Silvio Romano

Serial measurements of NT-proBNP are predictive of not-high-dose anthracycline cardiotoxicity in breast cancer patients

Background:The aim of this study was to assess the value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in predicting late cardiotoxicity in patients treated with not-high-dose chemotherapy (NHDC), and to compare the predictive value of NT-proBNP and cardiac troponin I (cTnI).Methods:In 71 patients undergoing NHDC with anthracyclines, NT-proBNP and cTnI levels were measured before and 24 h after each NHDC cycle. Left ventricular (LV) function was assessed by echocardiography at baseline, every two NHDC cycles, at the end of chemotherapy, and at 3-, 6- and 12-month follow-up.Results:During NHDC, only NT-proBNP showed abnormal values. According to NT-proBNP behaviour, patients were divided into two groups: group A (n=50) with normal (n=23) or transiently elevated NT-proBNP levels (n=27), and group B (n=21) with persistently elevated NT-proBNP levels. At follow-up, LV impairment was significantly worse in group B than in group A. %Δ (baseline–peak) NT-proBNP was predictive of LV impairment at 3-, 6- and 12-month follow-up, with a cutoff of 36%.Conclusion:Serial measurements of NT-proBNP may be a useful tool for the early detection of patients treated with NHDC at high risk of developing cardiotoxicity.

Early diagnosis of left ventricular diastolic dysfunction in diabetic patients: a possible role for natriuretic peptides

BackgroundThe aim of the present study was to verify whether BNP might detect pre-clinical diastolic dysfunction (LVDD) in type-2 diabetic patients.MethodsOne-hundred and twenty-seven consecutive outpatients with type-2 diabetes mellitus were enrolled into the study. Subjects with overt heart failure or NYHA class > 1, history of coronary artery disease, severe valvulopathy or chronic atrial fibrillation were excluded from the study. All patients underwent clinical evaluation, laboratory assessment of brain natriuretic peptide (BNP) and echocardiographic examination.ResultsNo patients showed systolic impairment of left ventricular function, whereas diastolic dysfunction was detected in 53 (42%) cases (all impaired relaxation). Median BNP was 27 pg/ml without any significant difference between 76 patients with normal left ventricular function and 53 with diastolic dysfunction; in 54 (43%) patients showing HBA1C≥8 (uncontrolled diabetes) normal function was found in 32 and diastolic dysfunction in 22, with a significant difference of BNP at multivariate analysis (OR = 1.02, 95%CI = 1.05-1.09, p = 0.003). In uncontrolled diabetic cohort, BNP was a strong predictor for LVDD (OR = 2.7, 95%CI = 1.3-5.6, p = 0.006) along with the duration of diabetes (OR = 1.6, 95%CI = 1.1-2.9, p = 0.046). BNP > 25 pg/ml was a cut-off value with high accuracy to detect a LVDD.DiscussionEarly screening of high-risk patients for diabetic cardiomyopathy development might be useful to better control glycemic profile in order to reduce heart disease progression or even to reverse itConclusionsBNP could be a cheap, easy and useful tool to screen those ones with preclinical ventricular diastolic dysfunction in a subset of patients particularly prone to develop cardiovascular complications, like uncontrolled diabetic patients.

Radial artery occlusion and hand strength after percutaneous coronary procedures: Results of the HANGAR study

Objectives: The aim of this prospective study was to evaluate muscle force of the hand, thumb, and forefinger in patients with prolonged radial occlusion after transradial percutaneous coronary procedures. Background: There are no data on hand strength and function in patients with prolonged radial occlusion after percutaneous coronary procedures. Methods: Elective patients with chronic stable angina undergoing percutaneous coronary procedures were evaluated the day before the procedure for radial artery patency, Allen test, hand grip, and thumb and forefinger pinch tests. The same measures were performed the day after the procedure and at follow‐up. At follow‐up, patients were divided in two groups according to the radial patency (group 1) or occlusion (group 2). Results: Of the 99 patients included in the study, 90 patients had a patent radial artery (group 1), and nine (9.1%) patients had an occluded artery (group 2). At baseline, there were no significant differences in hand grip test between the two groups (42 ± 11 kg in group 1 and 41 ± 17 kg in group 2, P = 0.74). In both groups, after the procedure, the hand grip test values was significantly reduced compared with baseline values (40 ± 11 kg in group 1, P < 0.0001 and 37 ± 17 kg in group 2, P = 0.007). Finally, at follow‐up, in both groups, the hand grip test values returned to baseline values. Thumb and forefinger pinch tests did not show significant differences after the procedure and at follow‐up, compared with baseline. Conclusions: Radial artery occlusion after percutaneous coronary procedures was not associated with a reduction in hand and finger strength.

Role of biomarkers in monitoring antiblastic cardiotoxicity.

Early detection of anticancer drug-induced cardiotoxicity (CTX) has been evaluated by most international scientific cardiology and oncology societies. High expectations have been placed on the use of specific biomarkers. In recent years, conventional biomarkers and molecules of more recent interest have been tested and compared in the context of anticancer drug-related CTX. Encouraging results were obtained from studies on molecules of myocardial damage, such as troponin and markers of myocardial wall stress, including circulating natriuretic peptides, as well as from the assessment of the products of inflammation or circulating levels of free radicals. However, clear guidelines on their sensitivity, specificity, and accuracy are not yet available, and many challenges, such as the optimal time of assessing, optimal schedule for evaluation, optimal cut-off point for positivity with the highest level of specificity, and optimal comparability of different assays for the measurements, remain unresolved. Given the importance of having a reliable and accurate tool for monitoring anticancer drug-induced CTX, this review will focus on the available data on the most effective and widely used biomarkers and the studies that are currently underway that aim to identify the effectiveness of new approaches in this therapeutic setting.

Left ventricular surgical remodelling: is it a matter of shape or volume? †

OBJECTIVE Left ventricular surgical remodelling (LVSR) can be targeted to volume reduction (VR), (independently of the final shape) or to conical shape (CS). The aim of this study was to evaluate the long-term clinical and echocardiographic results of these two surgical strategies. METHODS From January 1988 to December 2012, 401 patients underwent LVSR: 107 in Group VR (1988-2001) and 294 in Group CS (1998-2012). The latter group of patients had lower ejection fraction (EF) and higher mitral and tricuspid regurgitation grade, with higher incidence of pulmonary hypertension. A propensity score model was built to adjust long-term results for preoperative and operative profiles. RESULTS Thirty-day mortality was 6.0%. Median follow-up interval time was 100 (3-300) months. Overall 20-year and event-free survival were 36.1 ± 7.8 and 19.4 ± 7.2, respectively. No differences were found regarding 10-year survival (Group VR: 55.1 ± 4.8 vs Group CS: 64.2 ± 4.2, P = 0.16) and event-free survival (Group VR: 41.1 ± 4.8 vs Group CS: 50.5 ± 4.8, P = 0.12). However, Group CS provided better 10-year freedom from cardiac deaths (74.5 ± 3.7 vs 60.4 ± 4.8, P = 0.03) and from cardiac events (55.6 ± 5.0 vs 45.0 ± 4.9, P = 0.04). After propensity score adjustment, all the main outcomes were significantly better in Group CS. Multivariate Cox analysis confirmed this result; furthermore, to avoid any bias related to improved experience, 30-day mortality being higher in Group VR, we excluded the first month from Cox analysis: left ventricle VR (independently of the final shape) was still confirmed as the wrong approach. At the follow-up, Group CS showed significant improvement in EF (+18 vs +8%), end-systolic volume index (-35 vs -20%) and sphericity index (-6 vs +9%). CONCLUSIONS LVSR should aim to provide a more physiological shape (conical) rather than simple VR.

Operator radiation exposure during right or left transradial coronary angiography: A phantom study

BACKGROUND Previous studies showed a possible lower radiation dose absorbed by operators comparing LRA and RRA for percutaneous coronary procedures. The reasons of this lower radiation dose are not well known. The aim of this study was to evaluate the radiation dose absorbed by operators comparing left with right radial access (LRA and RRA respectively) during a simulated diagnostic coronary angiography using a phantom. METHODS A coronary angiography examination was simulated on a phantom by 5 operators using eight projections with 5 seconds fluoroscopy each. Each operator was equipped with 4 electronic dosimeters placed at thorax, at left wrist, at left head and at hip level. Radiation doses were expressed in picosievert and normalized by dose area product. RESULTS LRA compared to RRA was associated with a significant lower operator dose at wrist (36pSv/cGYcm(2) [IQR 18-59pSv/cGYcm(2)] and 48pSv/cGYcm(2) [IQR 22-148pSv/cGYcm(2)] respectively, p=0.01) and thorax (3pSv/cGYcm(2) [IQR 2-5pSv/cGYcm(2)] and 10pSv/cGYcm(2) [6-23pSv/cGYcm(2)] respectively, p<0.001) but with a significant higher radiation dose at hip level (102pSv/cGYcm(2) [IQR 44-199pSv/cGYcm(2)] and 67pSv/cGYcm(2) [IQR 39-132pSv/cGYcm(2)] respectively, p=0.02). Conversely the radiation dose at left side of the head did not show significant differences between the two approaches. CONCLUSIONS In this phantom study simulating a diagnostic coronarography the use of LRA compared to RRA was associated with a significant lower radiation dose at wrist and thorax but with an increased dose at hip level. SUMMARY To evaluate the radiation dose absorbed by operators comparing left with right radial access (LRA and RRA respectively) we simulated a diagnostic coronary angiography using a dedicated phantom. Operators were equipped with dedicated electronic dosimeters at wrist, hip, head and thorax level. LRA compared to RRA was associated with a significant lower operator dose at wrist and thorax but with a significant higher radiation dose at hip level whereas the radiation dose at left side of the head did not show significant differences between the two approaches.

Freestyle Aortic Root Bioprosthesis Is a Suitable Alternative for Aortic Root Replacement in Elderly Patients: A Propensity Score Study

BACKGROUND The aim of this retrospective study was to compare the early and midterm clinical outcomes of aortic root replacement in elderly patients receiving the Freestyle stentless bioprosthesis (FSB) (Medtronic Inc, Minneapolis, MN) with younger patients receiving a mechanical valve conduit. METHODS From January 2001 to December 2010, 185 consecutive patients underwent aortic root replacement. Of these, 79 (43%) patients received the Freestyle bioroot (Medtronic Inc, Minneapolis, MN) (group F) and 106 (57%) patients received a mechanical valve conduit (group M). Target endpoints were 30-day mortality, 5-year survival, 5-year freedom from cardiac death, and 5-year freedom from major adverse valve-related and cardiovascular events (MAVCE) (cardiac death, cerebrovascular accident, myocardial infarction, heart failure, valve prosthesis dysfunction requiring reoperation, and thromboembolic and hemorrhagic events). A propensity score model was built to adjust the results according to preoperative and operative characteristics of both groups. RESULTS Thirty-day mortality was similar in both groups (F group, 2.5% versus M group, 5.7%; p=0.407). Unadjusted analysis showed no differences between groups, whereas adjusted analysis showed a significantly higher 5-year freedom from cardiac death and MAVCE in group F (group F, 98.6±1.9 versus group M, 88.0%±3.0%; p=0.038; group F, 97.4%±2.6% versus group M, 81.2%±3.6%; p=0.010). Multivariate analysis confirmed a significantly higher risk for 5-year MAVCE in patients who did not undergo implantation with the Freestyle bioprosthesis (hazard ratio [HR], 6.87; 95% confidence limit [CL], 1.43-15.09; p=0.016). CONCLUSIONS In elderly patients, the FSB seems to be as safe as mechanical composite grafts in the perioperative period but results in superior freedom from MAVCE at 5 years postoperatively.

Determinants of operator radiation exposure during percutaneous coronary procedures

Background Radiation exposure is an important issue for interventional cardiologists that is often underevaluated. Our aim was to evaluate determinants of operator radiation exposure during percutaneous coronary procedures. Methods The RADIANT (NCT01974453) is a prospective, single‐center observational study involving 4 expert operators and 2 fellows performing percutaneous coronary procedures. The operator radiation dose was evaluated using dedicated electronic dosimeters in 2,028 procedures: 1,897 transradial access (TRA; 1,120 right and 777 left TRA) and 131 transfemoral access (TFA). Results In the whole population, operator radiation dose at the thorax did not differ between TFA (9 &mgr;Sv [interquartile range 5‐18 &mgr;Sv]) and TRA (9 &mgr;Sv [4‐21 &mgr;Sv]), but after propensity score matching analysis, TFA showed lower dose (9 &mgr;Sv [5‐18 &mgr;Sv]) compared with TRA (17 &mgr;Sv [9‐28 &mgr;Sv], P < .001). In the whole transradial group, left TRA (5 &mgr;Sv [2‐12 &mgr;Sv]) was associated with significant lower operator dose compared with right TRA (13 &mgr;Sv [6‐26 &mgr;Sv], P < .001).The use of adjunctive protective pelvic drapes was significantly associated with lower radiation doses compared with procedures performed without drapes (P < .001). Among the operators, an inverse relation between height and dose was observed. Finally, left projections and the use of angiographic systems not dedicated for coronary and high frame rates were all associated with a significant higher operator radiation exposure. Conclusions In a high‐volume center for transradial procedures, TFA is associated with lower operator radiation dose compared with TRA. The use of adjunctive anti‐rx drapes seems a valuable tool to reduce the higher operator radiation exposure associated with TRA. Graphical Abstract Figure. No caption available.

Chlamydia pneumoniae Clinical Isolate from Gingival Crevicular Fluid: A Potential Atherogenic Strain.

Chlamydia pneumoniae has been associated to atherosclerotic cardiovascular diseases. The aim of our study was to characterize, for the first time, a C. pneumoniae strain isolated from the gingival crevicular fluid of a patient with chronic periodontitis, described as a risk factor for cardiovascular diseases. C. pneumoniae isolate was characterized and compared to the respiratory AR-39 strain by VD4-ompA genotyping and by investigating the intracellular growth in epithelial and macrophage cell lines and its ability to induce macrophage-derived foam cells. Inflammatory cytokine levels were determined in the gingival crevicular fluid sample. C. pneumoniae isolate showed a 99% similarity with the AR-39 strain in the VD4-ompA gene sequence and shared a comparable growth kinetic in epithelial cells and macrophages, as evidenced by the infectious progeny and by the number of chlamydial genomic copies. C. pneumoniae isolate significantly increased the number of foam cells as compared to uninfected and LDL-treated macrophages (45 vs. 6%, P = 0.0065) and to the AR-39 strain (45 vs. 30%, P = 0.0065). Significantly increased levels of interleukin 1-β (2.1 ± 0.3 pg/μL) and interleukin 6 (0.6 ± 0.08 pg/μL) were found. Our results suggest that C. pneumoniae may harbor inside oral cavity and potentially be atherogenic, even though further studies will be needed to clarify the involvement of C. pneumoniae in chronic periodontitis as a risk factor for cardiovascular diseases.

Fenofibrate and Dyslipidemia: Still a Place in Therapy?

Dyslipidemia is one of the major cardiovascular risk factors, but beyond statin treatment—which represents the cornerstone of therapy—a relevant practical uncertainty regards the use of fibrate derivatives. In the lack of successful results from the main cardiovascular trials, guidelines recommend the use of peroxisome proliferator-activated receptor agonists in selected cases, i.e. patients with true atherogenic dyslipidemia. However, recent observations indicate that fenofibrate treatment may provide a reliable complementary support against residual cardiovascular risk. We therefore summarize current evidence on fenofibrate, seeking to provide an updated interpretation of recent studies in the field.