PCSK9 inhibitors: effectiveness of treatment and changes in background lipid-lowering therapy in a real world Italian population. The AT-TARGET-IT study

Introduction

PCSK9 inhibitors (PCSK9i) significantly decrease LDL cholesterol (LDL-C), either as monotherapy or in addition to the maximally tolerated dose of statin and/or ezetimibe. Yet, few data are available on efficacy and background lipid-lowering therapy (LLT) adjustment in patients treated with PCSK9i in real-world observations.

Purpose

AT-TARGET-IT is an Italian multicenter registry involving 9 Italian centers, designed to assess efficacy, adherence, and persistence of PCSK9i, as well as prescribing doctors' behavior in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia (FH). The aim of the present analysis was to assess efficacy and changes in background LLT therapy in patients on PCSK9i in a real-world single country observation.

Methods

From June through November 2021, we enrolled patients with PCSK9i first prescription from 6 months before inclusion through starting of PCSK9i use. Clinical and demographic characteristics, concomitant therapies, blood chemistry, were recorded at the time of first prescription and at the latest observation preceding inclusion in the study. Background therapy was assessed at baseline and during follow-up, evaluating treatment withdrawal, reduction of doses, or changes from statin-ezetimibe association to single drug therapy.

Results

We enrolled 798 patients (27% with FH) receiving either alirocumab or evolocumab and followed for a median time of 19.3 months. At the time of PCSK9i first prescription LDL-C was 147.6 mg/dl and reached 51.5 mg/dl at the time of latest observation (64% reduction), and 129 patients (16%) were not receiving any LLT, 669 patients received background LLT, of them 246 (31%) were taking ezetimibe alone and 423 (53%) were taking statins with or without ezetimibe. At the end of the observation period, 785 patients (98%) were still receiving PCSK9i and 550 (69%) did not change background LLT. Of 248 patients changing background LLT, 116 (47%) withdrew therapy, 132 (53%) changed dose or type of LLT. After stratification by achievement of LDL-C target according CV risk class, 483 patients achieved the target (60%). Target was achieved at the end of the observation period in 63% of patients taking triple therapy, 65% patients receiving PCSK9i plus statins, 62% of patients receiving PCSK9i plus ezetimibe and 55% receiving PCSK9i alone (Figure 1). No significant differences in terms of percentage of patients changing background LLT during PCSK9i treatment were found between patients at target for LDL-C and those not at target.

Conclusion

AT-TARGET-IT study shows that PCSK9i therapy is effective in reaching LDL-C target in the majority of patients, yet a sizable number of them (40%) remains undertreated. LLT background therapy is either reduced or withdrawn in 31% of patients, being responsible for not reaching target. Reasons for inappropriate LLT changes in patients receiving PCSK9i should be identified and removed to optimize lipid control.

Funding Acknowledgement

Type of funding sources: None.

Reverse cardiac remodeling after fluid balance optimization in patients with end-stage renal disease

Background

In patients with end‐stage renal disease (ESRD) undergoing hemodialysis, cardiovascular diseases, and in particular chronic heart failure are the leading causes of morbidity and mortality. Nevertheless, few data are available about the impact of fluid optimization on echocardiographic parameters of cardiac function in patients with ESRD.

Methods and Results

In five patients with ESRD undergoing hemodialysis who had developed nonischemic dilated cardiomyopathy, an optimal fluid volume management based on a strict bioelectrical impedance analysis‐assisted dry weight target and dietary sodium and water restriction led to left ventricular reverse remodeling and improvement in hemodynamic parameters. The reverse remodeling further improved after kidney transplantation.

Conclusions

This case series supports the possible beneficial effect of volume status optimization on cardiac function and the potential reversibility of cardiac dysfunction after kidney transplantation.

Effects of a Low Carb Diet and Whey Proteins on Anthropometric, Hematochemical, and Cardiovascular Parameters in Subjects with Obesity

BACKGROUND

The best way to lose body weight, without using drugs and/or suffering hunger and stress, has not yet been defined. The present study tested a low carbohydrate diet, enriched with proteins, in subjects with overweight and obesity.

METHODS

The study enrolled 22 uncomplicated overweight and obese subjects. Several parameters were examined before and after 6 weeks of a low-carbohydrate diet, enriched with 18 g of whey proteins. Anthropometric (body mass index, waist circumference) variables, fasting hormones (insulin, TSH, FT3, FT4), and metabolic (glucose, prealbumin, and lipid levels) parameters were measured. 25- OH-vitamin D (25 (OH) D), parathyroid hormone (PTH) and osteocalcin, were also quantified. Body composition parameters (fat mass, fat-free mass, body cell mass, total body water) were measured by electrical bioimpedance analysis. As cardiovascular parameters, blood pressure, endothelium flowmediated dilation (FMD), and common carotid artery intima-media thickness were also measured.

RESULTS

The low-carbohydrate diet integrated with proteins induced a significant decrease in body weight (P < 0.001), waist circumference (P < 0.001), fat mass (P < 0.001), diastolic blood pressure (P < 0.01), triglycerides (P < 0.001), total cholesterol (P < 0.001), pre-albumin (P < 0.001), insulin (P < 0.001), HOMAIR (P < 0.001), FT3 (P < 0.05), and c-IMT (P < 0.001), and a significant increase in FMD (P < 0.001) and 25 (OH) D (P < 0.001) was also observed.

CONCLUSION

All these results suggest that a short-term non-prescriptive low carbohydrate diet, enriched with whey proteins, may be a good way to start losing fat mass and increase health.

Influence of systemic manifestations of inflammatory bowel diseases on endothelial function and cardiovascular risk

BACKGROUND

Inflammatory bowel diseases (IBD) may be complicated by extraintestinal manifestations (EIM). Both conditions may be implicated in the overall increase of cardiovascular (CV) risk profile of the patients. The study aimed to assess CV risk in IBD patients with EIMs in relation to the stages of both diseases.

METHODS

A total of 70 (38 men, mean age 51.7±12.4 years) patients with IBD and 22 controls (12 men, mean age 49.2±13.6 years) were enrolled. All patients and controls were screened for extraintestinal manifestations and underwent physical and anthropometric examinations, standard laboratory investigations, ultrasound evaluation of carotid arteries and flow-mediated vasodilatation (FMD). Patients were divided into four groups in relation to their active or remission stage of disease: 1. IBD+ EIM+; 2. IBD+ EIM-; 3. IBD- EIM+; 4. IBD- EIM-.

RESULTS

The groups were homogenous according to their clinical characteristics. Patients with both IBD and EIM in active phase showed significantly lower values in FMD than controls (p=0.024). Carotid intima-media thickness values (cIMT) were similar among groups. Patients with active phases of IBD and/or EIM showed statistically significant lower values in FMD measurements (p=0.0008 and p=0.0011, respectively). Multivariate regression did not reveal any independent predictors for FMD values.

CONCLUSIONS

The active phase of IBD or EIM or both may promote endothelial dysfunction in patients, thus increasing their CV risk profile. Patients in remission phase showed endothelial function similar at controls.

Uric Acid in Metabolic and Cerebrovascular Disorders: A Review

BACKGROUND

Several studies showed a close link between metabolic syndrome (MetS), type 2 diabetes (T2DM) and cerebrovascular diseases. There is considerable debate regarding the role of uric acid (UA) as a risk factor in these conditions.

OBJECTIVE

The aim of this narrative review is to discuss the links between UA, MetS, T2DM and cerebrovascular disease.

METHODS

An extensive review has been conducted based on the scientific literature published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and Google Scholar from January to May 2019. Additional relevant studies published after the initial review were also considered during the period of June 2019-October 2019, during which, this manuscript was written. The Mesh Terms considered were: uric acid, antioxidant, oxidant, metabolic syndrome, diabetes, cerebrovascular diseases, stroke, haemorrhagic stroke, neurocognitive disorders, and their combinations.

RESULTS

The literature review shows a dose-dependent inflammatory action of UA, which occurs with serum concentrations >4 mg/dl (>0.24 mmol/l), representing one of the contributors to the chronic inflammatory process that underlies metabolic and cerebrovascular diseases.

CONCLUSION

UA, which is associated with arterial hypertension and cardiovascular diseases, represents one of the indicators of oxidative homeostasis. Increasing concentrations represent a status of active inflammation which is observed with metabolic and cerebrovascular diseases.

When should cardiovascular prevention begin? The importance of antenatal, perinatal and primordial prevention

Cardiovascular diseases represent a major health problem, being one of the leading causes of morbidity and mortality worldwide. Therefore, in this scenario, cardiovascular prevention plays an essential role although it is difficult to establish when promoting and implementing preventive strategies. However, there is growing evidence that prevention should start even before birth, during pregnancy, aiming to avoid the onset of cardiovascular risk factors, since events that occur early in life have a great impact on the cardiovascular risk profile of an adult. The two pillars of this early preventive strategy are nutrition and physical exercise, together with prevention of cardio-metabolic diseases during pregnancy. This review attempts to gather the growing evidence of the benefits of antenatal, perinatal and primordial prevention, discussing also the possibility to reverse or to mitigate the cardiovascular profile developed in the initial stages of life. This could pave the way for future research, investigating the optimal time and duration of these preventing measures, their duration and maintenance in adulthood, and the most effective interventions according to the different age and guiding in the next years, the best clinical practice and the political strategies to cope with cardiovascular disease.

P6507ST2L and sST2: relationship in the carotid plaque - a study on 76 cases underwent endarterectomy

Background

ST2 receptor (suppression of tumorigenity) has been described as receptor for the interleukin 33 (IL-33), a member of the IL-1 family of cytokines. This receptor is associated in various way to coronary artery disease, all-causes mortality and cardiovascular mortality. It's role in the pathogenesis of atherosclerosis is not well-defined yet.

Purpose

The present study was designed to assess the relationship between serum level of sST2, a decoy receptor, and immunohistochemicalespression of ST2L in atherosclerotic plaques of formalin fixed paraffin-embedded internal carotid arteries of patients underwent endarterectomy, accepted the predictive value of ST2 in atherosclerosis.

Methods

The study involved 76 cases (31 symptomatic= 41%, 45 asymptomatic= 59%), age range from 47 to 86 years old, underwent endarterectomy for the treatment of internal carotid stenosis in our vascular surgery of polyclinic, all procedures performed by the same physician. Patients were divided into three groups, depending on the presence of ST2Ltransmembrane receptor on the carotid plaque after immunoistochemical evaluation (group low presence of ST2L= 0–1+; moderate presence of ST2= 2+; high presence of ST2= 3+). Serum level of sST2 were defined through the use of an ELISA-kit, specific for ST2 and ready-to-use.

Results

There was a relationship between ST2L and sST2 values: if considering sST2 mean and median value referring to specific subgroup (low, moderate and high), this is lower if the group (i.e. ST2L presence on the atherosclerotic plaque) is higher, and vice-versa. This shows an inverse relationship between this two parameters. Moreover, using Pearson correlation coefficient, all the three sub-group show a strong correlation to the leukocytes value (low=0.658, moderate= 0.434, high= 0.358).

Conclusions

The ST2L immunohistochemical expression was for the first time investigated in a large number of human carotid atherosclerotic plaques. The inverse relationship between ST2L and sST2 supports the pathogenetic hypothesis that ST2L/IL33 axis could drive the mechanism of plaque development and eventually rupture. Correlation with leukocytes provides a further strong evidence confirming inflammatory pathogenesis of atherosclerosis, but most of all leukocytes' high value could be associated to a greater plaque instability.

Acknowledgement/Funding

None

P4547Serum biochemical determinants of peripheral congestion assessed by bioimpedance vector analysis in acute heart failure

Background

The pathophysiology of peripheral congestion is poorly investigated in patients with acute heart failure (AHF).

Purpose

This study evaluated the relative contribution of serum colloid osmotic pressure (COP), relative plasma volume status (PVS), biomarkers of renal function, electrolytes, haemoglobin, and brain natriuretic peptide (BNP) in peripheral fluid overload using bioimpedance vector analysis (BIVA).

Methods

We retrospectively analysed data from 485 patients with AHF. Hydration status was evaluated by semiquantitative and quantitative approach using BIVA (R/Xc graph) and Hydration Index (HI), respectively. COP was calculated from albumin and total protein concentration, while relative PVS was calculated from validated equations.

Results

Congestion assessed by BIVA was observed in 304 (63%) patients and classified as mild (30%), moderate (42%), and severe (28%). On univariate analysis, HI was inversely correlated with COP (P<0.01), glomerular filtration rate (P<0.01), and haemoglobin (P<0.01), while positive correlations were found for relative PVS (P<0.05), BNP (P<0.01), and blood urea nitrogen (BUN; P<0.01). On stepwise multivariate analysis, COP explained 12% of the total variability, while BUN, PVS, haemoglobin, and BNP added a further 6%, 4%, 2%, and 1%, respectively, to the final explanatory model.

Conclusions

COP was the major determinant of the presence and entity of peripheral congestion assessed by BIVA. BUN, PVS, haemoglobin, and BNP revealed reduced influence on congestion as compared with COP. Routine laboratory testing could be useful in peripheral fluid accumulation. Future studies should evaluate the relationship between COP and pharmacological target therapies for the fluid management of AHF patients.

Acknowledgement/Funding

None

The analysis of left atrial function predicts the severity of functional impairment in chronic heart failure: The FLASH multicenter study

BACKGROUND

Heart failure (HF) patients present with a variety of symptoms at different stages of the disease, but the underlying pathophysiology still is unclear. Left atrial (LA) function might be tightly related to changes in patients' symptoms, more than morphological and anatomic heart features, measurable by ultrasound imaging technique. This study sought to investigate the correlation between LA function, assessed by Speckle Tracking Echocardiography (STE) and Quality of Life (QoL), assessed by the Minnesota Living with Heart Failure Questionnaire (MLHFQ), in patients with chronic HF.

METHODS

Clinically stable HF outpatients (n = 369) were enrolled from 7 different international centres and underwent echocardiographic studies. Patients >75 years old and with atrial fibrillation were excluded. LA strain during reservoir phase (LASr) by STE was measured in all subjects by averaging the 6 atrial segments. LA size was assessed using biplane volume and 4-chamber area acquisition.

RESULTS

LASr strongly correlated with both MLHFQ total score (r = -0.87; p < 0.0001). Less significant correlations between MLHFQ and either LA volume or left ventricular global longitudinal strain (LV-GLS) were found (r = 0.28; p = 0.05 and r = 0.30; p = 0.01, respectively). No significant correlation was found between MLHFQ score, LVEF (r = -0.15; p = ns), E/E' ratio (r = 0.19; p = ns), and E/A ratio (r = 0.20; p = ns). Among all echocardiographic parameters analyzed, LASr presented the highest diagnostic accuracy (AUC = 0.74) in predicting a poor QoL (>45), when compared with LV-GLS (AUC = 0.61), LA volume (AUC = 0.54) and E/e' ratio (AUC = 0.51).

CONCLUSIONS

In patients with HF, irrespective of etiology, LA function strongly correlates with patients' QoL.

Platelet number is negatively and independently associated with carotid intima-media thickness in apparently healthy overweight/obese subjects

BACKGROUND AND AIM

A significant change of platelet number may be a risk factor for atherosclerotic cardiovascular disease. The aim of this study was to investigate the association between platelet number and early signs of atherosclerosis, evaluated by carotid intima-media thickness (c-IMT), in a apparently healthy population mainly represented by obese subjects.

METHODS AND RESULTS

As many as 961 subjects, 686 women and 275 men, aged between 18 and 74 years, were enrolled in the study. Of these, 54 individuals (5.6% of all subjects) were normal weight, 259 individuals (27.0% of all subjects) were overweight, and 648 individuals (67.4% of all subjects) were obese. Waist circumference (WC) and blood glucose, insulin, total cholesterol, high and low density lipoprotein cholesterol, triglycerides and platelet count were also detected in all subjects, who underwent carotid echo color doppler ultrasound to measure c-IMT. c-IMT was significantly and positively associated to age (r = 0.204, P < 0.0001), fasting glucose (r = 0.073, P < 0.0240), total cholesterol (r = 0.096, P = 0.0031), and systolic and diastolic blood pressure (r = 0.140, P < 0.0001 and r = 0.119, P < 0.0003 respectively); c-IMT was significantly and negatively correlated with platelet count (r = -0.165, P < 0.0001). Only age (P < 0.0001) and systolic blood pressure (P = 0.0393), positively, and platelet number (P < 0.0001), negatively, were significantly and independently associated to c-IMT in a final multiple regression analysis.

CONCLUSION

Lower platelet number represented an independent determinant of c-IMT in a population, mainly represented by obese patients. These results suggest that a decrease of platelet number may well be an early defensive mechanism in subjects developing the thickening of carotid artery.

Neonatal bacterial meningitis: a systematic review of European available data

INTRODUCTION

Despite advances in neonatal intensive care and the improvements in surveillance, prevention and vaccination programs, neonatal meningitis still represents an important cause of morbidity and mortality in infants, with the highest mortality in the newborn population. The aim of this article was to summarize current knowledge about this topic with particular attention to management of neonatal meningitis in order to provide a useful tool for clinicians.

EVIDENCE ACQUISITION

We reviewed the existent literature from five European Countries (France, German, Italy, Spain and UK) on the effectiveness of treatments for bacterial meningitis in newborns taking into consideration the antibiotic resistance phenomenon.

EVIDENCE SYNTHESIS

There are few data available on this topic; bacterial neonatal meningitis treatment and management is currently based more on experience than on high quality evidences.

CONCLUSIONS

Identification of the knowledge gaps may stimulate researchers to design new studies aiming to better define management strategies of bacterial meningitis in newborns.

Relationship between Mediterranean diet and asymptomatic peripheral arterial disease in a population of pre-menopausal women

BACKGROUND AND AIMS

The Mediterranean Diet (MedD) is considered a very healthy diet useful in the prevention of cardiovascular disease. The present study aims to evaluate adherence to MedD in unselected premenopausal women and its relation with ankle-brachial index (ABI), an index of preclinical atherosclerosis.

METHODS AND RESULTS

A group of 425 patients (age range 45-54 years) was investigated. They were enrolled only if they were asymptomatic for cardiovascular disease. Nutritional parameters were assessed by a self-administered food frequency validated questionnaire (116 items) completed by an interviewer administered 24 h diet recall. They all underwent ABI measurement. The mean MedD Score was 32.2 ± 6.1 (Q1-Q3 range 26-37) comparing with data from Italian population (46 ± 8.3) was significantly lower. Intake of food categories sources of antioxidants was higher in patients with a greater adherence to Med D and was mainly related to fruit and vegetables. Patients were categorized in quartile according to MedD Score and we evaluate the distribution of ABI index within quartile. 31.4% of women in Q1 (lower adherence to MedD) had an ABI lower than 0.9 compared to 18.3% of women in Q4 (higher adherence to MedD): p < 0.01. Obesity was more frequent in Q1 compared to Q4 and in women with lower ABI.

CONCLUSIONS

Women with a low MedD Score were more obese and showed instrumental sign of preclinical peripheral atherosclerosis. MedD rich in antioxidants from fruit, vegetables and nuts influenced the development of atherosclerosis and was associated with a lower incidence of asymptomatic atherosclerosis.

Idiopathic sudden sensorineural hearing loss and ménière syndrome: The role of cerebral venous drainage

OBJECTIVES

To evaluate the influence of cerebral venous drainage on the pathogenesis of idiopathic sudden sensorineural hearing loss (ISSHL) and Ménière syndrome (MD).

DESIGN

Observational, prospective, cohort study.

SETTING

ENT and Cardiology Departments (University of Bari, Policlinico Hospital, Bari, Italy).

PARTICIPANTS

We enrolled 59 consecutive patients (32 males, mean age 53.05 + 15.37 years): 40 ISSHL and 19 MD.

MAIN OUTCOME MEASURE

All patients underwent physical examination, biochemical evaluation (glycemic and lipid profile, viral serology, C reactive protein, etc), audiometric (tonal, vocal, vestibular evoked myogenic potentials and auditory brainstem response test) and impedentiometric examination. The pure tone average (PTA) was calculated for the following frequencies: 250, 500, 1000, 2000, 3000, 4000, 8000. An echo-color Doppler evaluation of the venous cerebral veins, internal jugular (IJV) and vertebral veins (VV) at supine and 90° position was performed.

RESULTS

No morphological alterations were found both in patients and controls. There were no signs of stenosis, blocked flow, membranes, etc. We found lower minimum, mean and maximum velocities in distal IJVs (P = .019; P = .013; P = .022; respectively) and left VVs (P = .027; P = .008; P = .001; respectively) in supine (0°) position in both MD and ISSHL patients as compared to controls. The same was for orthostatic position (90°). We found negative correlations between the velocities in extracranial veins and PTA values: therefore, the worst the audiometric performance of the subjects, the lower the velocities in the venous cerebral drainage.

CONCLUSIONS

Idiopathic sudden sensorineural hearing loss and Ménière syndrome patients showed altered venous flow in IJVs and VVs as compared to controls, independently from posture. This different behavior of venous tone control can influence the ear performance and may have a role in the pathogenesis of both diseases.

Speckle tracking analysis: a new tool for left atrial function analysis in systemic hypertension: an overview

Speckle tracking echocardiography (STE) is an imaging technique applied to the analysis of left atrial function. STE provides a non-Doppler, angle-independent and objective quantification of left atrial myocardial deformation. Data regarding feasibility, accuracy and clinical applications of left atrial strain are rapidly gathering. This review describes the fundamental concepts of left atrial STE, illustrates its pathophysiological background and discusses its emerging role in systemic arterial hypertension.

The association between cardiac and gastrointestinal disorders: causal or casual link?

Cardiovascular diseases are the leading cause of death worldwide: among them, coronary artery disease and arrhythmias represent the most frequent pathological conditions. Similarly, the gastrointestinal disorders, that is, gastroesophageal reflux and inflammatory bowel diseases, have a high incidence in the general population. Several pieces of evidence have documented a link between cardiac and gastrointestinal disorders as they often share similar risk factors and symptoms. Furthermore, both can simultaneously occur in the same patient, thus creating problems in the correct clinical diagnosis. It is well known that gastrointestinal disorders may present with chest pain and mimic angina pectoris. In contrast, they can also unmask heart disease, such as in the case of the angina-linked ischemia. The aim of this review was to elucidate the mechanisms underlying the relationship between cardiac and gastrointestinal diseases to better understand the causal or casual character of such a linkage.

Survival Benefits of Invasive Versus Conservative Strategies in Heart Failure in Patients With Reduced Ejection Fraction and Coronary Artery Disease

Background—

Heart failure with reduced ejection fraction caused by ischemic heart disease is associated with increased morbidity and mortality. It remains unclear whether revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) carries benefits or risks in this group of stable patients compared with medical treatment.

Methods and Results—

We performed a meta-analysis of available studies comparing different methods of revascularization (PCI or CABG) against each other or medical treatment in patients with coronary artery disease and left ventricular ejection fraction ≤40%. The primary outcome was all-cause mortality; myocardial infarction, revascularization, and stroke were also analyzed. Twenty-one studies involving a total of 16 191 patients were included. Compared with medical treatment, there was a significant mortality reduction with CABG (hazard ratio, 0.66; 95% confidence interval, 0.61–0.72; P <0.001) and PCI (hazard ratio, 0.73; 95% confidence interval, 0.62–0.85; P <0.001). When compared with PCI, CABG still showed a survival benefit (hazard ratio, 0.82; 95% confidence interval, 0.75–0.90; P <0.001).

Conclusions—

The present meta-analysis indicates that revascularization strategies are superior to medical treatment in improving survival in patients with ischemic heart disease and reduced ejection fraction. Between the 2 revascularization strategies, CABG seems more favorable compared with PCI in this particular clinical setting.

Carotid stenting versus endarterectomy in the same patient: A "direct" comparison

The aim of this study was to evaluate outcomes and feasibility of carotid artery stenting versus carotid endarterectomy, both procedures performed in the same patient. Forty-five subjects (33 males, 70 ± 7 years) underwent carotid endarterectomy or carotid artery stenting, the counter procedure on the contralateral carotid performed after a variable period. We evaluated the post-procedural percentage of carotid stenosis at 30, 180 days and one-year follow-up, and the occurrence of acute myocardial infarction, New York Heart Association class progression, stroke, death, cardiovascular death, angina, transient ischemic attack and renal failure. Carotid artery stenting treatment reduced the degree of re-stenosis after 180 days equally to carotid endarterectomy procedure (difference: 0.033%, P = 0.285). No statistically significant differences were observed according to the occurrence of acute myocardial infarction and New York Heart Association class progression, revealing odds ratio (OR) equal to 0.182 ( P = 0.361) for acute myocardial infarction and 0.303 ( P = 0.434) for New York Heart Association class progression. Carotid endarterectomy confirms its efficacy in carotid revascularization, but carotid artery stenting constitutes a good alternative when the procedures are selected based on patient-specific risk factors.

The role of very low birth weight and prematurity on cardiovascular disease risk and on kidney development in children: a pilot study

BACKGROUND

Cardiovascular and renal disease are nowadays among the leading cause of morbidity and mortality in Western Countries. Low birth weight has been recently considered a key factor in determining cardiovascular disease and long-term renal disease in adulthood.

METHODS

In our study we analyzed, through echocardiography, eco color Doppler of carotid arteries, ultrasound of abdominal aorta and kidneys, morphological characteristics of cardiovascular and renal system, in a group of children born preterm with very low birth weight, (birth weight<1500 grams) and in a group of children, age and sex matched, born at term with weight appropriate for gestational age. Fifteen children born very low birth weight preterm (cases), aged from 3 to 5 years, and 15, age and sex matched children, born appropriate for gestational age at term (controls) were enrolled in the study.

RESULTS

The two groups were homogeneous for interventricular septum diameter, left ventricular end-systolic diameter, left atrial diameter, and ejection fraction. Left ventricular end diastolic diameter was higher in case compared to controls (P=0.04), while aortic diameter root smaller (P=0.005). E and A waves peak velocities and E/A ratio resulted lower in cases compared to controls (P=0.02, P<0.001and P<0.001, respectively). Tei index, S, e' and a' waves velocities were similar in the two groups, while E/e' ratio was higher in cases (P=0.046). Intima-media thickness and antero-posterior diameter of abdominal aorta values did not differ in cases versus controls. Longitudinal diameters of both kidneys were reduced in cases compared to controls (P<0.05).

CONCLUSIONS

Although limited by the small sample size, our study highlighted an increased size of the left ventricle and altered left ventricular diastolic function in children born very low birth weight preterm, but no long-term consequences on systolic performance and vascular structure have been found. The finding of smaller kidneys in ex-preterm very low birth weight children could explain their higher susceptibility to develop renal disease in adulthood.

Coronary tortuosity: normal variant or pathological condition?

<p><strong>Highlights</strong><br />Coronary tortuosity is a common coronary angiography finding. The aetiology and the clinical significant are not well defined, generally considered a normal variant. We showed a case of marked tortuosity of all coronary arteries associated with myocardial ischemia. </p>

The role of omega-3 polyunsaturated fatty acids supplementation in childhood: a review

Dietary omega-3 polyunsaturated fatty acids (ω-3 PUFAs) benefits are not clearly defined in childhood although already well-defined in adults. Recent studies have demonstrated their positive effects on bronchial asthma, neuropsychiatric disorders and cognitive brain function in childhood. Furthermore, it has been demonstrated as a relationship between the increased incidence of childhood obesity and the role of ω-3 PUFAs in reducing the metabolic and vascular alterations induced by the fat accumulation since young age. Such relationship could be more important in prevention of future cardiovascular events. In fact, ω-3 PUFAs could improve endothelial function and structure since childhood. By considering endothelial dysfunction as a well-known early marker of atherosclerosis, its amelioration in the beginning years of individuals' life will certainly reduce the cardiovascular risk profile in adulthood. Nevertheless, their use is limited by several factors, such as the lack of studies in children and the awful taste of the products enriched with ω-3 PUFAs, although several patents have managed to overcome such defects and developed the use of these molecules. This paper is a literature study and patents analysis aiming to explore key issues regarding ω-3 PUFAs administration in childhood in order to take into account its routine intake daily. However, it is well-established that further studies are needed to endorse the promising results outlined by literature analysis.

Hypertensive Cardiomyopathy in asymptomatic patients: a neglected diagnosis

Hypertensive Cardiomyopathy diagnosis includes different clinical conditions, on asymptomatic patients, assessed by LV changes in geometry, mass and function, i.e. concentric remodeling, concentric or eccentric hypertrophy and filling impairment or early stage of diastolic dysfunction. Often LA is involved and increases its volume and undergoes to geometrical remodeling. Sometimes it occurs clinical heart failure, the patients became symptomatic, with either a preserved or a reduced LVEF. There is considerable variability in the progression from hypertension to Hypertensive Cardiomyopathy, according to differences in the pressure or volume load and to underlying neurohormonal status; but these differences in LV geometry probably are influenced on genetic basis too. A better comprehension of the mechanisms underlying the development of Hypertensive Cardiomyopathy on hypertensive patients will help to prevent among them the onset of cardiovascular events.

Correlation between coronary artery disease severity, left ventricular mass index and carotid intima media thickness, assessed by radio-frequency

Background

Intima-media thickness of the common carotid artery (CCA-IMT) is a validated marker of systemic atherosclerosis process. The aim of this study was to evaluate the association between coronary artery disease (CAD), left ventricular hypertrophy (LVH) and CCA-IMT, assessed by Radio Frequency-Quality Intima Media Thickness (^RFQIMT) method, the next generation of IMT real-time measurement, based on the direct analysis of the radiofrequency signal and endowed with high accuracy and reproducibility in early detection of arterial wall thickness.

Methods

115 patients (76 men, mean age: 65.1 ± 12 years) referred to our department and shown significant (≥ 70% luminal obstruction) stenosis at least in one major epicardial coronary artery were studied. Coronary angiograms were divided for severity and extent of the disease: 79 patients (69%) had one, 24 patients (21%) two, 12 patients (10%) three major epicardial coronary arteries with ≥ 70% stenosis. All patients underwent echocardiography and carotid ultrasound examination, assessed by RF.

Results

Dividing ^RFQIMT data in tertiles, dyslipidaemia (31 patients with IMT ≥ 1.20 mm vs 16 with IMT = 0.91-1.19 vs 25 with IMT ≤ 0.9, p = 0.004), LVMI (153.5 ± 20.6 g/m² in IMT ≥ 1.20 mm vs 131.2 ± 8.4 g/m² in IMT = 0.91-1.19 mm vs 114.3 ± 11.1 g/m² in IMT ≤ 0.9 mm, P < 0.001) and number of high stenosed coronary arteries (IMT ≥ 1.20 mm population more often showed three vessel diseases than IMT ≤ 0.90 mm one, P < 0.001) seemed to be significantly related to CCA-IMT increases. Furthermore, LVMI is positively related to IMT (r = 0.91; P < 0.001). In a multivariate regression model (R² = 0.88), ^RFQIMT remained significantly associated with the dyslipidemia (regression coefficient ± standard error [SE]: 0.057 ± 0.023; p = 0.017), LVMI (regression coefficient ± SE: 0.01 ± 0.001; P < 0.0001) and number of damaged coronaries (regression coefficient ± SE: 0.0174 ± 0.028; P < 0.0001).

Conclusions

^RFQIMT is a sophisticated method for carotid ultrasound evaluation. Its evaluation in patients with at least one important major epicardial coronary vessel stenosis would help the accuracy in the general assessment of the number of coronary lesions in these patients.

The clinical role of contrast-enhanced ultrasound in the evaluation of renal artery stenosis and diagnostic superiority as compared to traditional echo-color-Doppler flow imaging

AIM

The purpose of this study was to investigate the feasibility of contrast-enhanced ultrasound (CEUS) in the evaluation of renal artery stenosis as compared with traditional techniques: echo color Doppler (ECD) investigation and selective angiography .CEUS is a technique based on the injection of an intravascular biocompatible tracer, namely an intravenous contrast galactose microparticle suspension containing microbubbles (Levovist), that has a similar rheology to that of red blood cells, allowing quantification of renal tissue perfusion.

METHODS

A population of 120 hypertensive patients (82 men, mean age 55) with a systolic abdominal murmur and/or a diagnosis of poly-districtual atherosclerosis was studied by ECD and CEUS (Levovist). Selective angiography was performed in patients with renal artery stenosis demonstrated by one of the two ultrasonographic techniques.

RESULTS

Forty of the 120 patients in the study population showed renal artery stenosis at one of the two ultrasound techniques: ECD identified renal artery stenosis in 33 cases and CEUS in 38. Instead, selective angiography had detected renal artery stenosis in 38 patients, the same with renal artery stenosis diagnosed by CEUS. Thus, CEUS sensitivity, specificity and accuracy were similar to those of angiography while six false negatives and two false positives were obtained with ECD.

CONCLUSION

Our results suggest that this renal CEUS is a promising, new, non-invasive method for screening patients with suspected renal artery stenosis. This technique appears to be superior to traditional ECD flow imaging for diagnosing renal artery stenosis and so may be an important aid in cardiovascular diagnostics.

Macrophages and mast cells are involved in carotid plaque instability

The aim of this study was to evaluate the role of macrophages and mast cells and of microvascular density in atherosclerotic plaques collected from 63 consecutive symptomatic and asymptomatic patients undergoing carotid endarterectomy for carotid disease. Results have shown no statistically significant differences between the two groups as concerns: (i) the degree of stenosis; (ii) the extention of the lipidic core; (iii) the thickness of the fibrous cup; (iv) the inflammatory infiltrate; (v) the degree of calcification; (vi) the intraplaque hemorrhage. Otherwise, statistically significant difference was found in microvascular density, in the number of CD68-positive macrophages and tryptase-positive mast cells in plaques from symptomatic patients, as compared to asymptomatic patients. Overall, this study indicate that although advanced symptomatic and asymptomatic carotid plaques present similar histomorphological characteristics, the degree of macrophage and mast cell infiltration and differences in microvascular density could help to discriminate between symptomatic and asymptomatic patients.

Increased carotid IMT in overweight and obese women affected by Hashimoto's thyroiditis: an adiposity and autoimmune linkage?

Background

Hashimoto's thyroiditis is the most important cause of hypothyroidism. It is a systemic disease that can even affect the cardiovascular system, by accelerating the atherosclerotic process. Aim of this study was to examine whether autoimmune thyroiditis has an effect on the intima-media thickness of the common carotid artery (IMT-CCT), independently of the thyroid function and well-known cardiovascular risk factors. Hashimoto's thyroiditis is a systemic disease. The aim is to examine whether autoimmune thyroiditis and adiposity can effect carotid IMT independently of thyroid hormones and cardiovascular risk factors.

Methods

A total of 104 obese women (BMI ≥ 25.0 kg/m^-2), with FT3 and FT4 serum levels in the normal range and TSH levels < 4.5 μU/ml, were investigated. None of these patients was taking any kind of drug influencing thyroid function. Measurements were made of the IMT-CCT, BMI, waist circumference, blood pressure levels, as well as fasting TSH, FT3, FT4, anti-thyroid antibodies, insulin, fasting glycemia, triglycerides, total and HDL-cholesterol serum concentrations.

Results

Of the 104 women, 30 (28.8%) were affected by autoimmune thyroiditis. Significantly higher values of IMT-CCT (p < 0.05), TSH (p < 0.05), and triglycerides (p < 0.05) were obtained, and significantly lower values of FT4 (p < 0.05), in patients with Hashimoto's thyroiditis as compared to those with a normal thyroid function. When examining the whole group together, at multiple regression analysis Hashimoto's thyroiditis maintained a positive association with the IMT (p < 0.001), independently of age, hypertension, BMI, and the fasting serum levels of TSH, FT3, FT4, insulin, fasting glycemia, triglycerides, total and HDL-cholesterol levels.

Conclusions

The present study shows that Hashimoto's thyroiditis is associated to an increased IMT only in overweight and obese, independently of the thyroid function, BMI and cardiovascular risk factors. These results suggest that Hashimoto's thyroiditis is a marker of evolution of the atherosclerosis if combined to adiposity.