Michele Correale

Alcohol abuse and heart failure

Alcoholic patients who consume >90 g of alcohol a day for >5 years are at risk of developing asymptomatic alcoholic cardiomyopathy (ACM). Those patients who continue to drink may become symptomatic and develop signs and symptoms of heart failure (HF). This distinct form of congestive HF is responsible for 21–36% of all cases of non‐ischaemic dilated cardiomyopathy in Western Society. Without complete abstinence, the 4 year mortality for ACM is close to 50%. This short review summarizes the experimental and clinical evidence regarding the role of alcohol in the pathophysiology of ACM and HF.

Acute Phase Proteins In Atherosclerosis (Acute Coronary Syndrome)

Investigation of the mechanisms of atherosclerosis has determined that inflammation plays a central role in the development, progression, and outcome of acute coronary syndrome (ACS). C-reactive protein (CRP) plasma levels increase in patients with ACS. CPR is an important prognostic marker in ACS, following angioplasty, and in the long-term management of post-infarction patients. Although CRP will remain over time a useful marker, the role and implications of increased plasma concentrations of other acute phase proteins (APPs), such as alpha-1-antitrypsin (A1AT), alpha-1 glycoprotein (A1GP), haptoglobin (HG), ceruloplasmin (CP), and C3c and C4 complement fraction, in patients with ACS are still not completely defined. This short review summarizes the experimental and clinical evidence regarding the role, and the biological and clinical significance of these other APPs in ACS.

Exercise tolerance can explain the obesity paradox in patients with systolic heart failure: Data from the MECKI Score Research Group

AIMS Obesity has been found to be protective in heart failure (HF), a finding leading to the concept of an obesity paradox. We hypothesized that a preserved cardiorespiratory fitness in obese HF patients may affect the relationship between survival and body mass index (BMI) and explain the obesity paradox in HF. METHODS AND RESULTS A total of 4623 systolic HF patients (LVEF 31.5 ± 9.5%, BMI 26.2 ± 3.6 kg/m(2) ) were recruited and prospectively followed in 24 Italian HF centres belonging to the MECKI Score Research Group. Besides full clinical examination, patients underwent maximal cardiopulmonary exercise test at study enrolment. Median follow-up was 1113 (553-1803) days. The study population was divided according to BMI (<25, 25-30, >30 to ≤35 kg/m(2) ) and predicted peak oxygen consumption (peak VO2 , <50%, 50-80%, >80%). Study endpoints were all-cause and cardiovascular deaths including urgent cardiac transplant. All-cause and cardiovascular deaths occurred in 951 (28.6%, 57.4 per person-years) and 802 cases (17.4%, 48.4 per 1000 person-years), respectively. In the high BMI groups, several prognostic parameters presented better values [LVEF, peak VO2 , ventilation/carbon dioxide slope, renal function, and haemoglobin (P < 0.01)] compared with the lower BMI groups. Both BMI and peak VO2 were significant positive predictors of longer survival: both higher BMI and peak VO2 groups showed lower mortality (P < 0.001). At multivariable analysis and using a matching procedure (age, gender, LVEF, and peak VO2 ), the protective role of BMI disappeared. CONCLUSION Exercise tolerance affects the relationship between BMI and survival. Cardiorespiratory fitness mitigates the obesity paradox observed in HF patients.

Time intervals and myocardial performance index by tissue Doppler imaging

The application of tissue Doppler imaging (TDI) has shown remarkable growth in clinical practice during the past few years, especially, in risk stratification of patients with coronary heart disease or heart failure (systolic and diastolic). Myocardial performance index (MPI) is a Doppler echocardiographic parameter defined as the sum of the isovolemic contraction and relaxation times divided by the ejection time. It is considered as a reliable parameter to assess global left ventricular function. Cardiac time intervals and MPI have also been found as new applications in diagnosing cardiotoxicity from chemotherapy, COPD, valvular heart disease, pulmonary hypertension and endocrinopathies.

Deceptive meaning of oxygen uptake measured at the anaerobic threshold in patients with systolic heart failure and atrial fibrillation

Background Oxygen uptake at the anaerobic threshold (VO2AT), a submaximal exercise-derived variable, independent of patients’ motivation, is a marker of outcome in heart failure (HF). However, previous evidence of VO2AT values paradoxically higher in HF patients with permanent atrial fibrillation (AF) than in those with sinus rhythm (SR) raised uncertainties. Design We tested the prognostic role of VO2AT in a large cohort of systolic HF patients, focusing on possible differences between SR and AF. Methods Altogether 2976 HF patients (2578 with SR and 398 with AF) were prospectively followed. Besides a clinical examination, each patient underwent a maximal cardiopulmonary exercise test (CPET). Results The follow-up was analysed for up to 1500 days. Cardiovascular death or urgent cardiac transplantation occurred in 303 patients (250 (9.6%) patients with SR and 53 (13.3%) patients with AF, p = 0.023). In the entire population, multivariate analysis including peak oxygen uptake (VO2) showed a prognostic capacity (C-index) similar to that obtained including VO2AT (0.76 vs 0.72). Also, left ventricular ejection fraction, ventilation vs carbon dioxide production slope, β-blocker and digoxin therapy proved to be significant prognostic indexes. The receiver-operating characteristic (ROC) curves analysis showed that the best predictive VO2AT cut-off for the SR group was 11.7 ml/kg/min, while it was 12.8 ml/kg/min for the AF group. Conclusions VO2AT, a submaximal CPET-derived parameter, is reliable for long-term cardiovascular mortality prognostication in stable systolic HF. However, different VO2AT cut-off values between SR and AF HF patients should be adopted.

Statins in Heart Failure.

Clinical trials demonstrated that statin therapy is associated with a significant reduction in cardiovascular morbidity and mortality when used for either primary or secondary prevention of cardiovascular events. Several studies have shown that statins, having an important effect in the prevention of acute coronary syndromes, are also able to prevent heart failure (HF) in patients with coronary artery disease. This review summarizes the experimental and clinical evidence regarding the role of statins in the management of HF.

Tako-tsubo cardiomyopathy following an allergic asthma attack after cephalosporin administration.

Tako-Tsubo (TT) syndrome is characterized by acute onset ofchest symptoms, ECG changes with elevated cardiac markers mim-icking acute myocardial infarction, left ventricular (LV) wall motionabnormalities in the apical region with preserved function of base,and normal coronary arteries [1]. Those affected are typically olderwomen presenting after a stressful trigger, either emotional orphysical.A 70-year-old woman with history of hypertension, diabetes,asthma and allergy, was admitted with chest pain and dyspnea,whichsuddenly appearedafter asingle 1 g doseof ceftriaxonei.m.as-sumed because of cough and fever. On physical examination, bloodpressure was 120/70 mm Hg, heart rate 110 bpm, respiratory rate22 breaths/min, and diffuse bilateral wheezes were found. ECGshowed sinus rhythm and mild ST-elevation in anterior leads(Fig. 1a); troponin-I levels were increased (1.09 m ng/ml (n.v.b0.03)). Trans-thoracic echocardiogram showed LV systolic dysfunc-tion (ejection fraction [EF] 25%) with both apical dyskinesis andbasal hyperkinesis (Fig. 1c), and right ventricular (RV) apical dyskin-esis (Fig. 1d). Mild mitral regurgitation and tricuspid regurgitationwere also detectable at color Doppler analysis. Total IgE circulatinglevels were increased (1270 I.U./ml (n.v. b240 I.U./ml). Coronary an-giography showed normal coronary arteries and confirmed LV apicalballooning (Fig. 1e–f). Medical treatment with furosemide,levosimendan,ramipril,andbisoprololwasthereforestarted.Thepatientgradually recovered, and was discharged a week later, when all ECGanomalies, after transient onset of negative T-waves ( Fig. 1b) disap-peared. Pre-discharge echocardiography showed both improved LV (EF55%) and RV systolic functions.We report a case of transient apical ballooning triggered by admin-istration of antibiotics (cephalosporin). We therefore hypothesize thatallergic activation induced by antibiotic and featured by increased IgElevels may be related to TT phenomenon, as previously reported [2].RV apical ballooning, as found in this patient, was reported in 25% ofcases with TT syndrome [3].The exact mechanism leading to transient apical systolic dysfunc-tion is still not well elucidated. Increased catecholamine levels werethoughas responsible [4] , but also coronaryspasm has been reportedin subjects showing TT phenomenon [5].Several prior reports linked TT syndrome to bronchial asthma [6]anaphylactic reaction [7,8] and even cephalosporin administration[9], although in all these cases apical systolic dysfunction usually fol-lowed administration of i.v. epinephrine. We therefore postulate inthis patient a catecholamine independent pathway leading to TT phe-nomenon. Direct histamine effect consequent to allergic activationmay be presumed as responsible for transient apical dysfunction.Two cases of profound reversible myocardial dysfunction occurring inthe setting of anaphylaxis, with histamine discussed as a potential myo-cardial depressor, were previously reported [10]. Raper et al. noted thatstimulation of histamine receptors in both animal and human hearts ex-perimentally leads to myocardial depression, providing a possibleexplaining mechanism for our findings.References

Troponin in newborns and pediatric patients.

Cardiac troponin represents a sensitive and specific marker of ischemic myocardial damage in adult and neonatal populations. Cardiac function in neonates could be influenced by the severity of respiratory distress and its ventilatory management. This short review summarizes the experimental and clinical evidence regarding the role of cardiac troponin in assessment of cardiac function, in following findings: neonatal intensive care, respiratory distress syndrome, asphyxia, congenital heart disease and post cardiac surgery.

HIV-associated pulmonary arterial hypertension: from bedside to the future.

Pulmonary arterial hypertension (PAH) is a life‐threatening complication of HIV infection. The prevalence of HIV‐associated PAH (HIV‐PAH) seems not to be changed over time, regardless of the introduction of highly active antiretroviral therapy (HAART). In comparison with the incidence of idiopathic PAH in the general population (1–2 per million), HIV‐infected patients have a 2500‐fold increased risk of developing PAH. HIV‐PAH treatment is similar to that for all PAH conditions and includes lifestyle changes, general treatments and specific treatments.

Combined exogenous and endogenous catecholamine release associated with Tako-Tsubo like syndrome in a patient with atrio-ventricular block undergoing pace-maker implantation.

We report the case of a 65-year-old woman with complete atrio-ventricular block who underwent orciprenaline administration and pacemaker implantation. The intervention was complicated by pneumothorax and acute left ventricular systolic dysfunction with typical apical ballooning (Tako-Tsubo like syndrome). The patient was treated with diuretics and calcium-sensitizers and completely recovered. We speculate that both external and internal catecholamine triggered an acute left ventricular impairment with typical Tako-Tsubo features.