Machine learning to identify a composite indicator to predict cardiac death in ischemic heart disease

BACKGROUND

Machine learning (ML) employs algorithms that learn from data, building models with the potential to predict events by aggregating a large number of variables and assessing their complex interactions. The aim of this study is to assess ML potential in identifying patients with ischemic heart disease (IHD) at high risk of cardiac death (CD).

METHODS

3987 (mean age 68 ± 11) hospitalized IHD patients were enrolled. We implemented and compared various ML models and their combination into ensembles. Model output constitutes a new ML indicator to be employed for stratification. Primary variable importance was assessed with ablation tests.

RESULTS

An ensemble classifier combining three ML models achieved the best performance to predict CD (AUROC of 0.830, F1-macro of 0.726). ML indicator use through Cox survival analysis outperformed the 18 variables individually, producing a better stratification compared to standard multivariate analysis (improvement of ∼20%). Patients in the low risk group defined through ML indicator had a significantly higher survival (88.8% versus 29.1%). The main variables identified were Dyslipidemia, LVEF, Previous CABG, Diabetes, Previous Myocardial Infarction, Smoke, Documented resting or exertional ischemia, with an AUROC of 0.791 and an F1-score of 0.674, lower than that of 18 variables. Both code and clinical data are freely available with this article.

CONCLUSION

ML may allow a faster, low-cost and reliable evaluation of IHD patient prognosis by inclusion of more predictors and identification of those more significant, improving outcome prediction towards the development of precision medicine in this clinical field.

Psychological Impact of a Prenatal Diagnosis of Congenital Heart Disease on Parents: Is It Time for Tailored Psychological Support?

The prenatal diagnosis of congenital heart disease (CHD) represents, for both parents, a particularly stressful and traumatic life event from a psychological point of view. The present review sought to summarize the findings of the most relevant literature on the psychological impact of prenatal diagnosis of CHD on parents, describing the most common mechanisms employed in order to face this unexpected finding. We also highlight the importance of counseling and the current gaps in the effects of psychological support on this population.

A Close Association between Body Weight, Health-Related Quality of Life, and Risk Behaviors in a Sample of Italian High School Students

INTRODUCTION

Adolescents experience rapid physical, cognitive, and psychosocial growth with different factors contributing to health and well-being. In this view, an important role is played by body weight and related perceptions. The purpose was to determine, in a sample of Italian high school students, whether health-related quality of life (HRQoL) is associated with the different weight status categories (underweight, normal weight, overweight, obese), even considering sex differences.

MATERIAL AND METHODS

Data were collected from 1826 adolescents (n = 735 males). HRQOL was analyzed using the Italian version of KIDSCREEN-52.

RESULTS

Overweight adolescents showed reductions in psychological well-being (p < 0.05) and self-perception (p < 0.05) compared with individuals in other BMI categories. Subjects with obesity reported increased bullying victimization (p < 0.05) and reductions in self-perception and eating disorders (p < 0.001), while underweight individuals were characterized by altered adherence to the Mediterranean diet (p < 0.001), eating disorders (p < 0.001), and problematic use of social media (p < 0.05). No sex differences were found, except for socio-economic status perceptions, where underweight girls reported higher economic well-being than boys (p < 0.05).

CONCLUSIONS

Our findings may suggest that there is an association between weight status categories and HRQoL that is more pronounced in underweight and overweight adolescents. The association between BMI categories and psychosocial dimensions opens the need to define specific domains on which such preventive interventions should focus, always through a personalized perspective.

An Entangled Relationship between Bullying Perception and Psychosocial Dimensions in a Sample of Young Adolescents

BACKGROUND

Bullying is a hostile behavior repeated over a time period, affecting children and adolescents in different social settings, mainly small and stable ones like school, with negative effects on mental and physical health. In this study, we aimed to provide the degree of impairment of different variables related to health and well-being in bullying conditions, with attention to sex differences.

METHODS

Data were obtained from 5390 adolescents (mean age 13.08 ± 1.89; male 2729), and health-related quality of life (HRQoL) was assessed using the KIDSCREEN-52 questionnaire.

RESULTS

In all students, mood and emotion, self-perception, and parental relationships are the dimensions more compromised in bullying conditions, while lifestyle habit is the variable less involved. Bullied girls show a significant impairment of all HRQoL variables both with respect to the socially accepted counterpart and to the male population.

CONCLUSIONS

Our study highlights the strict association between bullying and emotional and social dimensions, suggesting that enhancing them preventively could facilitate earlier detection of problems, thereby reducing health risks.

The optimal healthy ranges of thyroid function defined by the risk of cardiovascular disease and mortality: systematic review and individual participant data meta-analysis

BACKGROUND

Reference intervals of thyroid-stimulating hormone (TSH) and free thyroxine (FT4) are statistically defined by the 2·5-97·5th percentiles, without accounting for potential risk of clinical outcomes. We aimed to define the optimal healthy ranges of TSH and FT4 based on the risk of cardiovascular disease and mortality.

METHODS

This systematic review and individual participant data (IPD) meta-analysis identified eligible prospective cohorts through the Thyroid Studies Collaboration, supplemented with a systematic search via Embase, MEDLINE (Ovid), Web of science, the Cochrane Central Register of Controlled Trials, and Google Scholar from Jan 1, 2011, to Feb 12, 2017 with an updated search to Oct 13, 2022 (cohorts found in the second search were not included in the IPD). We included cohorts that collected TSH or FT4, and cardiovascular outcomes or mortality for adults (aged ≥18 years). We excluded cohorts that included solely pregnant women, individuals with overt thyroid diseases, and individuals with cardiovascular disease. We contacted the study investigators of eligible cohorts to provide IPD on demographics, TSH, FT4, thyroid peroxidase antibodies, history of cardiovascular disease and risk factors, medication use, cardiovascular disease events, cardiovascular disease mortality, and all-cause mortality. The primary outcome was a composite outcome including cardiovascular disease events (coronary heart disease, stroke, and heart failure) and all-cause mortality. Secondary outcomes were the separate assessment of cardiovascular disease events, all-cause mortality, and cardiovascular disease mortality. We performed one-step (cohort-stratified Cox models) and two-step (random-effects models) meta-analyses adjusting for age, sex, smoking, systolic blood pressure, diabetes, and total cholesterol. The study was registered with PROSPERO, CRD42017057576.

FINDINGS

We identified 3935 studies, of which 53 cohorts fulfilled the inclusion criteria and 26 cohorts agreed to participate. We included IPD on 134 346 participants with a median age of 59 years (range 18-106) at baseline. There was a J-shaped association of FT4 with the composite outcome and secondary outcomes, with the 20th (median 13·5 pmol/L [IQR 11·2-13·9]) to 40th percentiles (median 14·8 pmol/L [12·3-15·0]) conveying the lowest risk. Compared with the 20-40th percentiles, the age-adjusted and sex-adjusted hazard ratio (HR) for FT4 in the 80-100th percentiles was 1·20 (95% CI 1·11-1·31) for the composite outcome, 1·34 (1·20-1·49) for all-cause mortality, 1·57 (1·31-1·89) for cardiovascular disease mortality, and 1·22 (1·11-1·33) for cardiovascular disease events. In individuals aged 70 years and older, the 10-year absolute risk of composite outcome increased over 5% for women with FT4 greater than the 85th percentile (median 17·6 pmol/L [IQR 15·0-18·3]), and men with FT4 greater than the 75th percentile (16·7 pmol/L [14·0-17·4]). Non-linear associations were identified for TSH, with the 60th (median 1·90 mIU/L [IQR 1·68-2·25]) to 80th percentiles (2·90 mIU/L [2·41-3·32]) associated with the lowest risk of cardiovascular disease and mortality. Compared with the 60-80th percentiles, the age-adjusted and sex-adjusted HR of TSH in the 0-20th percentiles was 1·07 (95% CI 1·02-1·12) for the composite outcome, 1·09 (1·05-1·14) for all-cause mortality, and 1·07 (0·99-1·16) for cardiovascular disease mortality.

INTERPRETATION

There was a J-shaped association of FT4 with cardiovascular disease and mortality. Low concentrations of TSH were associated with a higher risk of all-cause mortality and cardiovascular disease mortality. The 20-40th percentiles of FT4 and the 60-80th percentiles of TSH could represent the optimal healthy ranges of thyroid function based on the risk of cardiovascular disease and mortality, with more than 5% increase of 10-year composite risk identified for FT4 greater than the 85th percentile in women and men older than 70 years. We propose a feasible approach to establish the optimal healthy ranges of thyroid function, allowing for better identification of individuals with a higher risk of thyroid-related outcomes.

FUNDING

None.

Relationship between eating disorders perception and psychosocial profile in school-dropout adolescents

BACKGROUND

In body-mind relationship field, eating disorders (ED) are considered disabling disorders that can alter physical health status, inducing profound alterations in psychosocial, cognitive and emotional dimensions. These disorders, characterized by a strong comorbidity with other diseases, usually begin during childhood or adolescence, and include anorexia nervosa, bulimia nervosa and binge eating. Aim of this study was to investigate the associations between eating disorders perception and dimensions of health-related quality of life (HRQoL) and well-being perception (WBP) in school-dropout adolescents.

METHODS

Data were collected in 450 adolescents (19 ± 2 years, male 308), and HRQoL, WBP, and ED were assessed by means a battery of standardized questionnaire.

RESULTS

EDs are more pronounced in females than in males (p < 0.05) and are associated with lower HRQoL (p < 0.001) and lower well-being perception (p < 0.001). EDs are associated with an impairment of physical (p < 0.05) and psychological well-being perception (p < 0.001), emotional responses (p < 0.001), self-perception (p < 0.001), and a reduction of general well-being (p < 0.05).

CONCLUSIONS

Although it is complicated to distinguish between causes and consequences, these findings suggest a complex and multifaceted, association between ED and HRQoL domains. Thus, multiple factors need taking into account in the policy of EDs prevention, identifying all the components of well-being to focus and personalize healthy programs in adolescences.

Schoolteachers' well-being: A pilot study from the AVATAR project during COVID-19 school closure

BACKGROUND

Teachers are a category at high risk for co-occurring mental diseases.

OBJECTIVES

The purpose was to assess well-being of schoolteachers and psychological effects of coronavirus disease 2019 (COVID-19).

METHOD

Data were collected in April 2021, during the partial re-opening of public schools in Italy, from 838 schoolteachers who complete a battery of psychological tests on a multimedia platform.

RESULTS

In females, school closure increases anxiety (BAI, p < 0.001), depression (BDI-II, p < 0.05), stress-related insomnia (FIRST, p < 0.001), and perceived stress (PSS, p < 0.05). In males, on the contrary, rises perceived health (p < 0.001) and vitality (p < 0.001), also in terms of total score (PWBI p < 0.05). In addition, having a family member with COVID in the past month increased anxiety (BAI, p < 0.05), reduced perceived physical health (PWBI, p < 0.05) and vitality (PWBI, p < 0.05).

CONCLUSION

The main results of this pilot study showed that female teachers had a worse well-being perception with respect to men, in terms of health and vitality and an increase in negative emotional reactivity, that impaired when a family member was affected by COVID. The results emphasize the need to invest in prevention and wellness promotion programs in this professional category.

FIB-4 Index and Neutrophil-to-Lymphocyte-Ratio as Death Predictor in Coronary Artery Disease Patients

Nonalcoholic fatty liver disease (NAFLD)-associated liver fibrosis is likely related to coronary artery disease (CAD) by the mediation of systemic inflammation. This study aimed at evaluating the predictive value of neutrophil-to-lymphocyte-ratio (NLR) and fibrosis-4 index (FIB-4), indices of inflammation and fibrosis, respectively, on CAD mortality. Data from 1460 CAD patients (1151 males, age: 68 ± 10 years, mean ± SD) were retrospectively analyzed. Over a median follow-up of 26 months (interquartile range (IQR) 12−45), 94 deaths were recorded. Kaplan−Meier survival analysis revealed worse outcomes in patients with elevation of one or both biomarkers (FIB-4 > 3.25 or/and NLR > 2.04, log-rank p-value < 0.001). In multivariate Cox regression analysis, the elevation of one biomarker (NLR or FIB-4) still confers a significant independent risk for mortality (hazard ratio (HR) = 1.7, 95% confidence interval (95% CI): 1.1−2.7, p = 0.023), whereas an increase in both biomarkers confers a risk corresponding to HR = 3.5 (95% CI: 1.6−7.8, p = 0.002). Categorization of patients with elevated FIB-4/NLR could provide valuable information for risk stratification and reduction of residual risk in CAD patients.

409 PROGNOSTIC VALUE OF TENTING AREA ASSESSED BY CMR IN PATIENTS WITH ISCHEMIC MITRAL REGURGITATION

Objectives

Mitral regurgitation (MR) due to complications of coronary artery disease is defined as ischemic mitral regurgitation (IMR) and, in the chronic phase after myocardial infarction (MI), it has a negative prognostic value, independently of baseline patient characteristics and degree of left ventricular (LV) dysfunction. In this context, we aimed to determine the additive prognostic role of morphological parameters, assessed by cardiac magnetic resonance (CMR), in patients with ischemic mitral regurgitation (IMR).

Methods

250 patients were recruited with diagnosis of IMR, and they were divided into two groups: those with cardiac death (or appropriate ICD shocks) event at 10 years follow-up (35 patients) and those without cardiac death event (215 patients). All patients underwent CMR imaging for the assessment of left ventricular (LV) ejection fraction (EF), end-diastolic (EDV) and end-systolic volume (ESV), tenting area, tenting height, interpapillary muscles displacement and late gadolinium enhancement (LGE). Echocardiography was performed to assess MR.

Results

The average age of the entire sample is 64±10 years, with no significant differences between the two groups (63.2 ±10 vs 68 ±9). For what regards the echocardiographic parameters, there are no statistically significant differences in LVEDV, LVESV, SIV and PP; whereas telesystolic diameter (52 ±7 vs 42 ±9; p &lt; 0,0001), telediastolic diameter (61 ±4 vs 56 ±7; p = 0,003), the EROA (0.3 ±0.09 vs 0.25 ±0.6; p &lt; 0,0001) and left atrial volume (46±19 ml/m2 vs 38.7±11ml/m2 p= 0,0001) are greater in the event group. According to MRI data, patients in the event group, have significantly higher values of LVEDV (155 ±38 ml/m2 vs 111.09 ±38 ml/m2; p&lt;0,001), LVESV (114.04 ±36.8 ml/m2 vs 70 ± 38; p&lt;0,001), sphericity index (0.53 ±0.2 vs 0.44 ±0.1; p&lt;0,001), WMSI (2 ±0.3 vs 1.75 ±0.61, p=0,02), interpapillary distance (20 ±4 vs 18.4 ±6; p&lt;0,001) and posteromedial papillary muscle LGE (33% vs 16%; 0,03). Also, LVEF (28.2 ±9.03% vs 40.42 ±14.9%; p&lt;0,001) is more impaired in the cardiac death event group. There is statistically significant difference between the two groups for what concerns the tenting area (3.7 ±1.4 cm2 vs 2.6 ±0.8cm2; p&lt;0,001) and the tenting height (13 ±2.3 vs 10.5 ±2.6; p&lt;0,001) which are higher in patients with cardiac death event. In the univariate analysis, parameters that were significantly associated with a worst prognosis are: the severe extent of mitral regurgitation (HR 4,886; 95% CI 2,198-10,861), the tenting area (HR 1,009; 95% CI 1,006-1,013), the tenting height (HR 1,295; 95% CI 1,131-1,482; p&lt;0.05), the PISA radius (HR 1,329; 95% CI 1,083-1,631; p&lt;0.05) the EROA (HR 511,636; 95% CI 6,932-37763,8; p&lt;0.05), LGE PAP PM (HR 2,169; 95% CI 1,025-4,589; p&lt;0.05) and VTDi (HR 1,012; 95% CI 1,005-1,018; p&lt;0.05). In the multivariate analysis it appears that tenting area is an independent predictor (HR 1.009 IC (1.00–1.016) p&lt;0.05) of negative prognosis.

Conclusions

Increased tenting area, assessed by CMR, has independent negative prognostic value in patients with ischemic mitral regurgitation. This finding suggests that local remodeling, which occurs in ischemic cardiomyopathy, influences the severity and the prognosis of IMR, underscoring that anatomical compromission has a preeminent role in influencing outcomes in these patients, better than functional parameters.

Interaction of Uric Acid and Neutrophil-to-Lymphocyte Ratio for Cardiometabolic Risk Stratification and Prognosis in Coronary Artery Disease Patients

Oxidative stress and inflammation are key factors in cardiometabolic diseases. We set out to evaluate the relationship between serum uric acid (UA) and the neutrophil-to-lymphocyte ratio (NLR) with cardiometabolic risk factors in coronary artery disease (CAD) patients, and their additive and multiplicative interactive effects on outcomes (cardiac death/CD and hard events (HE)-death plus reinfarction). A total of 2712 patients (67 ± 11 years, 1960 males) who underwent coronary angiography was retrospectively analyzed and categorized into no-CAD patients (n =806), stable-CAD patients (n =1545), and patients with acute myocardial infarction (AMI) (n =361). UA and NLR were reciprocally correlated and associated with cardiometabolic risk factors. During a mean follow-up period of 27 ± 20 months, 99-3.6% deaths, and 213-7.8% HE were registered. The Kaplan-Meier survival estimates showed significantly worse outcomes in patients with elevated UA or NLR levels. Multivariate Cox regression analysis demonstrated that NLR independently predicted CD and HE. There was no multiplicative interaction between UA and NLR; however, the use of measures of additive interaction evidenced a positive additive interaction between UA and NLR for CD and HE. Although it is clear that correlation does not imply causation, the coexistence of NRL and UA appears to have a synergistic effect, providing further information for the risk stratification of CAD patients.

Synchronization between music dynamics and heart rhythm is modulated by the musician’s emotional involvement: A single case study

In this study we evaluated heart rate variability (HRV) changes in a pianist, playing in a laboratory, to investigate whether HRV changes are guided by music temporal features or by technical difficulty and/or subjective factors (e.g., experienced effort). The pianist was equipped with a wearable telemetry device for ECG recording during the execution of 4 classical and 5 jazz pieces. From ECG we derived the RR intervals series (tachogram), and, for each piece, analyzed HRV in the time (RR, RMSSD, Stress Index) and frequency domains (Total spectral power) and performed non-linear analysis (Multiscale Entropy). We also studied the correlation (Pearson) between the time course of music volume envelope and tachogram. Results showed a general reduction of parasympathetic and an increase of sympathetic activity, with the greatest changes during the classical pieces execution, the pianist appraised as more demanding than the jazz ones. The most marked changes occurred during the most technically/emotionally demanding piece, and correlation analysis revealed a negative association between music volume envelope time course and tachogram only for this piece, suggesting a modulation of the limbic system on the synchronization between heart rhythm and music temporal features. Classical music was also associated with the increase of entropy (1st scale) with respect to rest, indicating its effectiveness in driving flexible, healthy, heart dynamics. In conclusion, HRV seems modulated not only by the music temporal features, but also by the pianist’s emotional involvement, which is greatly influenced, in a non-trivial manner, by the technical demands and musician expertise.

Exercise-induced myocardial edema in master triathletes: Insights from cardiovascular magnetic resonance imaging

Background

Strenuous exercise has been associated with functional and structural cardiac changes due to local and systemic inflammatory responses, reflecting oxidative, metabolic, hormonal, and thermal stress, even in healthy individuals. We aimed to assess changes in myocardial structure and function using cardiovascular magnetic resonance (CMR) imaging in master triathletes early after a full-distance Ironman Triathlon race.

Materials and methods

Ten master triathletes (age 45 ± 8 years) underwent CMR within 3 h after a full-distance Ironman Triathlon race (3.8 km swimming, 180 km cycling, and 42.2 km running) completed with a mean time of 12 ± 1 h. All the triathletes had a 30-day follow-up CMR. Cine balanced steady-state free precession, T2-short tau inversion recovery (STIR), tagging, and late gadolinium enhancement (LGE) imaging sequences were performed on a 1.5-T MR scanner. Myocardial edema was defined as a region with increased T2 signal intensity (SI) of at least two SDs above the mean of the normal myocardium. The extent of myocardial edema was expressed as the percentage of left ventricular (LV) mass. Analysis of LV strain and torsion by tissue tagging included the assessment of radial, longitudinal, and circumferential peak systolic strain, rotation, and twist.

Results

Compared with postrace, biventricular volumes, ejection fraction, and LV mass index remained unchanged at 30-day follow-up. Global T2 SI was significantly higher in the postrace CMR (postrace 10.5 ± 6% vs. follow-up 3.9 ± 3.8%, P = 0.004) and presented with a relative apical sparing distribution (P < 0.001) matched by reduction of radial peak systolic strain of basal segments (P = 0.003). Apical rotation and twist were significantly higher immediately after the competition compared with follow-up (P < 0.05).

Conclusion

Strenuous exercise in master triathletes is associated with a reversible regional increase in myocardial edema and reduction of radial peak systolic strain, both presenting with a relative apical sparing pattern.

Efficacy and Safety of Triiodothyronine Treatment in Cardiac Surgery or Cardiovascular Diseases: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Low levels of the active thyroid hormone triiodothyronine (T3) in cardiac patients are associated with worse outcomes. The aim of this analysis was to assess if T3 treatment is beneficial and safe in patients undergoing cardiac surgery or those with cardiovascular diseases in whom there is observed or expected reduction in serum T3 levels. Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed as per the PRISMA guidelines. Pubmed, EMBASE, and Web of Science databases were searched for RCTs published between January 1, 1960 and March 30, 2022 that evaluated the effects of T3 therapy in patients undergoing cardiac surgery or with cardiovascular diseases. The primary outcomes were measures of cardiac function. Weighted mean difference (MD) or relative risk was calculated using a random effects model. PROSPERO registration number CRD42020211966. Results: Of the 3181 full-text articles screened, 34 studies with 2547 participants (number ranging between 13 and 223, mean ages between 0.5 and 73 years, mean percentage of women between 7% and 64%) were included. In 12 RCTs with 1093 adults undergoing cardiac surgery T3 therapy was associated with improvement in cardiac index (MD [95% confidence interval], 0.24 [0.08 to 0.40] L/min/m², I² = 74%). The quality of evidence was high to moderate. In 3 RCTs with 188 children undergoing cardiac surgery, 3 RCTs with 131 adult cardiac donors, 3 RCTs with 83 adult patients with heart failure, and 2 RCTs with 89 adults with acute myocardial infarction, T3 therapy did not improve cardiac index or left ventricular function; the quality of evidence ranged from high (pediatric cardiac surgery) to low (other groups). No detrimental effect of T3 therapy was observed on heart rate, risk of in-hospital atrial fibrillation, or mortality. Conclusions: Short-term T3 therapy is safe and trials in adults undergoing cardiac surgical procedures to evaluate longer term clinical endpoints are required. Current data do not support the routine use of T3 therapy in children undergoing cardiac surgery or in cardiac donors. Adequately designed trials are required to determine if T3 therapy improves cardiac function and clinical outcomes in patients with heart failure or acute myocardial infarction.

Gender Differences for Health Indicators in a Sample of School Dropout Adolescents: A Pilot Study

Background: The ever-increasing prevalence of school dropout (SD) highlights the need to gain insight into risk factors for dropout causes and consequences. The aim of this study was to evaluate the gender differences for health indicators in a sample of school dropout adolescents. Methods: Data were collected regarding 450 adolescent’s SD (19 ± 2 years; 308 males), and health-related quality-of-life (HRQoL) and risk behaviors were assessed by means of a standardized questionnaire. Results: The results revealed that the female population was characterized by a compromised health indicator profile in terms of both risk behaviors and HRQoL dimensions. Conclusion: These findings indicate that SD is a multidimensional phenomenon, for which the implementation of multiple educational, social, and psychological policies aimed at mitigating the issue are recommended.

C45 LATE CARDIAC OUTCOMES IN PATIENTS AFTER COVID–19: A CARDIAC MAGNETIC RESONANCE STUDY

Background

Myocardial injury can occur in patients with coronavirus disease (COVID)–19. Cardiac magnetic resonance (CMR) provides information on functional and morphological cardiac parameters, as well myocardial tissue characterization. Actually, there are few data on late cardiac outcomes in patients after COVID–19.

Aim of the Study

To assess late functional, morphological and myocardial tissue parameters in patients positive to COVID–19 Methods 55 patients (age 50±16 yrs, Female n = 17) with a prior diagnosis of COVID 19, without a previous history of cardiac disease were enrolled in the study. Of these, 35 were hospitalized. The time interval between COVID–19 diagnosis and CMR was 418±28 days. Cardiac function and myocardial tissue characterization have been evaluated with the current CMR techniques. In particular, the presence of late gadolinium enhancement (LGE), as a sign of myocarditis outcome has been evaluated.

Results

LGE was present in 19 patients (34.5%). In all cases, LGE was localized at the level of lateral wall of left ventricle within the myocardium or at the subepicardial level (non–ischemic pattern). Left and right ventricular (LV, RV) ejection fraction were within normal values (mean±SD 65±5% and 65±7%, respectively), as well as volumes (LV endiastolic and endsystolic volumes 71±15 and 27±8 ml/m2; RV endiastolic and endsystolic volumes 72±15 and 25±9 ml/m2). In one case, LGE was associated to regional wall hypokinesia. Among the hospitalized patients, the following factors were associated to the presence of LGE: prone position during assisted ventilation, duration of hospitalization. LGE was present in 67% of patients put in prone position, against 33% of patients not pronated (p = 0.009 Fisher‘s exact test). Duration of hospitalization was 9±5 and 16±7 respectively in patients without and with LGE (p = 0.007)

Conclusion

LGE, as an outcome of myocarditis, is present in a significant number of patients with a history of COVID–19, but it is not associated with dilatation or global and regional dysfunction of left ventricle. LGE is mainly present in pts with more severe clinical presentation of COVID–19

Magnetic Resonance for Differential Diagnosis of Left Ventricular Hypertrophy: Diagnostic and Prognostic Implications

BACKGROUND

Left ventricular hypertrophy (LVH) may be due to different causes, ranging from benign secondary forms to severe cardiomyopathies. Transthoracic Echocardiography (TTE) and ECG are the first-level examinations for LVH diagnosis. Cardiac magnetic resonance (CMR) accurately defines LVH type, extent and severity.

OBJECTIVES

to evaluate the diagnostic and prognostic role of CMR in patients with TTE and/or ECG evidence of LVH.

METHODS

We performed CMR in 300 consecutive patients with echocardiographic and/or ECG signs of LVH.

RESULTS

Overall, 275 patients had TTE evidence of LVH, with initial suspicion of hypertrophic cardiomyopathy (HCM) in 132 (44%), cardiac amyloidosis in 41 (14%), hypertensive LVH in 48 (16%), aortic stenosis in 4 (1%), and undetermined LVH in 50 (16%). The initial echocardiographic diagnostic suspicion of LVH was confirmed in 172 patients (57.3%) and changed in 128 patients (42.7%, p < 0.0001): the diagnosis of HCM increased from 44% to 71% of patients; hypertensive and undetermined LVH decreased significantly (respectively to 4% and 5%). CMR allowed for a diagnosis in 41 out of 50 (82%) patients with undetermined LVH at TTE. CMR also identified HCM in 17 out of 25 patients with apparently normal echocardiography but with ECG criteria for LVH. Finally, the reclassification of the diagnosis by CMR was associated with a change in survival risk of patients: after CMR reclassification, no events occurred in patients with undetermined or hypertensive LVH.

CONCLUSIONS

CMR changed echocardiographic suspicion in almost half of patients with LVH. In the subgroup of patients with abnormal ECG, CMR identified LVH (particularly HCM) in 80% of patients. This study highlights the indication of CMR to better characterize the type, extent and severity of LVH detected at echocardiography and suspected with ECG.

609 Prognostic role of renal function in patients with previous myocardial infarction. A study with cardiac magnetic resonance

Aims

There is not strong evidence in literature about the impact of renal function on the prognosis of patients with ischaemic cardiomyopathy. Thus, the aim of the study was to investigate mild renal impairment [estimated glomerular filtration rate (eGFR): 60–89 ml/min] as an independent prognostic factor in patients with history of myocardial infarction (MI).

Methods and results

We studied 339 consecutive patients (65 ± 13 years old, female 13%) from 2001 and 2012 with previous MI. Patients with eGFR &lt;60 ml/min were excluded. We performed cardiac magnetic resonance (CMR) in all patients to quantify left ventricular ejection fraction (LVEF), volumes, and wall motion score index (WMSI), and to measure the infarction extent by late gadolinium enhancement (LGE). Renal function was estimated by creatinine value with Cockcroft–Gault formula and patients were divided according to normal (≥90 ml/min) and reduced (60–89 ml/min) eGFR. Patients with normal eGFR were 106 (31%, 56.9 ± 10.5 years old), 233 (69%, 66.1 ± 9.9 years old) had renal impairment. During follow-up (median 3.5 years), cardiac events (cardiac death or appropriate intra-cardiac defibrillator shock) occurred in 28/233 (12%) of patients with eGFR &lt;90 ml/min and in 4/106 (4%) of patients with eGFR ≥90 ml/min (P &lt; 0.05). Furthermore, survival curve showed a significantly worst prognosis in patients with renal impairment (P &lt; 0.03). In the group of patients with ejection fraction (EF) &lt; 35% (121 patients), cardiac events were observed only in patients with eGFR &lt;90 ml/min (23/99, 23%, P &lt; 0.05). At multivariate stepwise analysis, age &gt;65 years old, eGFR &lt;90 ml/min and WMSI &gt;1.7 turned out to be independent predictor of cardiac events (P &lt; 0.05).

Conclusions

In patients with previous MI, a mild renal impairment (eGFR between 60 and 89 ml/min) was an independent predictor of prognosis, especially if combined with left ventricular disfunction.

Development of a Web-Based School Support System Within the AVATAR Project for Psychosocial Well-being in Adolescents: Pilot Feasibility Study

BACKGROUND

Health and well-being promotions are key points of educational programs for adolescents within schools. There are several health education programs mainly based on lifestyle habit changes; however, social and emotional dimensions should be considered within these educational strategies.

OBJECTIVE

This study aimed to (1) develop a new web-based school support system to assess and analyze individual, classroom, and scholastic institute data on lifestyle habits, social context, emotional status, and scholastic performance; (2) create a web tool for managing the well-being of adolescents through a dynamic and personalized interface that provides immediate feedback that allows the school to monitor progress; and (3) evaluate, in a pilot study, the feasibility of this web-based school support system in order to build health programs that are specific to the needs of the studied population.

METHODS

The AVATAR (a new purpose for the promotion and evaluation of health and well-being among healthy teenagers) method consists of integrating the information coming from different questionnaires. In particular, to allow planning didactic and educational actions based on the results obtained, the AVATAR approach allows subdivision of the results of the different observed variables and the 4 components into the following 3 percentile categories: modify, improve, and maintain. The AVATAR web platform was designed to collect data on lifestyle, emotional status, and social context from junior high schools in terms of the fundamental aspects of adolescent daily life, with free use by the scholastic community (scholars, teachers, and parents). In this pilot/feasibility study, data from 331 students were acquired between 2018 and 2019 at the beginning of the scholastic year (pre) and at the end following the school-based program (post).

RESULTS

Preliminary results showed that after school planning and specific program implementation, defined after AVATAR feedback, students reported better well-being perception characterized by higher perception in psychological well-being (P=.001), mood (P=.001), self-perception (P=.006), and autonomy (P=.001), and an increase in the perception of financial resources (P=.001), which helped in developing healthy lifestyle habits (P=.007). In the social context assessment, students reported stronger relationships with family (P=.02) and peers (P=.001), and a lower perception of bullying (P=.001).

CONCLUSIONS

The AVATAR web-based platform is a feasible and flexible tool for the health and well-being management of adolescents from epidemiological, preventive, and educational points of view. In particular, it can be used to (1) promote information campaigns aimed at modifying risk behaviors in the student population, (2) sensitize students and put them at the center of their growth path, (3) inform institutions about the health and well-being of the school population, (4) ensure health programs are acceptable and feasible to users before launching on a large scale, and (5) improve the relationship of users (school) and educational agencies with research groups.

A New Web Score to Predict Health Status in Paediatric Patients with Chronic Diseases: Design and Development of the PENSAMI Study

Paediatric chronic diseases (CD) are characterised by their ongoing duration and the fact that they are often managed throughout the lifespan, with the need to adjust lifestyle and expectations with the limitations coming from the CD. The aim of the PENSAMI study is to not only cure the disease, but to also care for the person from a clinical and psychosocial perspective. Data will be collected from 150 paediatric patients affected by heart disease, diabetes, and asthma admitted during in-hospital stay or outpatient visits, and from 200 healthy control subjects. The protocol will consist of two phases. The first one will aim at elaborating the predictive model by detecting (clinical, anthropometric at birth, environmental, lifestyle, social context, emotional state, and mental abilities) in order to develop a model predictive of the events considered: (1) re-hospitalisation; (2) severity and progression of the disease; (3) adherence to therapy; (4) HRQoL; (5) obesity and metabolic syndrome; (6) illness-stress related; (7) school drop-out; (8) school performance. The second one will address validating the previous predictive model. This model will aim to: (1) understand, prevent, and halt the progression of childhood CD; (2) develop new and improved diagnostic tools; (3) pave the way for innovative treatments and additional therapies to traditional clinical practice; and (4) create truly personalised therapeutic and preventive strategies in various sectors, such as cardiology, diabetes, and respiratory diseases.

Hypovitaminosis D and Low T3 Syndrome: A Link for Therapeutic Challenges in Patients with Acute Myocardial Infarction

Background and Aims: Vitamin D counteracts the reduction in the peripheral conversion of tiroxine (T4) into triiodothyronine (T3), which is the mechanism of low T3 syndrome (LT3) in acute myocardial infarction (AMI). The aim of this study was to assess the relationship between LT3 and hypovitaminosis D in AMI patients. Methods and Results: One hundred and twenty-four AMI patients were enrolled. Blood samples were taken at admission, and at 3, 12, 24, 48, and 72 h after admission. LT3 was defined as a value of fT3 ≤ 2.2 pg/mL, occurring within 3 days of hospital admission. Levels were defined as follows: sufficiency as a value of ±30 ng/mL, vitamin D insufficiency as 25-hydroxyvitamin D (25(OH)D) between 21 and 29 ng/mL, deficiency in 25(OH)D as below 20 ng/mL, and severe deficiency as values under 10 ng/mL. The percentage of subjects with severe 25(OH)D deficiency was significantly higher in the LT3 group (33% vs. 13%, p < 0.01). When LT3S was evaluated as a dependent variable, severe 25(OH)D deficiency (OR 2.6: 95%CI 1–6.7, p < 0.05) remained as an independent determinant after logistic multivariate adjustment together with age (>69 yrs, 50th percentile; OR 3.4, 95% CI 1.3–8.3, p < 0.01), but not female gender (OR 1.7, 95% CI 0.7–4.2, p = ns). Conclusions: This pilot study shows a relationship between hypovitaminosis D and LT3 in AMI patients. This association opens potential therapeutic challenges concerning the restoration of euthyroidism through vitamin D administration, together with the normalization of hypovitaminosis.

Non-transmural myocardial infarction associated with regional contractile function is an independent predictor of positive outcome: an integrated approach to myocardial viability

BACKGROUND

Cardiovascular magnetic resonance permits assessment of irreversible myocardial fibrosis and contractile function in patients with previous myocardial infarction. We aimed to assess the prognostic value of myocardial fibrotic tissue with preserved/restored contractile activity.

METHODS

In 730 consecutive myocardial infarction patients (64 ± 11 years), we quantified left ventricular (LV) end-diastolic (EDV) and end-systolic (ESV) volumes, ejection fraction (EF), regional wall motion (WM) (1 normal, 2 hypokinetic, 3 akinetic, 4 dyskinetic), and WM score index (WMSI), and measured the transmural (1-50 and 51-100) and global extent of the infarct scar by late gadolinium enhancement (LGE). Contractile fibrotic (CT-F) segments were identified as those showing WM-1 and WM-2 with LGE ≤ or ≥ 50%.

RESULTS

During follow-up (median 2.5, range 1-4.7 years), cardiac events (cardiac death or appropriate implantable defibrillator shocks) occurred in 123 patients (17%). At univariate analysis, age, LVEDV, LVESV, LVEF, WMSI, extent of LGE, segments with transmural extent > 50%, and CT-F segments were associated with cardiac events. At multivariate analysis, age > 65 years, LVEF < 30%, WMSI > 1.7, and dilated LVEDV independently predicted cardiac events, while CT-F tissue was the only independent predictor of better outcome. After adjustment for LVEF < 30% and LVEDV dilatation, the presence of CT-F tissue was associated with good prognosis.

CONCLUSIONS

In addition to CMR imaging parameters associated with adverse outcome (severe LV dysfunction, poor WM, and dilated EDV), the presence of fibrotic myocardium showing contractile activity in patients with previous myocardial infarction yields a beneficial effect on patient survival.

Plasma Ceramides Pathophysiology, Measurements, Challenges, and Opportunities

Ceramides are a family of lipid molecules, composed of sphingosine and a fatty acid, and transported by lipoproteins (primarily by low-density lipoproteins) in the bloodstream. They are not only structural lipids, but multifunctional and bioactive molecules with key roles in many important cellular pathways, such as inflammatory processes and apoptosis, representing potential biomarkers of cardiometabolic diseases as well as pharmacological targets. Recent data reported ceramide modulation by diet and aerobic exercise, suggesting nutrients and exercise-targeting sphingolipid pathways as a countermeasure, also in combination with other therapies, for risk and progression of chronic disease prevention and health maintenance. In this review, we focus on the available data regarding remarks on ceramide structure and metabolism, their pathophysiologic roles, and the effect of dietary habit and aerobic exercise on ceramide levels. Moreover, advancements and limitations of lipidomic techniques and simplification attempts to overcome difficulties of interpretation and to facilitate practical applications, such as the proposal of scores, are also discussed.

Vitamin D, Thyroid Hormones and Cardiovascular Risk: Exploring the Components of This Novel Disease Triangle

The role of thyroid hormones (THs) in the cardiovascular (CV) system, through several direct and indirect effects is recognized. Even very small modification in TH levels (as those observed in subclinical hypothyroidism or hyperthyroidism, and low triiodothyronine syndrome) may adversely affect the CV system, whereas thyroid hormones benefit the CV system and improve the prognosis. There is also evidence of vitamin D effects on cardiometabolic disease (e.g., through modulation of endothelial and smooth muscle cell activity, renin-angiotensin-aldosterone system, nitric oxide, oxidative stress, and inflammatory response), as well as an association between vitamin D [25(OH)D] deficiency and autoimmune thyroid diseases or cancer, and a relationship between vitamin D concentration and titers of antibodies and thyroid autoimmunity replacement. Interestingly, experimental data indicate a direct effect of vitamin D on Type 2 deiodinase expression causing subsequential peripheral conversion of T4 into T3. However, the functional links among THs, vitamin D and the cardiovascular system, and clinical effects of coexisting abnormalities in this new troublesome triad, have not yet been reviewed. The main aim of this review is to discuss pathophysiology of this relationship, proposing new mechanistic insights involving vitamin D in the modulation of cardiometabolic disease and thyroid profile.

CMR predictors of secondary moderate to severe mitral regurgitation and its additive prognostic role in previous myocardial infarction

BACKGROUND

We aimed to determine predictors and the additive prognostic role of moderate to severe (MS) ischemic mitral regurgitation (MR) in myocardial infarction (MI).

METHODS

Four hundred twenty-two patients with previous MI underwent cardiac magnetic resonance (CMR) imaging for the assessment of left ventricular (LV) ejection fraction (EF), end-diastolic (EDV) and end-systolic volume (ESV), sphericity index, wall motion score index (WMSI), and late gadolinium enhancement (LGE). Echocardiography was performed to assess MR.

RESULTS

Thirty-eight had from moderate to severe MR (MS-MR group) and 384 did not (No MS-MR group). The S-MR group had higher LV volumes, sphericity index, WMSI, and LGE extent, and lower LVEF. At univariate logistic regression analysis, dilated volumes, SI >0.43, dyskinesia of inferolateral wall, papillary muscle (PM)-LGE, and LGE extent >16% were associated with MS-MR. At multivariate analysis, only SI (OR=5.7) and PM-LGE (OR=3) were independently associated with MS-MR. Considering only patients without LV dilatation, only dyskinesia in the inferolateral wall was a predictor of MS-MR (OR 34.8). Thirty cardiac events (cardiac death, appropriate implantable cardioverter-defibrillator firing, and resuscitated cardiac arrest) occurred during a median follow-up of 1,276 days. After adjusting the prognostic variables at univariate analysis by age (>65 years) and selecting those that were significant (EDV > 95 ml/m², ESV >53 ml/m², EF <30%, WMSI >1.65, LGE >12%, S-MR), only WMSI >1.65 and MS-MR remained an independent predictor of cardiac events.

CONCLUSIONS

Increased WMSI and PM-LGE in the overall population and inferolateral dyskinesia in patients without ESV dilatation are predictors of MS-MR; MS-MR and elevated WMSI have independent negative prognostic value.

Sodium Radiofrequency Coils for Magnetic Resonance: From Design to Applications

Sodium (23Na) is the most abundant cation present in the human body and is involved in a large number of vital body functions. In the last few years, the interest in Sodium Magnetic Resonance Imaging (23Na MRI) has considerably increased for its relevance in physiological and physiopathological aspects. Indeed, sodium MRI offers the possibility to extend the anatomical imaging information by providing additional and complementary information on physiology and cellular metabolism with the heteronuclear Magnetic Resonance Spectroscopy (MRS). Constraints are the rapidly decaying of sodium signal, the sensitivity lack due to the low sodium concentration versus 1H-MRI induce scan times not clinically acceptable and it also constitutes a challenge for sodium MRI. With the available magnetic fields for clinical MRI scanners (1.5 T, 3 T, 7 T), and the hardware capabilities such as strong gradient strengths with high slew rates and new dedicated radiofrequency (RF) sodium coils, it is possible to reach reasonable measurement times (~10–15 min) with a resolution of a few millimeters, where it has already been applied in vivo in many human organs such as the brain, cartilage, kidneys, heart, as well as in muscle and the breast. In this work, we review the different geometries and setup of sodium coils described in the available literature for different in vivo applications in human organs with clinical MR scanners, by providing details of the design, modeling and construction of the coils.

Well-Being Perception during COVID-19 Pandemic in Healthy Adolescents: From the Avatar Study

The COVID-19 pandemic provided an extraordinary and naturalistic context to observe young people’s psychosocial profiles and to study how a condition of environmental deprivation and lack of direct social contact, affects the well-being and health status of adolescents. The study explored whether the COVID-19 outbreak changes, in the short term, the acute well-being perception in adolescents, as measured by a Personalized Well-Being Index (PWBI) and the four components affecting health (i.e., lifestyle habits, social context, emotional status, mental skills), in a sample of early adolescent students. Data from 10 schools were collected on 1019 adolescents (males 48.3%, mean age 12.53 ± 1.25 y). Measurements were obtained at two time points, in September/October 2019, (baseline condition, BC) as part of the “A new purpose for promotion and eVAluation of healTh and well-being Among healthy teenageRs” (AVATAR) project and during the Italian Lockdown Phase (mid–late April 2020, LP), with the same students using an online questionnaire. During COVID-19 quarantine, adolescents showed a lower PWBI (p < 0.001) as compared to the BC. Considering the four health-related well-being components, lifestyle habits (p < 0.001), social context (p < 0.001), and emotional status (p < 0.001), showed significantly lower values during LP than BC. However, mental skills, in LP, displayed a significant increase as compared to BC (p < 0.001). In this study, we have provided data on the personalized well-being index and the different components affecting health in adolescents during the COVID-19 lockdown, showing a general decrease in well-being perception, expressed in lifestyle habits, social, and emotional components, demonstrating detrimental effects in the first phase of quarantine on adolescents’ psychosocial profiles. Our results shed new light on adolescence as a crucial period of risk behavior, especially when social support is lacking.

Ignoring a basic pathophysiological mechanism of heart failure progression will not make it go away

A link between heart failure (HF) and low thyroid hormone (TH) function has been known for over a century. Nonetheless, there is a general belief that TH treatment of patients with HF may not be worth the risk. This is largely based on two clinical trials where heart patients were treated with excessive doses of TH analogs, not actual THs. Further complicating the matter is the fact that normalization of THs in noncardiac patients can often be challenging. This issue is not going away as noted by a steady increase in TH-HF citations in recent years. In this article, we discuss what we know and how we may move the field forward.

Health-Related Quality of Life in Italian Adolescents During Covid-19 Outbreak

Coronavirus disease 2019 (COVID-19) outbreak represented an experience of social isolation potentially leading to changes in the health quality of life. The aim of this study is to investigate the health-related quality of life during quarantine in early adolescents. Data were collected from 1,289 adolescents (mean age, 12.5; male, 622), at the beginning of the school year (September 2019, Standard Condition, SC) as part of the AVATAR project and during Phase 1 of the Italian lockdown (mid-late April 2020) (COVID-19 Quarantine, CQ) using an online questionnaire. In the CQ period, with respect to SC, adolescents showed lower perception in the dimensions, such as psychological (p = 0.001), physical well-being (p = 0.001), mood/emotion (p = 0.008), autonomy (p = 0.001), and financial resources (p = 0.018). Relationship with the family (p = 0.021) and peers (p = 0.001), as well as the perception of bullying (p = 0.001) were reduced. In lifestyle, adolescents developed higher adherence to the Mediterranean diet (p = 0.001). Adolescents living in the village had greater reduction in both autonomy (p = 0.002) and peer relationships (p = 0.002). Moreover, the perception of physical well-being was lower in those living in the city instead of those living in the countryside (p = 0.03), in an apartment instead of a detached house (p = 0.002), and in those who did not have green space (p = 0.001). Gender effect emerged for the psychological (p = 0.007) and physical well-being (p = 0.001), mood/emotion (p = 0.001), and self-perception (p = 0.001). The study showed that health-related quality of life during quarantine changed in its psychosocial dimensions, from mood and self-esteem to social relationships, helping to define the educational policies at multiple points in the promotion process of health.

Lung magnetic resonance imaging in systemic sclerosis: a new promising approach to evaluate pulmonary involvement and progression

INTRODUCTION/OBJECTIVES

Interstitial lung disease (ILD) is frequent and highly disabling in systemic sclerosis (SSc). Magnetic resonance imaging (MRI) is not routinely used to evaluate the lung, due to poorer spatial resolution compared to high-resolution computed tomography (HRCT). We aimed to compare lung MRI signal with HRCT and evaluate the role of MRI in predicting ILD progression.

METHODS

Thirty SSc patients underwent lung MRI and HRCT. STIR and T1 mapping sequences were acquired before and after gadolinium injection. Patients were classified as normal (group 1 with normal HRCT and MRI), discordant (group 2 without ILD signs on HRCT but areas of hyperintensity on MRI), and abnormal (group 3 with ILD signs on HRCT and areas of hyperintensity on MRI). Patients were followed up for ILD progression.

RESULTS

Mean STIR and T1 values were different between the three groups (p < 0.0001). STIR values correlated with HRCT score (R = 0.79, p < 0.0001), lung ultrasound B-lines (R = 0.73, p < 0.0001), and %DLco (R = - 0.63, p = 0.0001). Nine events were recorded during a follow-up of 25 ± 20 months. Continuous STIR values were independently associated with events (HR 1.018; CI 1.005-1.031, p = 0.005). A STIR value >90 ms discriminated patients at a higher risk of worsening pulmonary involvement (HR 8.80; CI 1.81-42.74; p < 0.007).

CONCLUSIONS

Lung MRI can detect SSc-related ILD, with good correlations with other ILD markers. STIR values, independently of HRCT appearance, may predict worsening lung involvement. Lung MRI, although very preliminary, is a promising tool that in a near future could help selecting patients for an early treatment of SSc-related ILD and a more appropriate use of HRCT. Key points • Lung MRI has the potential to differentiate inflammation-predominant versus fibrosis-predominant lesions, but it is not currently used in routine clinical practice to assess SSc-related ILD. • Lung MRI STIR and T1 values are significantly different between patients with and without SSc-related ILD. STIR values, independently of HRCT appearance, are also able to predict worsening lung involvement over time. • These preliminary data suggest that, in a near future, MRI could support the choice for an early treatment of SSc-related ILD, as well as a more appropriate use of HRCT.

Comparison of different prediction models for the indication of implanted cardioverter defibrillator in patients with arrhythmogenic right ventricular cardiomyopathy

Aims

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is associated with a high risk of sudden cardiac death. Three different prediction models for the indication of implanted cardioverter defibrillator (ICD) are now available: the 5 year ARVC risk score, the International Task Force Consensus (ITFC) criteria, and the Heart Rhythm Society (HRS) criteria. We compared these three prediction models in a validation cohort of patients with definite ARVC.

Methods and results

In a cohort of 140 patients with definite ARVC, the 5 year ARVC risk score and the ITFC and HRS criteria were compared for the prediction of a major combined endpoint of sudden cardiac death, appropriate ICD intervention, resuscitated cardiac arrest, and sustained ventricular tachycardia. During the follow‐up, 65 major events occurred. The 5 year ARVC risk score with a threshold >10%, derived from the maximally selected rank statistic, predicted 62 (95%) events [odds ratio (OR) 9.1, 95% confidence interval (CI) 2.6–32, P = 0.0006], the ITFC criteria 53 (81%, OR 4.8, 95% CI 2.2–10.3, P = 0.0001), and the HRS criteria 29 (45%, OR 4.2, 95% CI 1.9–9.3, P = 0.0003). At the analysis of decision curve for ICD implantation, a 5 year ARVC risk score >10% showed a greater net benefit than the ITFC and HRS criteria over a wide range of threshold probability of events. Finally, at multivariate analysis, the 5 year ARVC risk score >10% was the only independent predictor of major events.

Conclusions

The 5 year score with a threshold of >10% was more effective for predicting events than the ITFC and HRS criteria.

Acute Pulmonary Edema in Healthy Subjects

INTRODUCTION: Healthy individuals may present with acute pulmonary edema when exposed to extreme environments (high-altitude or deep diving) or while performing strenuous exercises. Recent data support the hypothesis that these forms of acute pulmonary edema might be due to a limited number of stimuli, often overlapping each other, inducing pulmonary capillary stress failure.DISCUSSION: Pathophysiology of nontoxic pulmonary edema occurring in healthy people is still incompletely understood, but recent data suggest a role of three factors (hypoxia, increase in ambient pressure, and physical exercise) that, alone or in combination, may increase pulmonary capillary pressure up to a level overcoming the mechanical resistance of the blood-gas barrier. Evidence has been recently provided to support the existence of a genetic pattern predisposing healthy subjects to pulmonary edema. This paper reviews the evidence supporting a common background for pulmonary edema triggered by extreme environments or heavy effort; a preventive and therapeutic strategy will also be proposed. From these data, hypotheses on the pathophysiology of other forms of noncardiac related pulmonary edema, as those associated with obstructive sleep-apnea syndrome or during post-surgery intensive care, will be proposed.Marabotti C, Cialoni D, Pingitore A. Acute pulmonary edema in healthy subjects. Aerosp Med Hum Perform. 2020; 91(8):662-668.

New inflammatory and oxidative stress-based biomarker changes in response to a half-marathon in recreational athletes

BACKGROUND

Modulation of oxidative stress/inflammation during exercise may have both positive and negative health effects, depending by a number of factors (e.g. training status, and exercise type, intensity and duration) and the oxidative stress or inflammation-related biomarkers considered, which may reflect different levels of the oxidative stress/inflammatory multi entities. The aim of this study was to evaluate oxidative stress and inflammatory multi-biomarker panel in response to a half-marathon during early and delayed recovery.

METHODS

Blood samples (baseline, postrace within 20 min after the race end, and 24 h and 48 h after the run) from runners (N.=31, 20 males, mean age 47±6 years) were assessed for reactive oxygen species (ROM assay) and total antioxidant capacity (OXY test), leukocyte telomere length (LTL), procoagulant activity of circulating microparticles (MP-PCA), inflammatory parameters obtained by hemocrome, and irisin.

RESULTS

A significant decrease for OXY (from 375±71 to 280±66, 239±54, 239±45 µmolHClO/mL) after the half-marathon and during recovery was observed. A reduction for ROMs was also evidenced respect to baseline (from 328±46 to 301±39, 290±56, 320±55 AU). Instead, MP-PCA increased after the race (from 6.2±6 to 10.5±6, 7±4.3 and 5.8±2.1 nmol/L), whereas the other biomarkers did not significantly change.

CONCLUSIONS

The oxidant counterpart did not increase in response to the half-marathon, likely counteracted by antioxidants, which appeared greatly worn out. MP-PCA and WBC increase, always within the normality range, may represent an adaptation to regular chronic endurance training. In any case, antioxidant supply could be considered and tailored for each athlete in this exercise setting.

The impact of menarche on health-related quality of life in a sample of Italian adolescents: evidence from school-based AVATAR project

Adolescence is a period characterized by rapid physical maturation, involving bodily changes that often necessitate a reorganization of self-perception. The current study investigated the impact of menarche on the determinants of quality of life in healthy female adolescents. Data were collected from 361 healthy female adolescents divided into two groups: pre- and post-menarcheal event. Participants, according the AVATAR project, completed Italian version of KIDSCREEN-52 questionnaires on health-related quality of life. Pre-menarcheal females had the higher score in psychological well-being and mood than post-menarcheal females. As concerns self-perception, post-menarcheal females exhibited lower score compared to pre-menarcheal females. In social context, pre-menarcheal females perceived a better school environment, also when we considered it in terms of social acceptance.Conclusion: Menarche event affects all the components of quality of life, from mood, self-esteem to social relationships, underlining how this hormonal variation is responsible of psychological and emotional changes, opening up the opportunity for preventive approaches aimed not only at traditional risk factors but according a more integrated perspective.What is Known:• Adolescence is a time of increasing behavioural divergence between males and females, probably due to the different hormonal development.• There is a possible link between menarche and the health-related quality of life variables.What is New:• Menarche condition affects all the components of quality of life, from mood to social relationships.• Post-menarcheal condition is associated to psychosocial and emotional changes, with possible multiple pathways to post-pubertal depressive symptoms.

A new integrated approach for adolescent health and well-being: the AVATAR project

Background

Limited number of studies examined the relationship between factors (lifestyle, social, emotional, cognitive) affecting adolescents’ health and well-being. The aims of this study were to identify the more important variables of the different components affecting adolescents’ health [lifestyle habits (LH); emotional status (ES); social context (SC); and cognitive abilities (CA)], and explore the relationship between the aforementioned components.

Methods

Data were collected between 2017 and 2018 from 756 eligible students, recruited from 5 Italian junior high school, by using KIDSCREEN-52 and cognitive processing using the Stroop Test. School engagement was estimated through questions concerning the scholastic achievement.

Results

Of 756 adolescents, 395 were boys with a mean (SD) age of 12.19 (0.81) years. Compared to International T-value of reference group for KIDSCREEN-52, autonomy, bullying, psychological well-being and mood were lower than the reference groups, while self-perception score was higher. For LH, the most important predictor was autonomy (p < .0001). The most important aspects in the SC were the relationship with the parents (p < .0001), and the adolescent’s relationships with peers (p < .0001). For ES, mood variables had the greatest contribution (p < .0001). The School performance related to Language & Literature (p < .0001) was the most important predictor in the CA latent variable. LH was positively associated with SC (p < .0001), ES (p < .0001), and CA (p < .0001). SC was positively associated with ES (p < .0001) and with CA (p < .0001).

Conclusions

This study suggests the importance of an integrated approach to characterize adolescents’ health and well-being. The approach suggested here may highlight additive synergistic effects of the various components in health and well-being assessment that may not be considered with a late approach and focused only on single factors.

Adolescent Health: A Framework for Developing an Innovative Personalized Well-Being Index

Adolescence is not only typically considered a time of good health but also characterized by an emergence of risk factors that may have long-term consequences for well-being that represents strong predictors of adverse health outcomes. The aim of the study is to assess adolescence well-being through the development of an integrated Well-Being Index (WBI) including variables of lifestyle habits, social context, emotional status, and mental skills. One thousand two hundred forty-eight healthy adolescents (Female 48%; Male 52%; mean age 13 years) were recruited from five Italian junior high schools, by KIDSCREEN-52 and cognitive processing using the Stroop Test. School performance was estimated by questions concerning the scholastic achievement. Social context was the most important predictor of perceived well-being (β = 0.972, SE = 0.014, p < 0.0001), with parent relation (p < 0.0001) as the most observed variable. Subsequently, WBI was strongly represented by lifestyle habits (β = 0.954, SE = 0.017, p < 0.000) with autonomy (p < 0.0001), and emotional status (β = 0.949, SE = 0.017, p < 0.000) with psychological well-being perception (p < 0.0001). Finally, mental skills (β= -0.1417, SE = 0.031, p < 0.0.00) was the least important predictor for the WBI index (p < 0.0001). Personalised (P) WBI was obtained by the sum of each centered and scaled WBI variable, weighted by the corresponding ratio between factor loading and residual variance. Social context was the more important predictor of WBI, followed by lifestyle, emotional factors, and lastly mental skills. PWBI provides an integrated and personalized perspective of adolescents' well-being, on the basis of a cooperation between school, family, and community with the common intent to promote and protect adolescent health.

Comparison Between Total Thyroidectomy and Medical Therapy for Amiodarone-Induced Thyrotoxicosis

CONTEXT

It is not known whether total thyroidectomy is more favorable than medical therapy for patients with amiodarone-induced thyrotoxicosis (AIT).

OBJECTIVE

To compare total thyroidectomy with medical therapy on survival and cardiac function in AIT patients.

METHODS

Observational longitudinal cohort study involving 207 AIT patients that had received total thyroidectomy (surgery group, n = 51) or medical therapy (medical therapy group, n = 156) over a 20-year period. AIT types and left ventricular ejection fraction (LVEF) classes were determined at diagnosis of AIT. Cardiac and thyroid function were reevaluated during the study period. Survival was estimated using the Kaplan-Meier method.

RESULTS

Overall mortality and cardiac-specific mortality at 10 and 5 years, respectively, were lower in the surgery group than in the medical therapy group (P = 0.04 and P = 0.01, respectively). The lower mortality rate of the surgery group was due to patients with moderate to severely compromised LVEF (P = 0.005 vs medical therapy group). In contrast, mortality of patients with normal or mildly reduced LVEF did not differ between the 2 groups (P = 0.281 and P = 0.135, respectively). Death of patients with moderate to severe LV systolic dysfunction in the medical therapy group occurred after 82 days (interquartile range, 56-99), a period longer than that necessary to restore euthyroidism in the surgery group (26 days; interquartile range, 15-95; P = 0.038). Risk factors for mortality were age (hazard ratio [HR] = 1.036) and LVEF (HR = 0.964), whereas total thyroidectomy was shown to be a protective factor (HR = 0.210). LVEF increased in both groups after restoration of euthyroidism, above all in the most compromised patients in the surgery group.

CONCLUSIONS

Total thyroidectomy could be considered the therapeutic choice for AIT patients with severe systolic dysfunction, whereas it is not superior to medical therapy in those with normal or mildly reduced LVEF.

Thyroid Hormones and Cardiovascular Function and Diseases

Thyroid hormone (TH) receptors are present in the myocardium and vascular tissue, and minor alterations in TH concentration can affect cardiovascular (CV) physiology. The potential mechanisms that link CV disease with thyroid dysfunction are endothelial dysfunction, changes in blood pressure, myocardial systolic and diastolic dysfunction, and dyslipidemia. In addition, cardiac disease itself may lead to alterations in TH concentrations (notably, low triiodothyronine syndrome) that are associated with higher morbidity and mortality. Experimental data and small clinical trials have suggested a beneficial role of TH in ameliorating CV disease. The aim of this review is to provide clinicians dealing with CV conditions with an overview of the current knowledge of TH perturbations in CV disease.

Emerging Biomarkers of Oxidative Stress in Acute and Stable Coronary Artery Disease: Levels and Determinants

Background: Oxidative stress is crucial in the pathogenesis of atherosclerosis and acute myocardial infarction (AMI). Under the generic terms “oxidative stress” (OS), many biomarkers belonging to different pathways have been proposed. Aim: To compare the levels of recently proposed OS-related parameters in acute coronary syndromes (ACS) and stable coronary artery disease (CAD), to evaluate their effectiveness as additive risk or illness indicators of stable and acute ischemic events, and their response over time during the course of AMI. Methods: 76 ACS, 77 CAD patients, and 63 controls were enrolled in the study. Different OS-related biomarkers, including reactive oxygen metabolites (ROM), the total antioxidant capacity (OXY), nitrite/nitrate (final nitric oxide products, NO_x), and Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1), were evaluated. Moreover, time response during AMI course (admission, and 6, 12, 18, 24, 36, and 48 hours after, T0-T6, respectively) and correlation with traditional cardiovascular (CV) risk factors (age, gender, hypertension, diabetes mellitus, dyslipidemia, smoking habit) were also assessed. Results: Over time, ROM progressively increased while OXY and NO_x decreased. Kinetics of LOX-1 during AMI shows that this biomarker boosts early during the acute event (T1 and T2) and then progressively decreases, being significantly lower from T0 to T6. Different OS-related biomarkers were differentially associated with CV risk factors and CAD or ACS presence. Conclusion: Differences in OS-related biomarkers (between groups, according to the response over time during AMI, and to the presence of CV risk factors) confirmed OS involvement in the transition from healthy status to stable CAD and ACS, although evidencing the heterogeneous nature of redox processes. In future, a multi-marker panel including different biomarkers and pathways of oxidative stress could be evaluated as an additive tool to be used in the CV prevention, diagnosis, patient stratification, and treatment.

Usefulness of Triiodothyronine Replacement Therapy in Patients With ST Elevation Myocardial Infarction and Borderline/Reduced Triiodothyronine Levels (from the THIRST Study)

The aim of the study was to investigate whether TH replacement therapy is safe and impact infarct size, left ventricular (LV) volumes and function in patients with acute myocardial infarction (AMI) and low T3 syndrome (LT3S). Thirty-seven AMI/LT3S patients were randomly treated or untreated with liothyronine (T3) therapy (maximum dosage 15 mcg/m²/die) in addition to standardized treatment (T3-treated group, n = 19; untreated group, n = 18). TH and thyroxine (TSH) during hospital stay and at 1-month and 6 months were evaluated. At discharge and at 6 months LV volumes, ejection fraction, wall motion score index (WMSI) and infarct extent were measured by cardiac MR. T3-treated patients had a significant increase in fT3 (p = 0.003 and p <0.001) at discharge and 1-month. These patients had no signs or symptoms of hyperthyroidism or arrhythmias. At follow-up, there was a significant reduction in WMSI in both groups (T3-treated group: Δ = -0.12, p = 0.001; untreated group: Δ = -0.04, p = 0.04) and the difference value (discharge/follow-up) was significantly higher in T3-treated group than in untreated group (mean difference between groups = 0.08, 95% confidence interval [CI]: 0.01 to 0.15, p = 0.05). Also, stroke volume increased significantly in the T3-treated group (Δ = 3.4, 95% CI: 0.8 to 6, p <0.01) at follow-up. In conclusion, this is the first pilot experience in which T3 replacement therapy resulted safe and able to improve regional dysfunction in patients with STEMI/LT3S.

Cardioprotection and Thyroid Hormones in the Clinical Setting of Heart Failure

Ischemic heart disease is the main cause of morbidity and mortality worldwide and is becoming more widespread with population aging. Cardioprotection is a dynamic process characterized by mechanisms related to myocardial damage and activation of protective factors. Targeting these processes could be attractive as a new therapeutic strategy in the evolution of post-ischemic heart failure (HF). In this context, the role of thyroid hormone (TH)-mediated cardioprotection is supported by a number of findings regarding the modulation of neuroendocrine systems, inflammatory and oxidative stress status, pro-survival intracellular pathways, and epigenetic factors, its effects on cardiac angiogenesis, structure, and function and on the preservation of mitochondrial function and morphology, and its beneficial effects on cell growth and redifferentiation. Moreover, the numerous effects of TH on the heart involve genomic mechanisms, which include cardiac differentiation during the perinatal period and non-genomic action, directed toward the maintenance of cardiovascular homeostasis. This evidence suggests that there is an opportunity to treat HF patients with TH. This review is mainly focused on the clinical evidence of the role of the thyroid system in the complex setting of HF.

Prognostic Role of Cardiac Magnetic Resonance in Arrhythmogenic Right Ventricular Cardiomyopathy

We sought to evaluate the prognostic role of cardiac magnetic resonance (CMR) in patients with definite, borderline and possible diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) as defined by the International Task Force (TF) in 2010. CMR was performed in 175 patients: 52 with definite, 50 with borderline and 73 possible ARVC. Abnormal-CMR was defined as the presence of ≥1 CMR abnormalities (including abnormalities of right ventricular and left ventricular wall motion, fat infiltration, late gadolinium enhancement, dilation and dysfunction of either ventricles). During the follow-up time 35 patients had hard cardiac events (sudden cardiac death, appropriate implantable cardioverter defibrillator shock and resuscitated cardiac arrest), and 34 of them occurred in patients with abnormal-CMR (negative predictive value = 96.9%). At the multivariate Cox-regression analysis LV involvement at CMR (fat infiltration and/or late gadolinium enhancement), and episode of nonsustained ventricular tachycardia (NSVT) were independent predictors of cardiac events in both the whole population (LV involvement: HR 3.69, 95% CI 1.57-8.65, p = 0.0002; NSVT: HR 5.8, 95% CI 2.82-11.9, p < 0.0001), and in the group of patients with definite ARVC (LV involvement: HR 3.03, 95% CI 1.15 to 8.02, p = 0.02; NSVT: HR 12.1, 95% CI 4.02-36.5, p < 0.0001). In conclusion, CMR evidence of LV involvement is a strong independent predictor of cardiac events in patients with definite, borderline or possible ARVC diagnosis. Abnormal CMR has very high negative predictive value for hard cardiac events.