Showing papers by "Andrea Mortara published in 2022"

Combined Role of Troponin and Natriuretic Peptides Measurements in Patients With Covid-19 (from the Cardio-COVID-Italy Multicenter Study)

Abstract: Data concerning the combined prognostic role of natriuretic peptide (NP) and troponin in patients with COVID-19 are lacking. The aim of the study is to evaluate the combined prognostic value of NPs and troponin in hospitalized COVID-19 patients. From March 1, 2020 to April 9, 2020, consecutive patients with COVID-19 and available data on cardiac biomarkers at admission were recruited. Patients admitted for acute coronary syndrome were excluded. Troponin levels were defined as elevated when greater than the 99th percentile of normal values. NPs were considered elevated if above the limit for ruling in acute heart failure (HF). A total of 341 patients were included in this study, mean age 68 ± 13 years, 72% were men. During a median follow-up period of 14 days, 81 patients (24%) died. In the Cox regression analysis, patients with elevated both NPs and troponin levels had higher risk of death compared with those with normal levels of both (hazard ratio 2.94; 95% confidence interval 1.31 to 6.64; p = 0.009), and this remained significant after adjustment for age, gender, oxygen saturation, HF history, and chronic kidney disease. Interestingly, NPs provided risk stratification also in patients with normal troponin values (hazard ratio 2.86; 95% confidence interval 1.21 to 6.72; p = 0.016 with high NPs levels). These data show the combined prognostic role of troponin and NPs in COVID-19 patients. NPs value may be helpful in identifying patients with a worse prognosis among those with normal troponin values. Further, NPs' cut-point used for diagnosis of acute HF has a predictive role in patients with COVID-19.

Right and left ventricular structures and functions in acute HFpEF: comparing the hypertensive pulmonary edema and worsening heart failure phenotypes

Abstract: Background Limited data are available on right (RV) and left (LV) ventricular structures and functions in acute heart failure with preserved ejection fraction (AHF-pEF) presenting with hypertensive pulmonary edema (APE) versus predominant peripheral edema (peHF). Methods and Results In a prospective study of consecutive patients with AHF-pEF, 80 patients met inclusion and not exclusion criteria, and underwent echocardiographic and laboratory examination in the emergency ward. The survived (94%) were re-evaluated at the discharge. At admission, systolic, diastolic, pulse blood pressure (BP), and high sensitivity troponin I were higher (all P < 0.05) with APE than with peHF while brain-type natriuretic peptide (BNP), hemoglobin and estimated glomerular filtration rate (eGFR) did not differ between the two phenotypes. LV volumes and EF were comparable between APE and peHF, but APE showed lower relative wall thickness (RWT), smaller left atrial (LA) volume, higher pulse pressure/stroke volume (PP/SV), and higher ratio between the peak velocities of the early diastolic waves sampled by traditional and tissue Doppler modality (mitral E/e′, all P < 0.05). Right ventricular and atrial (RA) areas were smaller, tricuspid anular plane systolic excursion (TAPSE) and estimated pulmonary artery peak systolic pressure (sPAP) were higher with APE than with peHF (all P < 0.05) while averaged degree of severity of tricuspid insufficiency was greater with peHF than with APE. At discharge, PP/SV, mitral E/e′, sPAP, RV sizes were reduced from admission in both phenotypes (all P < 0.05) and did not differ anymore between phenotypes, whereas LV EF and TAPSE did not show significant changes over time and treatments. Conclusion In AHF-pEF, at comparable BNP and LV EF, hypertensive APE showed eccentric LV geometry but smaller RV and RA sizes, and higher RV systolic function, increased LV ventricular filling and systemic arterial loads. AHF resolution abolished the differences in PP/SV and LV diastolic load between APE and peHF whereas APE remained associated with more eccentric RV and higher TAPSE.

BLITZ‐HF: a nationwide initiative to evaluate and improve adherence to acute and chronic heart failure guidelines

Abstract: To assess adherence to guideline recommendations among a large network of Italian cardiology sites in the management of acute and chronic heart failure (HF) and to evaluate if an ad‐hoc educational intervention can improve their performance on several pharmacological and non‐pharmacological indicators.

NT-ProBNP and mortality across the spectrum of glucose tolerance in the general US population

Abstract: Even though hyperglycemia is a well-known cardiovascular risk factor, the absolute risk of cardiovascular events varies to a great extent within each glycemic category. The aim of this study is to evaluate whether N-terminal pro-B natriuretic peptide (NT-ProBNP) could help identify subjects at higher cardiovascular risk, independently of blood glucose levels.Serum NT-ProBNP levels were measured in 5502 people aged 45-79 years without heart failure from the general population (3380 with normoglycemia, 1125 with pre-diabetes and 997 with diabetes) that participated in the 1999-2004 cycles of the National Health and Nutrition Examination Survey. We applied Cox and Fine Gray models adjusted for cardiovascular risk factors to evaluate the association between NT-ProBNP levels and all-cause and cardiovascular mortality through December 2015.After a median follow-up of 13 years, 1509 participants died, 330 of cardiovascular causes. In the multivariable-adjusted models, compared with participants with NT-ProBNP < 100 pg/ml, those with levels 100-300 pg/ml and ≥ 300 pg/ml had a higher incidence of both all-cause mortality (HR 1.61, 95% CI 1.12-2.32, p = 0.012 and HR 2.96, 95% CI 1.75-5.00, p < 0.001, respectively) and cardiovascular mortality (HR 1.57, 95% CI 1.17-2.10, p = 0.011 and HR 2.08, 95% CI 1.47-2.93, p < 0.001, respectively). The association was consistent in subgroup analyses based on glycemic status, obesity, age and sex.Elevated NT-ProBNP is independently associated with all-cause and cardiovascular mortality in the general population and could help identify patients at the highest risk. Further studies are needed to evaluate whether intensification of treatment based on biomarker data might lead to improvements in cardiovascular risk reduction.

Machine learning for prediction of in-hospital mortality in coronavirus disease 2019 patients: results from an Italian multicenter study

Abstract: Background Several risk factors have been identified to predict worse outcomes in patients affected by SARS-CoV-2 infection. Machine learning algorithms represent a novel approach to identifying a prediction model with a good discriminatory capacity to be easily used in clinical practice. The aim of this study was to obtain a risk score for in-hospital mortality in patients with coronavirus disease infection (COVID-19) based on a limited number of features collected at hospital admission. Methods and results We studied an Italian cohort of consecutive adult Caucasian patients with laboratory-confirmed COVID-19 who were hospitalized in 13 cardiology units during Spring 2020. The Lasso procedure was used to select the most relevant covariates. The dataset was randomly divided into a training set containing 80% of the data, used for estimating the model, and a test set with the remaining 20%. A Random Forest modeled in-hospital mortality with the selected set of covariates: its accuracy was measured by means of the ROC curve, obtaining AUC, sensitivity, specificity and related 95% confidence interval (CI). This model was then compared with the one obtained by the Gradient Boosting Machine (GBM) and with logistic regression. Finally, to understand if each model has the same performance in the training and test set, the two AUCs were compared using the DeLong's test. Among 701 patients enrolled (mean age 67.2 ± 13.2 years, 69.5% male individuals), 165 (23.5%) died during a median hospitalization of 15 (IQR, 9–24) days. Variables selected by the Lasso procedure were: age, oxygen saturation, PaO2/FiO2, creatinine clearance and elevated troponin. Compared with those who survived, deceased patients were older, had a lower blood oxygenation, lower creatinine clearance levels and higher prevalence of elevated troponin (all P < 0.001). The best performance out of the samples was provided by Random Forest with an AUC of 0.78 (95% CI: 0.68–0.88) and a sensitivity of 0.88 (95% CI: 0.58–1.00). Moreover, Random Forest was the unique model that provided similar performance in sample and out of sample (DeLong test P = 0.78). Conclusion In a large COVID-19 population, we showed that a customizable machine learning-based score derived from clinical variables is feasible and effective for the prediction of in-hospital mortality.

Sex-related differences in patients with coronavirus disease 2019: results of the Cardio-COVID-Italy multicentre study

Abstract: Introduction The role of sex compared to comorbidities and other prognostic variables in patients with coronavirus disease (COVID-19) is unclear. Methods This is a retrospective observational study on patients with COVID-19 infection, referred to 13 cardiology units. The primary objective was to assess the difference in risk of death between the sexes. The secondary objective was to explore sex-based heterogeneity in the association between demographic, clinical and laboratory variables, and patients’ risk of death. Results Seven hundred and one patients were included: 214 (30.5%) women and 487 (69.5%) men. During a median follow-up of 15 days, deaths occurred in 39 (18.2%) women and 126 (25.9%) men. In a multivariable Cox regression model, men had a nonsignificantly higher risk of death vs. women (P = 0.07). The risk of death was more than double in men with a low lymphocytes count as compared with men with a high lymphocytes count [overall survival hazard ratio (OS-HR) 2.56, 95% confidence interval (CI) 1.72–3.81]. In contrast, lymphocytes count was not related to death in women (P = 0.03). Platelets count was associated with better outcome in men (OS-HR for increase of 50 × 103 units: 0.88 95% CI 0.78–1.00) but not in women. The strength of association between higher PaO2/FiO2 ratio and lower risk of death was larger in women (OS-HR for increase of 50 mmHg/%: 0.72, 95% CI 0.59–0.89) vs. men (OS-HR: 0.88, 95% CI 0.80–0.98; P = 0.05). Conclusions Patients’ sex is a relevant variable that should be taken into account when evaluating risk of death from COVID-19. There is a sex-based heterogeneity in the association between baseline variables and patients’ risk of death.

[ANMCO Position paper: Care pathway for advanced heart failure patients candidate for heart transplantation/ventricular assist device].

Abstract: Heart failure is a complex clinical syndrome with a severe prognosis, despite therapeutic progress. The management of the advanced stages of the syndrome is particularly complex in patients who are referred to palliative care as well as in those who are candidates for cardiac replacement therapy. For the latter group, a prompt recognition of the transition to the advanced stage as well as an early referral to the centers for cardiac replacement therapy are essential elements to ensure that patients follow the most appropriate diagnostic-therapeutic pathway. The aim of this document is to focus on the main diagnostic and therapeutic aspects related to the advanced stages of heart failure and, in particular, on the management of patients who are candidates for cardiac replacement therapy.

307 a cardiac mass in a patient with gorlin-goltz syndrome: incidental diagnosis or something to look for?

Abstract: Gorlin-Goltz syndrome or nevoid basal cell carcinoma syndrome (NBCCS) is a rare autosomal dominant, multisystem, tumor-predisposing disorder. The primary manifestation of NBCCS is the development of multiple basal cell carcinomas (BCCs) but is also associated with a variety of other benign and malignant tumors. Cardiac fibromas are increased in frequency in patients with NBCCS, developing in approximately 3 percent of affected individuals. They typically present in infancy. They are benign growths, and almost all develop within the ventricular myocardium. Although usually asymptomatic, they can result in impaired left ventricular function and conduction defects, necessitating resection. we presented a case of a 59-years-old woman with a diagnosis of Gorlin-Goltz syndrome and no history of cardiovascular diseases who underwent a right knee arthroplasty in our hospital. After the surgery the patient was admitted to rehabilitation department. Electrocardiogram that showed sinusal rhythm with inverted T waves in lateral leads and a transthoracic echocardiography examination were performed. Echocardiography showed a large mass within the basal and middle segments of left ventricle lateral wall. Left ventricular ejection fraction was preserved. Cardiac magnetic resonance (CMR) revealed an intramyocardial mass with well-defined borders and several calcifications, hypointense on T1-weighted and T2-weighted images and delayed-contrast hyper-enhancement with hypoenhancing central cores. Based on these imaging features, the mass was suggestive of cardiac fibroma with calcifications. The patients was asymptomatic. Afterwards, a total body CT was performed to exclude other tumours in other sites. This case was discussed with cardiac surgeons and since the patient was asymptomatic with no conduction abnormalities or heart failure signs, urgent surgical intervention was excluded. The patient was discharged with a 3 months follow-up. our case highlights the importance of echocardiography evaluation before surgery in patients with genetic syndrome like Gorlin-Goltz syndrome. Last guidelines published in 2021 recommend that all patients with NBCCS should be screened with a cardiac ultrasound and if cardiac symptoms occur in a patient with NBCCS, a cardiac ultrasound should be repeated to exclude a late-onset cardiac tumour. Furthermore, CMR plays an important role in characterizing cardiac masses and determining the management.

681 right arm pain with right bundle branch block: should we perform troponin assay?

Abstract: We present the case report of a 67 year old man with no previous cardiovascular history, who was admitted to our emergency department (ED) for two days onset of right arm pain which was not responsive to painkillers. On admission, he was asymptomatic for typical angina. His BP was 190/100 mmHg, HR 80 bpm, SpO2 99% and apyretic. The clinical examination was unremarkable. The ECG showed sinus rhythm, complete right-bundle-branch-block (RBBB) and left-axis deviation, negative T-waves in V1-V2 and positive T-waves in V3 > V6 (figure 1A) (no previous ECGs were available). The blood samples showed normal renal function and blood count. Surprisingly, there was a progressive rise in troponin I levels 0.023 > 0.061 > 0.38 ng/ml (ULN 0.010 ng/ml). Echocardiography revealed preserved LVEF without major regional wall motion abnormalities (RWMA), nor any valvulopathy. Despite the atypical presentation and ECG, the troponin rise was strongly suggestive for an acute coronary syndrome (ACS), so the patient was sent to the Cath lab to undergo coronary angiography (CAG). At the time of the CAG he was asymptomatic. The exam revealed thrombotic occlusion of mid-segment left anterior descending artery (LAD). Primary PCI with DES implantation was performed obtaining TIMI 3 flow (figure2). The remaining hospital stay was uneventful, the patient was discharged asymptomatic after 4 days. Pre-discharge echocardiography reported normal LVEF with no RWMA. Discharge ECG showed persistency of the RBBB with negative T-waves from V1 to V4 (figure 1B). On 3 months follow up visit the patient is asymptomatic with preserved LVEF. On ECG there is persistency of RBBB and normalization of the T-waves in the precordial leads (figure 1C). This case report is an atypical presentation of acute thrombotic occlusion of an epicardial coronary artery, without the typical ST segment elevation (STEMI equivalent) and without the typical angina. RBBB may represent an uncommon ECG presentation of acute myocardial ischemia, with an incidence from 2 to 6% overall, with TIMI 0 flow in the infarct-related artery only in half of the cases. RBBB (especially new or presumably new onset RBBB) is also associated with increased mortality and morbidity, possibly due to delay in diagnosis and primary reperfusion strategies. Troponin dosage was fundamental to understand that we were facing an acute coronary syndrome, however we were not expecting complete occlusion of the LAD. In conclusion, the presence of RBBB on admission may delay primary reperfusion strategies, especially when symptoms are atypical. However, in case of unresponsive pain and presumably new-onset conduction disturbances on ECG it is mandatory to perform troponin assay and therefore drive the correct timing of coronary revascularization.

366 right heart failure in carcinoid heart disease: a multidisciplinary approach

Abstract: Carcinoid heart disease occurs in more than 50% of patients with neuroendocrine gastrointestinal tumors, and it is the initial presentation of carcinoid syndrome in up to 20% of patients. The disease is characterized by pathognomonic plaque-like deposits of fibrous tissue in the endocardium of valvular cusps, cardiac chambers, and occasionally, the intima of the pulmonary arteries or aorta. The tricuspid and the pulmonary valve are most often affected by carcinoid disease, with several combinations of valve dysfunction (usually pulmonic stenosis + tricuspid regurgitation). Valvular dysfunction can lead to peripheral edema, ascites and right-sided heart failure, extreme cases may present with low cardiac output syndrome. Valve surgery may relieve symptoms and it should be considered in patients with controlled neoplasia. a 47-years-old man with a history of operated neuroendocrine gastrointestinal tumor (ileal resection+right hemicolectomy+mesenteric lymphadenectomy) was admitted to our department for right heart failure. His clinical examination was remarkable for ankle swelling, flushing, liver congestion, ascites; moreover the patient reported progressive compromise of functional capacity and weight loss due to anorexia. Laboratory findings were in the normal range except for BNP 184 pg/ml (UNL <100 pg/dl). ECG: sinus rhythm 80 bpm, diffuse repolarization abnomarlities. Transthoracic echocardiography showed: severe right chambers remodeling with RV+RA dilatation associated with systo-diastolic septal bulge (pressure + volume overload), torrential tricuspid regurgitation (secondary to fibrotic retraction of valve leaflets and severe coaptation deficiency with apical tethering), moderate-to-severe pulmonic regurgitation associated with valve stenosis; on the left side: mitral and aortic valves were normal, there was mild reduction of left ventricle ejection fraction secondary to ventricular interdipendence. The patient was discussed in Heart Team: right sided valves were both considered responsible for patient's symptoms, so he was scheduled for surgical intervention after achieving adeguate haemodinamic stability. Pre-surgery right catetherization showed normal pulmonary pressures. Coronary arteries were normal. Before, during and after surgery he was treated with octreotide to reduce the risk of Carcinoid Crisis in the perioperative period. The patient underwent surgical replacement of tricuspid and pulmonary valves with biological prosthesis Mosaic n°33 and Avalus n°23 respectively. Histological examination of the valves showed extensive deposits of fibrous tissue in the valvular endocardium. Post-surgical hospital stay was uneventful, the patient was discharged 14 days after surgery on normal sinus rhythm and in good clinical conditions. In order to prevent thromboembolic events anticoagulant therapy with Warfarin was introduced. this is the report of a rare cardiac condition responsible for right heart failure symptoms. Heart Team discussion and multidisciplinary approach involving surgeons and oncologist are mandatory in order to establish the best treatment strategy and timing for interventions. However, since this is a rare condition, more evidence is needed to better understand long term clinical outcomes and treatment options (including future percutaneous perspectives).

P240 short–term effect of sglt2i on echocardiographic parameters in hfref patients treated with arni

Abstract: Treatment with Sacubitril / Valsartan (ARNI) in patients with heart failure and reduced ejection fraction (HFrEF) promotes significant improvement of left ventricular remodeling along with positive outcomes in terms of hospitalization for heart failure, quality of life and mortality. In a previous study we demonstrated that ARNI significantly modifies myocardial longitudinal strain (GLS), one of the most reliable markers of myocardial contractility. It is still debated whether this effect remains unchanged regardless of the presence of diabetes and if it can be further increased by SGLT2 inhibitors, which in turn have been shown to reduce hospitalizations for heart failure and cardiovascular mortality. of this ongoing study is to measure, in HFrEF patients with or without T2DM, treated with ARNI and SGLT2i, short–term changes (6 months follow up) of the main echocardiographic parameters, including GLS Methods We enrolled 40 outpatients (32 male, age 65 + 10 years, EF 29,7 + 6,5%) on optimized medical treatment with class I medications, including ARNI at the maximum tolerated dose (starting dose 75 + 15mg, maximum titrated dose 190 + 10mg). Population was then divided into three groups: group 1 (20 pts) without T2DM; group 2 (11 pts) with T2DMI; group 3 (9 pts) with T2DM on SGLT2i treatment (4 with empaglifozin 10 mg, 5 with dapaglifozin 10 mg). No hemodynamic or metabolic complications related with therapy were observed, and no patients needed discontinuation or down–titration of therapy All patient underwent echocardiographic study at baseline and after six–month follow–up. This ongoing study confirms that, in HFrEF patients, ARNI positively modifies left ventricular contraction and remodeling, and this effect is still verified regardless of the presence of T2DM. The association with SGLT2i, conversely, does not appear to provide further positive benefits on remodeling.

SGLT2 inhibitors in real-world patients with heart failure with preserved ejection fraction

Abstract: The diagnosis and management of heart failure with preserved ejection fraction (HFpEF) is challenging since ejection fraction is normal, clinical signs are often lacking and there are few therapeutic options. Two randomized clinical trials have tested SGLT2i for the treatment of HFpEF: DELIVER (pending results) and EMPEROR-PRESERVED; the findings of the latter trial show that empagliflozin, a sodium-glucose cotransporter inhibitor (SGLT2i) reduces the risk of cardiovascular death or hospitalization for HF in patients with HFpEF regardless the presence of diabetes. The results of this clinical trial have allowed European Medicine Agency (EMA) to extend the indication also to the patients with HFpEF, however the characteristics of the trial population don't often correspond to real-word HF population. This study aims to investigate the eligibility of the EMPEROR-PRESERVED and DELIVER trial to a real-world heart failure population comparing the baseline characteristics of our patients to the recruited patients of clinical trials. In this retrospective, observational study, 206 HF outpatients were enrolled from September 2018 to September 2019. The percentages of eligible patients according to EMPEROR PRESERVED and DELIVER inclusion criteria were analyzed, then we analyzed the difference between the characteristics of our HFpEF population and trials population. 72 patients (35% of HF population) had heart failure with preserved ejection fraction. The EMPEROR-PRESERVED criteria and DELIVER trial were applied to these patients: 13 (18.1%) and 12 (16.7%) patients respectively fulfilled all enrolment criteria, whereas considering only EMA label criteria (EF >40% and eGFR >20 ml/min) 71 patients (98.6%) were eligible. The eligible patients according EMA criteria were significantly younger (67.3±14.3) than EMPEROR-PRESERVED population (72±9, p<0.001) and DELIVER population (72±10, p<0.001). The ejection fraction was significantly lower (50.2±5.8 vs 54±8.8; p<0.001) whereas eGFR was no significantly different (64.4±22.7 vs 60.6±19.8; p=0.17). Only a small percentage of our heart failure with preserved ejection fraction population was eligible for SGLT2 inhibitors according trials criteria, whereas according to EMA label almost all patients are candidate to these drugs. Furthermore, these patients were younger than EMPEROR-PRESERVED and DELIVER population with lower EF. The difference of eligibility between trials and real population is related to inclusion criteria, in particular the trial patients had elevated NT-proBNP levels whereas in the real world this criterion isn't considered. There is a lack of data about real-world patients who are often different from trials population. National and international registries of HF population may resolve this issue. Type of funding sources: None.