most common clinically significant arrhythmia observed both in the general population and in competitive athletes. The most important risk factors are all preventable by regular physical activity. However, although the benefits of moderate physical activity in controlling cardiovascular risk factors and decreasing the risk of atrial fibrillation have been extensively proved, concerns have arisen about the potential negative effects of vigorous exercise, particularly in endurance athletes. Furthermore, in a subset of patients with atrial fibrillation younger than 60 years, routine evaluation does not reveal any cardiovascular disease or any other known causal factor. This condition is called ‘lone atrial fibrillation’, and the potential mechanisms underlying this condition are speculative and remain to be clarified. Atrial ectopy, increased vagal tone, changes in electrolytes, left atrial dilatation, and fibrosis have been proposed among others as potential mechanisms. However, no convincing data still exist. Particularly, the increase in left atrial size represents in athletes a physiological adaptation to exercise conditioning and the presence of biatrial fibrosis has not been demonstrated in humans. Thus, contrary to patients with cardiovascular disorders, the atrial substrate seems to play a secondary role in healthy athletes. This review article analyzes the controversial relationship between atrial fibrillation and physical activity, with a particular attention on the pathophysiological mechanisms that could be responsible for atrial fibrillation in the athletic population.

Speckle tracking analysis: a new tool for left atrial function analysis in systemic hypertension: an overview.

Speckle tracking echocardiography (STE) is an imaging technique applied to the analysis of left atrial function. STE provides a non-Doppler, angle-independent and objective quantification of left atrial myocardial deformation. Data regarding feasibility, accuracy and clinical applications of left atrial strain are rapidly gathering. This review describes the fundamental concepts of left atrial STE, illustrates its pathophysiological background and discusses its emerging role in systemic arterial hypertension.

Aortic Valve Sclerosis: Is It a Cardiovascular Risk Factor or a Cardiac Disease Marker?

Background: Aortic valve sclerosis, without stenosis, has been associated with an increased cardiovascular mortality and morbidity due to myocardial infarction. However, it is unclear whether it is a cardiovascular risk factor or a cardiac disease marker. The goal of our study is to evaluate the difference in the prevalence of cardiovascular disease and risk factors among patients with or without aortic sclerosis. Methods: This observational study compared a group of 142 consecutive subjects with aortic valve sclerosis, assigned as group S, with a group of 101 subjects without aortic sclerosis, assigned as group C. Patients with bicuspid aortic valves and those with antegrade Doppler velocity across aortic valve leaflets exceeding 2.0 m/sec were excluded. Results: Mean ages of groups S and C were 71 ± 8, and 68.8 ± 6 years, respectively (P value = not significant). The prevalence of smoking, diabetes, hypercholesterolemia, hypertension, pulse pressure, left ventricular diastolic dysfunction, atrial fibrillation, and stroke was not significantly different between the two groups. However, there was a significantly higher prevalence of left ventricular hypertrophy (P = 0.05), ventricular arrhythmias (P = 0.02), myocardial infarction (P = 0.04), and systolic heart failure (P = 0.04) in aortic sclerosis group. Conclusions: Aortic sclerosis is associated with a higher prevalence of left ventricular hypertrophy, ventricular arrhythmias, myocardial infarction, and systolic heart failure, while the prevalence of cardiovascular risk factors is not different between aortic sclerosis patients and controls. Hence, aortic sclerosis represents a cardiac disease marker useful for early identification of high‐risk patients beyond cardiovascular risk factors rate.