Paola Sormani

Blood Pressure Control in Italian Essential Hypertensives Treated by General Practitioners

BACKGROUND Adequate control of blood pressure (BP) is limited worldwide. This has serious consequences for public health because in hypertensive patients, uncontrolled BP is associated with a higher incidence of cardiovascular events, particularly stroke. The aim of this study was to investigate BP control in a cohort of treated patients with diagnosed hypertension, who were under general practitioner care in Italy. METHODS Data were collected by 2,643 physicians on 8,572 individual Italian patients. Office BP was measured 5 min after seating each patient and then 3-5 min later. For each patient, data such as medical history of patients, physical examination data, antihypertensive drug usage, and self-BP measurement frequency were obtained. RESULTS Male prevalence was 48.4%, and mean age was 64.3 ± 10.5 years. Based on the second measurement, BP control (<140/90 mm Hg) was observed in 33.5% of all patients (34.2% in men and 33.4% in women). BP control was much lower for systolic BP than for diastolic BP (35.9 vs. 61.3%, P < 0.0001); moreover, BP control was much more common in patients who were engaged in self-BP measurement (61.2 vs. 38.8%, P < 0.0001). A stricter BP control recommended by the guidelines of the European Society of Hypertension (ESH) and European Society of Cardiology (ESC) (<130/80 mm Hg) was observed in only 5.5% of diabetic patients. CONCLUSIONS In treated Italian hypertensives effective BP control remains uncommon largely due to the failure to appropriately reduce the systolic BP. The stricter values recommended by the ESH/ESC guidelines for diabetic patients are achieved only by a small fraction of hypertensive diabetic population.

Survival and Left Ventricular Function Changes in Fulminant Versus Nonfulminant Acute Myocarditis

Background: Previous reports have suggested that despite their dramatic presentation, patients with fulminant myocarditis (FM) might have better outcome than those with acute nonfulminant myocarditis (NFM). In this retrospective study, we report outcome and changes in left ventricular ejection fraction (LVEF) in a large cohort of patients with FM compared with patients with NFM. Methods: The study population consists of 187 consecutive patients admitted between May 2001 and November 2016 with a diagnosis of acute myocarditis (onset of symptoms <1 month) of whom 55 required inotropes and/or mechanical circulatory support (FM) and the remaining 132 were hemodynamically stable (NFM). We also performed a subanalysis in 130 adult patients with acute viral myocarditis and viral prodrome within 2 weeks from the onset, which includes 34 with FM and 96 with NFM. Patients with giant-cell myocarditis, eosinophilic myocarditis, or cardiac sarcoidosis and those <15 years of age were excluded from the subanalysis. Results: In the whole population (n=187), the rate of in-hospital death or heart transplantation was 25.5% versus 0% in FM versus NFM, respectively (P<0.0001). Long-term heart transplantation–free survival at 9 years was lower in FM than NFM (64.5% versus 100%, log-rank P<0.0001). Despite greater improvement in LVEF during hospitalization in FM versus NFM forms (median, 32% [interquartile range, 20%–40%] versus 3% [0%–10%], respectively; P<0.0001), the proportion of patients with LVEF <55% at last follow-up was higher in FM versus NFM (29% versus 9%; relative risk, 3.32; 95% confidence interval, 1.45–7.64, P=0.003). Similar results for survival and changes in LVEF in FM versus NFM were observed in the subgroup (n=130) with viral myocarditis. None of the patients with NFM and LVEF ≥55% at discharge had a significant decrease in LVEF at follow-up. Conclusions: Patients with FM have an increased mortality and need for heart transplantation compared with those with NFM. From a functional viewpoint, patients with FM have a more severely impaired LVEF at admission that, despite steep improvement during hospitalization, remains lower than that in patients with NFM at long-term follow-up. These findings also hold true when only the viral forms are considered and are different from previous studies showing better prognosis in FM.

Quantitative changes in late gadolinium enhancement at cardiac magnetic resonance in the early phase of acute myocarditis

BACKGROUND The presence of late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) has diagnostic and prognostic value in patients with acute myocarditis (AM). Aim of our study was to quantify the changes in LGE extension (LGE%) early after AM and evaluate its relations with biventricular function and morphology. METHODS We investigated 76 consecutive patients with AM (acute onset of chest pain/heart failure/ventricular arrhythmias not explained by other causes, and raised troponin) that met CMR criteria based on myocardial oedema at T2-weighted images and LGE on post-contrast images at median time of 6days from onset of symptoms. We quantified LGE% at baseline and after 148days in 49 patients. RESULTS Median left ventricular (LV)-ejection fraction (EF) was 64% (interquartile range [Q1-Q3]: 56-67%), and LGE% 9.4% (Q1-Q3: 7.5-13.2%). LGE% was correlated with LV end-systolic volume index (LV-ESVi; r=+0.34; p=0.003). LGE% was inversely correlated with LV-EF (r=-0.31; p=0.009) and time to CMR scan (r=-0.25; p=0.028). In the 49 patients with a second CMR scan, despite no significant variations in LV-EF, a significant decrease of LGE% was observed (p<0.0001) with a relative reduction of 42% compared with baseline. Patients showing increased LV-ESVi at follow up had a lower decrease of LGE% (p=0.038). CONCLUSIONS In the acute phase of AM the LGE extension is a dynamic process that reflects impairment of LV function and is time dependent. LGE% appears one of the CMR parameters with the largest relative variations in the first months after AM.

Clinical Presentation and Outcome in a Contemporary Cohort of Patients with Acute Myocarditis: The Multicenter Lombardy Registry

Background: There is controversy about the outcome of patients with acute myocarditis (AM), and data are lacking on how patients admitted with suspected AM are managed. We report characteristics, in-hospital management, and long-term outcome of patients with AM based on a retrospective multicenter registry from 19 Italian hospitals. Methods: A total of 684 patients with suspected AM and recent onset of symptoms (<30 days) were screened between May 2001 and February 2017. Patients >70 years of age and those >50 years of age without coronary angiography were excluded. The final study population comprised 443 patients (median age, 34 years; 19.4% female) with AM diagnosed by either endomyocardial biopsy or increased troponin plus edema and late gadolinium enhancement at cardiac magnetic resonance. Results: At presentation, 118 patients (26.6%) had left ventricular ejection fraction <50%, sustained ventricular arrhythmias, or a low cardiac output syndrome, whereas 325 (73.4%) had no such complications. Endomyocardial biopsy was performed in 56 of 443 (12.6%), and a baseline cardiac magnetic resonance was performed in 415 of 443 (93.7%). Cardiac mortality plus heart transplantation rates at 1 and 5 years were 3.0% and 4.1%. Cardiac mortality plus heart transplantation rates were 11.3% and 14.7% in patients with complicated presentation and 0% in uncomplicated cases (log-rank P<0.0001). Major AM-related cardiac events after the acute phase (postdischarge death and heart transplantation, sustained ventricular arrhythmias treated with electric shock or ablation, symptomatic heart failure needing device implantation) occurred in 2.8% at the 5-year follow-up, with a higher incidence in patients with complicated forms (10.8% versus 0% in uncomplicated AM; log-rank P<0.0001). &bgr;-Adrenoceptor blockers were the most frequently used medications both in complicated (61.9%) and in uncomplicated forms (53.8%; P=0.18). After a median time of 196 days, 200 patients had follow-up cardiac magnetic resonance, and 8 of 55 (14.5%) with complications at presentation had left ventricular ejection fraction <50% compared with 1 of 145 (0.7%) of those with uncomplicated presentation. Conclusions: In this contemporary study, overall serious adverse events after AM were lower than previously reported. However, patients with left ventricular ejection fraction <50%, ventricular arrhythmias, or low cardiac output syndrome at presentation were at higher risk compared with uncomplicated cases that had a benign prognosis and low risk of subsequent left ventricular systolic dysfunction.

Partial Anomalous Pulmonary Venous Return as Rare Cause of Right Ventricular Dilation: A Retrospective Analysis.

INTRODUCTION Partial anomalous pulmonary venous return (PAPVR) is an uncommon cause of right ventricular dilation. It may be difficult to identify and often remains undiagnosed. METHODS We reviewed the database of the Cardiac Magnetic Resonance (CMR) Laboratory of Niguarda Hospital, in order to identify the cases of PAPVR between 2008 and 2014. RESULTS On a total number of 7832 CMR scans, we identified 24 patients with PAPVR (14 male, age 41 ± 18 y) corresponding to 0.31% of the total population. Only 30% of patients had been referred for known or suspected PAPVR, 33% of patients had been referred for suspected right ventricular arrhythmogenic dysplasia and 37% had been referred for other cardiac disease. PAPVR involved mainly the right pulmonary veins (18 patients, 75%) and in 62% of our cases was associated with an atrial septal defect. Eight patients underwent corrective surgery in our institution, which confirmed and successfully repaired the anomalies. CONCLUSIONS PAPVR is a rare congenital cardiac pathology which should be suspected in case of unexplained right chambers enlargement. CMR imaging allows an accurate anatomic and functional definition of this pathology and associated abnormalities. Early correction has an excellent prognosis and prevents long term complications like pulmonary hypertension, right ventricular failure and atrial fibrillation.

Determinants of carotid-femoral pulse wave velocity progression in hypertensive patients over a 3.7 years follow-up

Abstract Objective: The role of risk factors on the progression of arterial stiffness has not yet been extensively evaluated. The aim of the current longitudinal study was to evaluate the determinants of the PWV progression over a 4 years follow-up period in hypertensive subjects. Materials and Methods: We enrolled 333 consecutive hypertensive outpatients 18–80 aged, followed by the Hypertension Unit of St. Gerardo Hospital (Monza, Italy). At baseline anamnestic, clinical, BP, laboratory data and cfPWV were assessed. We performed a PWV follow-up examination with a median time amounting to 3.75 ± 0.53 years. Results: At baseline the mean age was 54.5 ± 12.6 years, SBP and DBP were 141.3 ± 18.6 and 86.4 ± 10.4 mmHg and PWV was 8.56 ± 1.92 m/s. Despite an improvement in BP control (from 37 to 60%), at follow-up the population showed a PWV increase (ΔPWV 0.87 ± 3.05 m/s). PWV and ΔPWV gradually increased in age decades. In patients with uncontrolled BP values at follow-up ΔPWV showed a greater increase as compared to patients with controlled BP (1.46 ± 3.67 vs 0.62 ± 2.61 m/s, p < .05). The independent predictors of ΔPWV were age, baseline PWV, baseline SBP/MBP and ΔSBP/MBP. Conclusions: the accelerated arterial aging in treated hypertensive subjects is in large measure explained by age and BP values. PWV changes over time would probably give important information that need further future research studies.

Type A Personality as the principal psychological determinants of Left Ventricular Mass Index in hypertensive patients

Selected Abstracts From XXXIV National Congress of the Italian Society of Hypertension (SIIA), Milan, 5–7 October 2017 Springer International Publishing AG 2017 METABOLIC ASPECTS AND RISK FACTORS PSYCHOLOGICAL CORRELATES IN DIABETIC PATIENTS WITH AND WITHOUT METABOLIC SYNDROME. A PRELIMINARY STUDY M. Bonomo, J. Guidi, S. Gostoli, G. Marchetti, R. Roncuzzi, C. Rafanelli Department of Psychology, University of Bologna, Italy; Division of Cardiology, Bellaria Hospital, Bellaria, Italy Introduction: The combination between Diabetes and Metabolic Syndrome (MetS) has a major impact on health increasing the risk for Cardiovascular Diseases. Despite previous studies have shown some psychological features characterizing MetS, little is known about the subpopulation of diabetic patients with MetS. Aim: to evaluate if the presence of psychological distress, psychosomatic syndromes, Allostatic Overload (AO), and psychological well-being impairments characterize patients with MetS in a diabetic population. Methods: 126 diabetic patients were considered for the current study. Clinical and biomedical data were collected on the basis of their medical records. The Structured Clinical Interview for DSM-5, the Diagnostic Criteria for Psychosomatic Research (DCPR), Symptom Questionnaire (SQ), PsychoSocial Index and Psychological Well-Being scales (PWB) were used for the psychological assessment. Results: 60% of diabetic patients in our sample satisfied criteria forMetS. Binge Eating Disorder (p = 0.007), DCPR cluster of psychological factors affecting medical conditions (p = 0.023), higher levels of SQ Somatic Symptoms (p = 0.05) and presence of AO (p = 0.021) were more frequently reported by patients with both diabetes andMetS. Conclusions: The presence of specific psychological features characterizes diabetic patients with MetS compared to diabetics only. A deeper understanding of the relationship between psychological status and the onset of such health risk factor in high-risk population could have a positive impact on health promotion and illness prevention. ASSOCIATION BETWEEN URIC ACID AND CARDIAC, VASCULAR AND RENAL TARGET ORGAN DAMAGE IN HYPERTENSIVES SUBJECTS A. Maloberti, M. Varrenti, N. Triglione, L. Occhi, F. Panzeri, M. Alloni, L. Giupponi, P. Vallerio S. Signorini, R. Falbo, M. Casati, G. Grassi, G. Mancia, C. Giannattasio Medicine and Surgery Department, Milano-Bicocca University, Milan, Italy; Cardiology IV Unit, ‘‘A. De Gasperis’’ Department, Ospedale Niguarda Ca’ Granda, Milan, Italy; Biochemical Laboratory, San Gerardo Hospital, Monza, Italy Introduction: To date no definitive results exist about the relationship of Serum Uric Acid (SUA) and Target Organ Damage (TOD) in hypertensive patients (HT). Aim: to determine if such an association exist between SUA and subclinical cardiac, vascular and renal alterations in HT. Methods: we enrolled 632 consecutive outpatients, followed by the Hypertension Unit of S. Gerardo Hospital (Monza, Italy) affected by essential HT. We evaluated High Blood Press Cardiovasc Prev (2017) 24:475–549 DOI 10.1007/s40292-017-0225-0

[PP.32.04] PREDICTORS OF PWV PROGRESSION OVER A THREE YEARS FOLLOW UP: FOCUS ON PSYCHOLOGICAL CHARACTERISTICS

Objective: Abnormal large artery function plays an important role in the pathogenesis of cardiovascular (CV) diseases. Prior studies have suggested that the principal determinants of arterial stiffening are age, Blood Pressure (BP) and others CV risk factors such as dyslipidemia and diabetes. However the role of psychological characteristics on the long-term progression of arterial stiffness has not yet been evaluated. The aim of the current longitudinal study was to evaluate the psychological determinants of the Pulse Wave Velocity (PWV) progression over a 3 years follow-up period in treated hypertensives subjects. Design and method: We enrolled 350 consecutive 18–80 aged outpatients, followed by the Hypertension Unit of S. Gerardo Hospital (Monza, Italy) affected by essential hypertension. At baseline (T0) anamnestic data, clinical BP, laboratory data and PWV were evaluated; also psychological tests were performed. In a subgroup of 50 subjects, after a median follow-up time of 2.96 ± 0.33 years, we performed again psychological tests and PWV examination (T1). Psychological tests were administered by trained researchers for measuring perceived stress, resiliency factors (self-esteem, sense of coherence), and perceived social support. Results: At T0 the mean age was 55.9 ± 10.1years, SBP and DBP were 135.6 ± 17.7 and 82.5 ± 9.1mmHg and PWV was 8.6 ± 2.1m/s. Despite a significant improvement in the blood pressure control (from 72 to 84%; PAS from 135.6 ± 17.7 to 130.1 ± 14.2, p = 0.08; PAD from 82.5 ± 9.1 to 77.5 ± 9.4, p < 0.05), at follow-up examination PWV didn’t showed significant changes (from 8.6 ± 2.1 to 8.6 ± 2.4, p = 0.87) with a mean deltaPWV of −0.05 ± 2.8m/s. Focusing on PWV changes over the follow-up period and on psychological test, subjects where then divided accordingly to their deltaPWV in those in which an increase was showed and those in which the values decrease. For similar baseline values, subjects with positive deltaPWV showed higher T1 values of stress (37.4 ± 1.1vs36.8 ± 0.8, p = 0.02) and lower values of self-esteem (2.9 ± 0.5 vs 3.3 ± 0.4, p = 0.02), sense of coherence (4.4 ± 0.7vs4.9 ± 0.8, p = 0.02), and a worse family climate (3.5 ± 0.9vs4.1 ± 0.8, p = 0.02). No significant differences were showed regarding BP values and CV risk factors. Conclusions: The current longitudinal study shows that arterial stiffness didn’t shown any significant changes despite BP improvement. PWV increase is related to higher stress and lower self-esteem and familiar support.

Giant apparently not dissecting aneurysm and severe aortic valve insufficiency in an elite athlete

A 25-year-old female professional volleyball player with an aortic ectasia diagnosed 5 years earlier (aortic root 38 mm, Z score +3), underwent echocardiographic evaluation because of fatigue and lower sport performance. The ultrasound examination showed a severe dilatation of the aortic root and the ascending aorta ( Panel A , see Supplementary material …

Echocardiographic assessment and successful valvular repair of congenital mitral arcade

Anomalous mitral arcade is a rare congenital anomaly affecting the mitral tensor apparatus. This condition causes a restrictive movement of the leaflets and interferes with the normal closure of the valve during ventricular systole. We report a case of a 15-year-old female with this condition and initial left ventricular dysfunction, who successfully underwent mitral valve repair. This reparative technique is more technically challenging then valve replacement and only few cases are described in literature.