Frail hypertensive older adults with prediabetes and chronic kidney disease: insights on organ damage and cognitive performance - preliminary results from the CARYATID study

BACKGROUND

Hypertension and chronic kidney disease (CKD) pose significant public health challenges, sharing intertwined pathophysiological mechanisms. Prediabetes is recognized as a precursor to diabetes and is often accompanied by cardiovascular comorbidities such as hypertension, elevating the risk of pre-frailty and frailty. Albuminuria is a hallmark of organ damage in hypertension amplifying the risk of pre-frailty, frailty, and cognitive decline in older adults. We explored the association between albuminuria and cognitive impairment in frail older adults with prediabetes and CKD, assessing cognitive levels based on estimated glomerular filtration rate (eGFR).

METHODS

We conducted a study involving consecutive frail older patients with hypertension recruited from March 2021 to March 2023 at the ASL (local health unit of the Italian Ministry of Health) of Avellino, Italy, followed up after three months. Inclusion criteria comprised age over 65 years, prior diagnosis of hypertension without secondary causes, prediabetes, frailty status, Montreal Cognitive Assessment (MoCA) score < 26, and CKD with eGFR > 15 ml/min.

RESULTS

237 patients completed the study. We examined the association between albuminuria and MoCA Score, revealing a significant inverse correlation (r: 0.8846; p < 0.0001). Subsequently, we compared MoCA Score based on eGFR, observing a significant difference (p < 0.0001). These findings were further supported by a multivariable regression analysis, with albuminuria as the dependent variable.

CONCLUSIONS

Our study represents the pioneering effort to establish a significant correlation between albuminuria and eGFR with cognitive function in frail hypertensive older adults afflicted with prediabetes and CKD.

C2CD4B Evokes Oxidative Stress and Vascular Dysfunction via a PI3K/Akt/PKCα-Signaling Pathway

High glucose-induced endothelial dysfunction is an important pathological feature of diabetic vasculopathy. While genome-wide studies have identified an association between type 2 diabetes mellitus (T2DM) and increased expression of a C2 calcium-dependent domain containing 4B (C2CD4B), no study has yet explored the possible direct effect of C2CD4B on vascular function. Vascular reactivity studies were conducted using a pressure myograph, and nitric oxide and oxidative stress were assessed through difluorofluorescein diacetate and dihydroethidium, respectively. We demonstrate that high glucose upregulated both mRNA and protein expression of C2CD4B in mice mesenteric arteries in a time-dependent manner. Notably, the inhibition of C2CD4B expression by genetic knockdown efficiently prevented hyperglycemia-induced oxidative stress, endothelial dysfunction, and loss of nitric oxide (NO) bioavailability. Recombinant C2CD4B evoked endothelial dysfunction of mice mesenteric arteries, an effect associated with increased reactive oxygen species (ROS) and decreased NO production. In isolated human umbilical vein endothelial cells (HUVECs), C2CD4B increased phosphorylation of endothelial nitric oxide synthase (eNOS) at the inhibitory site Thr495 and reduced eNOS dimerization. Pharmacological inhibitors of phosphoinositide 3-kinase (PI3K), Akt, and PKCα effectively attenuated oxidative stress, NO reduction, impairment of endothelial function, and eNOS uncoupling induced by C2CD4B. These data demonstrate, for the first time, that C2CD4B exerts a direct effect on vascular endothelium via a phosphoinositide 3-kinase (PI3K)/Akt/PKCα-signaling pathway, providing a new perspective on C2CD4B as a promising therapeutic target for the prevention of oxidative stress in diabetes-induced endothelial dysfunction.

Acute heart failure: mechanisms and pre-clinical models-a Scientific Statement of the ESC Working Group on Myocardial Function

While chronic heart failure (CHF) treatment has considerably improved patient prognosis and survival, the therapeutic management of acute heart failure (AHF) has remained virtually unchanged in the last decades. This is partly due to the scarcity of pre-clinical models for the pathophysiological assessment and, consequently, the limited knowledge of molecular mechanisms involved in the different AHF phenotypes. This scientific statement outlines the different trajectories from acute to CHF originating from the interaction between aetiology, genetic and environmental factors, and comorbidities. Furthermore, we discuss the potential molecular targets capable of unveiling new therapeutic perspectives to improve the outcome of the acute phase and counteracting the evolution towards CHF.

Interventions to Address Cardiovascular Risk in Obese Patients: Many Hands Make Light Work

Obesity is a growing public health epidemic worldwide and is implicated in slowing improved life expectancy and increasing cardiovascular (CV) risk; indeed, several obesity-related mechanisms drive structural, functional, humoral, and hemodynamic heart alterations. On the other hand, obesity may indirectly cause CV disease, mediated through different obesity-associated comorbidities. Diet and physical activity are key points in preventing CV disease and reducing CV risk; however, these strategies alone are not always sufficient, so other approaches, such as pharmacological treatments and bariatric surgery, must support them. Moreover, these strategies are associated with improved CV risk factors and effectively reduce the incidence of death and CV events such as myocardial infarction and stroke; consequently, an individualized care plan with a multidisciplinary approach is recommended. More precisely, this review explores several interventions (diet, physical activity, pharmacological and surgical treatments) to address CV risk in obese patients and emphasizes the importance of adherence to treatments.

Sacubitril/Valsartan vs. Standard Medical Therapy on Exercise Capacity in HFrEF Patients

Sacubitril/valsartan (Sac/Val) reduces mortality in patients with heart failure with reduced ejection fraction (HFrEF) compared to enalapril. However, its effects on functional capacity remain uncertain; consequently, we sought to compare Sac/Val vs. standard medical therapy, in terms of effects on prognostically significant CPET parameters, in HFrEF patients during a long follow-up period. We conducted a single-center, observational study in an HF clinic; specifically, we retrospectively identified that 12 patients switched to Sac/Val and 13 patients that managed with standard, optimal medical therapy (control group). At each visit, baseline, and follow-up (median time: 16 months; IQ range: 11.5-22), we collected demographic information, medical history, vital signs, cardiopulmonary exercise testing, standard laboratory data, pharmacological treatment information, and echocardiographic parameters. The study's primary end-point was the change from baseline in peak VO2 (adjusted to body weight). We did not observe significant differences between the two study groups at baseline. Similarly, we did not observe any significant differences during the follow-up in mean values of peak VO2 corrected for body weight: Sac/Val baseline: 12.2 ± 4.6 and FU: 12.7 ± 3.3 vs. control group: 13.1 ± 4.2 and 13.0 ± 4.2 mL/kg/min; p = 0.49. No significant treatment differences were observed for changes in VE/VCO2 slope: Sac/Val baseline: 35.4 ± 7.4 and FU: 37.2 ± 13.1 vs. control group: 34.6 ± 9.1 and 34.0 ± 7.3; p = 0.49. In conclusion, after a median follow-up period of 16 months, there was no significant benefit of Sac/Val on peak VO2 and other measures of CPET compared with standard optimal therapy in patients with HFrEF.

Artificial intelligence in cardiovascular prevention: new ways will open new doors

Prevention and effective treatment of cardiovascular disease are progressive issues that grow in tandem with the average age of the world population. Over recent decades, the potential role of artificial intelligence in cardiovascular medicine has been increasingly recognized because of the incredible amount of real-world data (RWD) regarding patient health status and healthcare delivery that can be collated from a variety of sources wherein patient information is routinely collected, including patient registries, clinical case reports, reimbursement claims and billing reports, medical devices, and electronic health records. Like any other (health) data, RWD can be analysed in accordance with high-quality research methods, and its analysis can deliver valuable patient-centric insights complementing the information obtained from conventional clinical trials. Artificial intelligence application on RWD has the potential to detect a patient's health trajectory leading to personalized medicine and tailored treatment. This article reviews the benefits of artificial intelligence in cardiovascular prevention and management, focusing on diagnostic and therapeutic improvements without neglecting the limitations of this new scientific approach.

Artificial Intelligence in Hypertension Management: An Ace up Your Sleeve

Arterial hypertension (AH) is a progressive issue that grows in importance with the increased average age of the world population. The potential role of artificial intelligence (AI) in its prevention and treatment is firmly recognized. Indeed, AI application allows personalized medicine and tailored treatment for each patient. Specifically, this article reviews the benefits of AI in AH management, pointing out diagnostic and therapeutic improvements without ignoring the limitations of this innovative scientific approach. Consequently, we conducted a detailed search on AI applications in AH: the articles (quantitative and qualitative) reviewed in this paper were obtained by searching journal databases such as PubMed and subject-specific professional websites, including Google Scholar. The search terms included artificial intelligence, artificial neural network, deep learning, machine learning, big data, arterial hypertension, blood pressure, blood pressure measurement, cardiovascular disease, and personalized medicine. Specifically, AI-based systems could help continuously monitor BP using wearable technologies; in particular, BP can be estimated from a photoplethysmograph (PPG) signal obtained from a smartphone or a smartwatch using DL. Furthermore, thanks to ML algorithms, it is possible to identify new hypertension genes for the early diagnosis of AH and the prevention of complications. Moreover, integrating AI with omics-based technologies will lead to the definition of the trajectory of the hypertensive patient and the use of the most appropriate drug. However, AI is not free from technical issues and biases, such as over/underfitting, the "black-box" nature of many ML algorithms, and patient data privacy. In conclusion, AI-based systems will change clinical practice for AH by identifying patient trajectories for new, personalized care plans and predicting patients' risks and necessary therapy adjustments due to changes in disease progression and/or therapy response.

The Dark Side of Sphingolipids: Searching for Potential Cardiovascular Biomarkers

Cardiovascular diseases (CVDs) are the leading cause of death and illness in Europe and worldwide, responsible for a staggering 47% of deaths in Europe. Over the past few years, there has been increasing evidence pointing to bioactive sphingolipids as drivers of CVDs. Among them, most studies place emphasis on the cardiovascular effect of ceramides and sphingosine-1-phosphate (S1P), reporting correlation between their aberrant expression and CVD risk factors. In experimental in vivo models, pharmacological inhibition of de novo ceramide synthesis averts the development of diabetes, atherosclerosis, hypertension and heart failure. In humans, levels of circulating sphingolipids have been suggested as prognostic indicators for a broad spectrum of diseases. This article provides a comprehensive review of sphingolipids' contribution to cardiovascular, cerebrovascular and metabolic diseases, focusing on the latest experimental and clinical findings. Cumulatively, these studies indicate that monitoring sphingolipid level alterations could allow for better assessment of cardiovascular disease progression and/or severity, and also suggest them as a potential target for future therapeutic intervention. Some approaches may include the down-regulation of specific sphingolipid species levels in the circulation, by inhibiting critical enzymes that catalyze ceramide metabolism, such as ceramidases, sphingomyelinases and sphingosine kinases. Therefore, manipulation of the sphingolipid pathway may be a promising strategy for the treatment of cardio- and cerebrovascular diseases.

Cardiovascular Implications of microRNAs in Coronavirus Disease 2019

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic continues to be a global challenge due to resulting morbidity and mortality. Cardiovascular (CV) involvement is a crucial complication in coronavirus disease 2019 (COVID-19), and no strategies are available to prevent or specifically address CV events in COVID-19 patients. The identification of molecular partners contributing to CV manifestations in COVID-19 patients is crucial for providing early biomarkers, prognostic predictors, and new therapeutic targets. The current report will focus on the role of microRNAs (miRNAs) in CV complications associated with COVID-19. Indeed, miRNAs have been proposed as valuable biomarkers and predictors of both cardiac and vascular damage occurring in SARS-CoV-2 infection. SIGNIFICANCE STATEMENT: It is essential to identify the molecular mediators of coronavirus disease 2019 (COVID-19) cardiovascular (CV) complications. This report focused on the role of microRNAs in CV complications associated with COVID-19, discussing their potential use as biomarkers, prognostic predictors, and therapeutic targets.

874 A NOT-SO-RARE COMPLICATION OF CONNECTIVE TISSUE DISEASE

Pulmonary hypertension is a not-so-rare complication of connective tissue diseases and is usually related with an inauspicious prognosis. We present the case of a 67-years-old woman hospitalized for progressive dyspnea.

Two-dimensional echocardiography showed numerous features related to pulmonary hypertension (PH) with moderate Mitral Regurgitation.

The right cardiac catheterization confirmed mixed PH (pre and post capillary) without chest angio-TC evidence of pulmonary thromboembolism.

Thanks to optimized medical therapy (B-Blocker, ACE-i and diuretics), there was a significant clinical improvement documented at discharge.

After 1 year, due to recurrence of dyspnea, she was admitted to our medical unit.

Her clinical examination showed some of the characteristics of a connective tissue disease.

Compared to previous echocardiography, a moderate to mild reduction of MR was documented.

Chest CT scan revealed interstitial lung disease likely related to patient's underlying pathology. Immunological screening tests detected the presence of antinuclear (ANA) and anti-topoisomerase (ATA) antibodies. Right heart catheterization documented a worsening of PH with only pre-capillary component. On the basis of the above findings, a diagnosis of CREST syndrome complicated with PH was made, and the patient was started on oral combination of macitentan and riociguat. The frequency of this complication in connective tissue disease, the need for screening tests and different treatment approaches of pre and post capillary pulmonary hypertension is discussed.

360 CARDIOMEMS HF SYSTEM: CONTINUOUS REMOTE MONITORING FOR OPTIMIZE HF PATIENTS' MANAGEMENT AND RESOURCES CONSUMPTION

Background

Heart failure (HF) alternates phases of stability and phases of exacerbation, with a progressive decline in the patient's functional capacity and quality of life; the need to anticipate and improve the effectiveness of management of HF exacerbation has led to the development of several remote monitoring tools.

We report our experience with CardioMEMS HF system (implantable device to monitor changes in pulmonary artery diastolic pressure (PAPd) as early indicator of the onset of worsening HF) in order to optimize the pharmaceutical treatments strategy (e.g. Levosimendan infusion) and to assess the impact on hospital resources consumption and costs.

Methods

We enrolled 7 patients (69.00±4.88 years; 30% female) with end-stage HF, implanted with CardioMEMS and daily monitored remotely, in order to optimize both tailored adjustment of home therapy and infusions of Levosimendan. More in detail, if the cardiologist detected a tendency for PAPd to rise, patients were contacted for home therapeutic changes. If no further changes were possible, the patient was hospitalized for the infusion of Levosimendan.

In order to calculate the impact of this remote monitoring strategy on resources consumption, we collected data on hospitalizations (e.g. causes, numbers, length, high-cost drugs and costs) taking into account the same number of months pre and post-CardioMEMS implant for each patient.

Results

Following the implantation of CardioMEMS we observed a 45% reduction in the total number of hospitalizations and a 62% reduction in the days of hospitalization (from a total of 421 days before implantation to a total of 159 days post implantation in the observation period).

From an economic point of view, a significant hospital cost reduction was recorded in terms of both hospitalization costs (HF related re-hospitalization and CardioMEMS's implant related cost) and drugs infusion costs (hospital stay and drug costs); more specifically, the total savings for the 7 patients are around € 236,000 and total days of hospitalization avoided are around 500 days including the hospitalizations avoided for drugs infusion.

Accordingly, was recorded an improvement in patients’ quality of life measured with EQ5D (pre-implantation 75.17±2.06 vs post-implantation 108.60±8.70, p 0.0078).

Conclusions

Our preliminary results support the usefulness of this system in the remote management of the HF patients and in the re-hospitalization reduction both for exacerbation and drug management. In fact, the parameters’ monitoring through the CardioMEMS device allows a personalized management of drug therapy; more precisely, considering the drug Levosimendan, instead of a periodic standard timing for infusion, a patient-tailored timing of infusion was applied.

In conclusion, our innovative strategy contributes to achieve the organizational efficiency of the healthcare facilities, as well as to the adequate use and allocation of financial and human resources with a better outcome for HF patients.

589 THE EFFECT OF DAPAGLIFLOZIN ON SYMPTOMS, QUALITY OF LIFE AND ECHOCARDIOGRAPHIC PARAMETERS IN A REAL-WORLD POPULATION OF HFREF PATIENTS

Background

Large cardiovascular (CV) trials enrolling patients with type 2 diabetes showed that sodium glucose co-transporter-2 inhibitors (SGLT2i) significantly decreased heart failure (HF) hospitalization, both in patients with or without a history of HF.

Accordingly, DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure)

demonstrated the efficacy of dapagliflozin, for the reduction of CV death/HF hospitalization in patients with HF with reduced ejection fraction (HFrEF) regardless of type 2 diabetes status. However, there are still few real-word data and it is still not well known how early the clinical benefits are after the introduction of the drug into therapy; consequently, we aimed to evaluate the effect of dapagliflozin three months after its introduction in therapy in our real-world population.

Methods

From February 2022 to September 2022 we introduced Dapagliflozin in 23 HFrEF patients’ therapy and we collected data of 11 patients (66.78±3.96 years; 89% men) at 3-months-FU. Specifically, on the first visit we collected the clinical, laboratory and echocardiographic parameters and dapagliflozin was added to optimal medical therapy of patients; then, the patients were evaluated after 3 months (follow-up).

Results

At follow-up, all patients were free from side effects and we did not record statistically significant differences in laboratory parameters and/or blood pressure values.

As regards the echocardiographic parameters, there was an improvement in FE (28.11±2.95 vs 37.00±5.71%, p0.17), PAPS (46.89±3.94 vs 37.63±5.27mmHg, p0.17), and LVEDVind (75.34±10.58 vs 57.20±13.55 ml/m2, p0.30), although not statistically significant. Moreover, we observed a statistically significant reduction in the diameter of the inferior vena cava (18.89±1.78 vs 11.5±1.15 mm, p&lt;0.01), in NYHA class (2.78±0.15 vs 2±0, p&lt;0.001), in basal SO2 (95.67±0.78 vs 97.67±0.47%, p0.04) and an improvement of quality of life (EQ5Dtot 73.33±4.71 vs 86.67±4.41, p0.05; pain/discomfort 3.67±0.29 vs 4.78±0.22, p&lt;0.01; anxiety/depression 3.67±0.29 vs 4.67±0.24, p0.0163). Finally, we recorded a not statistically significant reduction in the amount of mineralocorticoid receptor antagonists (MRAs) at follow-up (62.5±12.5 vs 37.5±5.59 mg of eplerenone, p0.09).

Conclusions

Dapagliflozin improved symptoms, and quality of life in patients with HFrEF of our real world population already after 12 weeks, accordingly with previous data of DEFINE-HF trial. Moreover, already after 3 months was possible to record improvements in the echocardiographic parameters, even if they are not statistically significant. Certainly, it will be necessary to continue with the study to evaluate these results on a larger sample.

719 CIRCULATING SORTILIN LEVELS ARE INCREASED IN PATIENTS RECEIVING LONG-TERM WARFARIN AND ITS INHIBITION ATTENUATES WARFARIN-INDUCED VASCULAR CALCIFICATION

Long-term use of the vitamin K antagonist (VKA) warfarin, has been shown to accelerate vascular and valvular calcification both in rodents and in humans. Increasing evidence suggests that vascular endothelium contributes to calcification via endothelial-mesenchymal transition (EndMT). However, additional research is warranted to elucidate the signaling mechanisms involved. In the last decade, a prominent role for sortilin has been demonstrated in cardiovascular calcification. Moreover, we recently demonstrated that the increase of sortilin in the endothelium promotes endothelial dysfunction, a known initiator of EndMT.

Thus, we aim to investigate a potential contribution of sortilin in vascular calcification induced by warfarin. For this purpose, human endothelial cells and aortic rings from wild type C57BL/6J mice were cultured in promineralization medium in the presence of therapeutic levels of warfarin. Plasma sortilin and calcium levels were measured in 19 patients under VKA therapy who were stratified into short-term (3-12 months) or long-term group (24-45 months) based on VKA treatment duration.

Increased protein expression of sortilin was found both in the endothelial and in the medial smooth muscle layers of aortic rings. Sortilin immunostaining was found to co-localize with α-SMA in the endothelium of warfarin-treated aortic rings, a hallmark of EndMT. Interestingly, pharmacological inhibition of sortilin with AF38469 reduced calcification and prevented loss of expression of the endothelial marker von Willebrand Factor (vWF) induced by warfarin treatment in human endothelial cells and mouse aortas.

Finally, along with elevated plasma calcium levels, patients receiving long-term VKA showed increased circulating sortilin levels when compared to short term VKA-treated patients.

Our data provide evidence for a potential role for endothelial-derived sortilin in regulating vascular calcification promoted by warfarin, and suggest that targeting circulating sortilin may be beneficial for the prevention of warfarin-associated cardiovascular calcification.

Predictors of sacubitril/valsartan high dose tolerability in a real world population with HFrEF

AIMS

The angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril/valsartan (Sac/Val) demonstrated to be superior to enalapril in reducing hospitalizations, cardiovascular and all-cause mortality in patients with ambulatory heart failure and reduced ejection fraction (HFrEF), in particular when it is maximally up-titrated. Unfortunately, the target dose is achieved in less than 50% of HFrEF patients, thus undermining the beneficial effects on the outcomes. In this study, we aimed to evaluate the role of Sac/Val and its titration dose on reverse cardiac remodelling and determine which echocardiographic index best predicts the up-titration success.

METHODS AND RESULTS

From January 2020 to June 2021, we retrospectively identified 95 patients (65.6 [59.1-72.8] years; 15.8% females) with chronic HFrEF who were prescribed Sac/Val from the HF Clinics of 5 Italian University Hospitals and evaluated the tolerability of Sac/Val high dose (the ability of the patient to achieve and stably tolerate the maximum dose) as the primary endpoint in the cohort. We used a multivariable logistic regression analysis, with a stepwise backward selection method, to determine the independent predictors of Sac/Val maximum dose tolerability, using, as candidate predictors, only variables with a P-value < 0.1 in the univariate analyses. Candidate predictors identified for the multivariable backward logistic regression analysis were age, sex, body mass index (BMI), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), dyslipidaemia, atrial fibrillation, systolic blood pressure (SBP), baseline tolerability of ACEi/ARBs maximum dose, left ventricle global longitudinal strain (LVgLS), LV ejection fraction (EF), tricuspid annulus plane systolic excursion (TAPSE), right ventricle (RV) fractional area change (FAC), RV global and free wall longitudinal strain (RVgLS and RV-FW-LS). After the multivariable analysis, only one categorical (ACEi/ARBs maximum dose at baseline) and three continuous (younger age, higher SBP, and higher TAPSE), resulted significantly associated with the study outcome variable with a strong discriminatory capacity (area under the curve 0.874, 95% confidence interval (CI) (0.794-0.954) to predict maximum Sac/Val dose tolerability.

CONCLUSIONS

Our study is the first to analyse the potential role of echocardiography and, in particular, of RV dysfunction, measured by TAPSE, in predicting Sac/Val maximum dose tolerability. Therefore, patients with RV dysfunction (baseline TAPSE <16 mm, in our cohort) might benefit from a different strategy to titrate Sac/Val, such as starting from the lowest dose and/or waiting for a more extended period of observation before attempting with the higher doses.

P416 A NOT–SO–RARE COMPLICATION OF CONNECTIVE TISSUE DISEASE

Pulmonary hypertension is a not–so–rare complication of connective tissue diseases and is usually related with an inauspicious prognosis.We present the case of a 67–years–old woman hospitalized for progressive dyspnea. Two–dimensional echocardiography showed numerous features related to pulmonary hypertension (PH) with moderate Mitral Regurgitation. The right cardiac catheterization confirmed mixed PH (pre and post capillary) without chest angio–TC evidence of pulmonary thromboembolism. Thanks to optimized medical therapy (B–Blocker, ACE–i and diuretics), there was a significant clinical improvement documented at discharge. After 1 year, due to recurrence of dyspnea, she was admitted to our medical unit. Her clinical examination showed some of the characteristics of a connective tissue disease. Compared to previous echocardiography, a moderate to mild reduction of MR was documented. Chest CT scan revealed interstitial lung disease likely related to patient’s underlying pathology. Immunological screening tests detected the presence of antinuclear (ANA) and anti–topoisomerase (ATA) antibodies. Right heart catheterization documented a worsening of PH with only pre–capillary component. On the basis of the above findings, a diagnosis of CREST syndrome complicated with PH was made, and the patient was started on oral combination of macitentan and riociguat. The frequency of this complication in connective tissue disease, the need for screening tests and different treatment approaches of pre and post capillary pulmonary hypertension is discussed.

A Novel Combination of High-Load Omega-3 Lysine Complex (AvailOm®) and Anthocyanins Exerts Beneficial Cardiovascular Effects

Omega-3 fatty acids have been shown to exert several beneficial effects in the prevention of cardiovascular and cerebrovascular diseases. The objective of the present study was to analyze the effects of a novel high-load omega-3 lysine complex, AvailOm^®, its related constituents and a novel mixture of AvailOm^® with specific vasoactive anthocyanins on vascular function in mice resistance artery. Pressure myograph was used to perform vascular reactivity studies. Nitric oxide and oxidative stress were assessed by difluorofluorescein diacetate and dihydroethidium, respectively. Increasing doses of AvailOm^® exerted a dose-response vasorelaxation via AMPK-eNOS-mediated signaling. Omega-3 Ethyl Ester was identified as the main bioactive derivative of AvailOm^®, being capable of inducing vasorelaxant action to the same extent of entire product. The combination of AvailOm^® with a mix of potent vasoactive anthocyanins (C3-glu + DP3-glu + Mal3-glu + Mal3-gal + PEO3-gal), strongly protected mesenteric arteries from vascular dysfunction and oxidative stress evoked by oxidized-LDL. These data demonstrate for the first time the direct effects of AvailOm^® on resistance arteries. The evidence that the combination of specific vasoactive anthocyanins and AvailOm^® further enhanced the vasculoprotective properties of these compounds, may offer new promising perspectives for preventing the onset of cardiovascular and cerebrovascular events.

A Multistep Approach to Deal With Advanced Heart Failure: A Case Report on the Positive Effect of Cardiac Contractility Modulation Therapy on Pulmonary Pressure Measured by CardioMEMS

During the last years, the management of heart failure (HF) made substantial progress, focusing on device-based therapies to meet the demands of this complex syndrome. In this case report, we present a multistep approach to deal with HF. Specifically, we report the first patient subjected to the implantation of both Optimizer Smart^® (Impulse Dynamics Inc., Marlton, NJ, USA) and CardioMEMS devices. A 72-year-old male patient with HF and reduced ejection fraction (HFrEF) was admitted to our cardiology department in January 2021, following a progressive shortening of the time between hospitalizations for levosimendan infusions. Specifically, the patient was monitored daily by CardioMEMS, and a strategy of levosimendan infusions guided by the device had been adopted. He was also a carrier of MitraClips and cardiac resynchronization therapy defibrillator (CRT-D) and had optimized HF medical therapy. In January 2021, the patient implanted Optimizer Smart^® device for cardiac contractility modulation (CCM) therapy because of poor response to therapy and elevated pulmonary artery pressure (PAP). CCM significantly reduced PAP values following discharge (systolic PAP 33.67 ± 2.92 vs. 40.6 ± 3.37 mmHg, diastolic PAP 14.5 ± 2.01 vs. 22.5 ± 2.53 mmHg, mean PAP 22.87 ± 2.20 vs. 30.9 ± 2.99 mmHg, HR 60.93 ± 1.53 vs. 80.83 ± 3.66 bpm; p < 0.0001), with persisting effect at 9 months. The usefulness of CCM is objectively demonstrated for the first time by continuous invasive monitoring of PAP by CardioMEMS, which can suggest the correct timing for CCM implantation.

Post-COVID-19 Syndrome: Involvement and Interactions between Respiratory, Cardiovascular and Nervous Systems

Though the acute effects of SARS-CoV-2 infection have been extensively reported, the long-term effects are less well described. Specifically, while clinicians endure to battle COVID-19, we also need to develop broad strategies to manage post-COVID-19 symptoms and encourage those affected to seek suitable care. This review addresses the possible involvement of the lung, heart and brain in post-viral syndromes and describes suggested management of post-COVID-19 syndrome. Post-COVID-19 respiratory manifestations comprise coughing and shortness of breath. Furthermore, arrhythmias, palpitations, hypotension, increased heart rate, venous thromboembolic diseases, myocarditis and acute heart failure are usual cardiovascular events. Among neurological manifestations, headache, peripheral neuropathy symptoms, memory issues, lack of concentration and sleep disorders are most commonly observed with varying frequencies. Finally, mental health issues affecting mental abilities and mood fluctuations, namely anxiety and depression, are frequently seen. Finally, long COVID is a complex syndrome with protracted heterogeneous symptoms, and patients who experience post-COVID-19 sequelae require personalized treatment as well as ongoing support.

611 Mild cognitive impairment is associated with subclinical left ventricular dysfunction as assessed by global longitudinal strain in hypertensive patients

Aims

Left ventricular global longitudinal strain (GLS) detects subtle systolic abnormalities in various cardiovascular conditions, which represent significant risk factors for cognitive impairment and stroke. Specifically, GLS has emerged as a more precise myocardial function measure than left ventricular ejection fraction (LVEF). This study investigated the relationship of GLS with mild cognitive impairment (MCI) in hypertensive patients.

Methods and results

From February 2020 to October 2021 were enrolled hypertensive patients without atrial fibrillation and/or cerebrovascular and/or neurodegenerative diseases. Complete demographic, clinical characteristics, laboratory analyses, conventional echocardiographic parameters were collected. Finally, MCI was defined by accurate the Quick Mild Cognitive Impairment (QMCI) Screen corrected for age and education. This score explores spatial and temporal orientation, registration, delayed recall, clock design, logical memory, and verbal fluency in a brief time (5 min—score 0–100); a compliance questionnaire (Morisky medication adherence scale); a questionnaire on nutritional status (MNA). 81 hypertensive patients [66 ± 7.27 years; 9 (11%) female] were included in the study. Concerning echocardiographic evaluation, LVEF was 50.47 ± 9.95% and mean GLS was −16.00 ± 3.66. Mean QMCI corrected for age and education was 56.45 ± 9.37, and MCI was detected in 21 patients (26%). When comparing the patients with MCI (QMCItot &lt;49.4) and without MCI (QMCItot &gt;49.4), a statistically significant difference of GLS values was detected (no MCI: −16.52 ± 3.66 vs. MCI: −14.18 ± 3.23; P = 0.032); on the other hand, the two groups did not differ in LVEF (no MCI: 50.58 ± 9.70 vs. MCI: 48.86 ± 11.93; P = 0.864). Furthermore, excluding patients with FE ≥ 45% from the analysis, a statistically significant linear regression was observed between QMCI (corrected for age and education) and the GLS (P = 0.014) (Figure 1).

Conclusions

Compromised GLS, but not LV EF, is related to MCI in hypertensive patients who are free of clinical dementia, stroke, and neurodegenerative disease. Moreover, our study demonstrates for the first time the existence of a significant association between the QMCI and GLS; consequently, GLS could be an additional parameter in clinical practice for early recognition of MCI. However, studies on a larger population will be needed to confirm this association.

364 Pulmonary hypertension: survival and prognostic factors by subgroups

Aims

The definition of pulmonary hypertension (PH) requires the documentation of mean pulmonary arterial pressure (PAPm) ≥20 mmHg at rest, assessed by right cardiac catheterization. This condition can characterize multiple clinical conditions with different pathophysiological and haemodynamic aspects. Specifically, in pulmonary arterial hypertension (IAP) (Group 1), the increase in PAP is due to an intrinsic pathology of the pulmonary microcirculation; Group 2 includes the forms of IP associated with a pathology of the left heart; Group 3 includes all pathologies of the pulmonary parenchyma and/or hypoxic conditions that lead to a secondary impairment of the small circulation; Group 4 identifies patients with chronic thromboembolic pulmonary heart (CPCTE); finally, Group 5 includes rare clinical conditions in which IP is linked to direct involvement or ab extrinsic compression of the pulmonary vessels.

Methods and results

To examine the number of deaths and the differences between the various subgroups, we analyzed the follow-up of approximately 76 patients (64.30 ± 13.20 years, 37% male) enrolled in the Pulmonary Hypertension Clinic of the San Giovanni AOU Dio and Ruggi d’Aragona of Salerno from 2014 to 2020 excluding patients with IP under definition and those ‘screened’ who did not show pulmonary hypertension at rest. At each visit, the patients were subjected to anamnestic data collection, physical examination, measurement of blood pressure, heart rate, arterial saturation, transthoracic cardiac echo color Doppler at rest, attribution of the functional class NYHA, evaluation of functional capacity by performing the test of the 6-min walk test (6MWT) and possible programming of right cardiac catheterization. From the data analysis it was found that 26 patients (34.21%, 55.81 ± 13.90 years, 27% males) were affected by IP group 1; 15 patients (19.48%, 74.12 ± 6.26 years, 20% male) were affected by IP group 2; 14 patients (18.18%, 63.34 ± 11.52 years, 71% male) were affected by IP group 3; 12 patients (15.58%, 67.22 ± 11.53 years, 33% male) were affected by IP group 4; 2 patients (2.60%, 71.57 ± 12.48 years, 0% male) were affected by IP group 5; 7 patients (9.09%, 70.07 ± 8.27 years, 57% male) were affected by group 2–3 mixed IP. Analysing the number of deaths, of the 76 patients, 17 deaths were recorded in total (22.37%). All patients in group 1 had been treated with specific therapy and survival was 88% at 3 years. Of the three deaths (12%) in this group, one patient had idiopathic PAH non-responder to pulmonary vasoreactivity test, one patient belonged to the IAP subgroup associated with congenital heart shunt but with concomitant lung disease, and the third patient belonged to the IAP subgroup associated with connective tissue disease (specifically Takayasu’s arteritis). From the analysis of the idiopathic IAP subgroup it emerged that the patients were all women, with an average age of 50.81 ± 3.98 years, and that the deceased patient was distinguished at the first visit from the other patients for: a history of arterial hypertension, dysthyroidism, and obesity; worst NYHA class (III vs. II), elevated heart rate (102 vs. 70.00 ± 7.07 b.p.m.) and blood pressure (SBP: 150.00 vs. 127.50 ± 10.61; DBP 90.00 vs. 75.00 ± 7.07 mmHg) at rest at the clinic visit. Transthoracic echocardiography revealed elevated PAPs values (100.00 vs. 42.50 ± 20.51 mmHg), low TAPSE values (20.00 vs. 26.50 ± 3.54 mm), reduced pulmonary acceleration time (ACT 60 ms), enlargement of the right atrium (area 22 cm2), worst exercise tolerance parameters (6MWT 300 m and 86% final SO2 vs. 427.50 ± 74.25 m and 96.50 ± 0.71% final SO2).

Conclusions

The percentage of deaths in the different groups appears very heterogeneous, especially if we consider the six deaths (42.86%) in group 3 and three deaths (42.86%) in patients with mixed IP groups 2 and 3. In these two groups, age and advanced NYHA class were the most representative prognostic factors. On the other hand, analysing patients belonging to the idiopathic IAP subgroup, a worse prognosis is entrusted to the negativity of the vasoreactivity test, to the presence of cardiovascular comorbidities (arterial hypertension and dysthyroidism in our case), to worse echocardiographic values (PAPs, TAPSE, ACT, atrial area right) and reduced functional capacity at the 6MWT. However, early treatment and innovative drugs together with a careful strategy have been allowed.

487 Instrumental evaluation of mild cognitive decline in hypertensive patients: the role of transcranial doppler

Aims

Hypertension is a known risk factor for stroke and vascular dementia. Recent studies have also shown that arterial hypertension represents a clear risk factor for mild cognitive decline and its evolution into Alzheimer’s disease. Really, mild cognitive decline significantly compromises the patient’s quality of life, reducing compliance with therapy and increasing mortality and hospitalization. Diagnosis of dementia is challenging and requires both ruling out potentially treatable underlying causes and ruling in a diagnosis of dementia subtype. Currently, this diagnosis is based on the execution of second-level investigations (e.g. neuroimaging), that are expensive and not always available. For this reason, we analysed a population of hypertensive patients without atrial fibrillation and/or cerebrovascular and/or neurodegenerative diseases, with the aim of verifying the existence of an association between cognitive impairment and flows on the middle cerebral artery (MCA).

Methods

We considered 33 hypertensive patients (age 64.90 co1.40 years; 72% male). Specifically, we considered anthropometric, clinical, laboratory, and echocardiographic parameters. Also, we administered: an accurate, sensitive, and specific screening test (QMCI) for the assessment of intermediate cognitive decline (MCI), which explores spatial and temporal orientation, registration, delayed recall, clock design, logical memory and verbal fluency in a concise time (5 min—score 0–100); a compliance questionnaire (Morisky medication adherence scale); a questionnaire on nutritional status (MNA). Finally, we recorded transcranial Doppler flows on the MCA.

Results

There is no QMCItot score compatible with dementia (&lt;20) among the patients analysed. A statistically significant inverse association emerged between total QMCI score and Morisky score (P &lt; 0.0001); in addition, the analysis of the different sections of the QMCI questionnaire showed: an inverse relationship between the Morisky score and the clock test (P 0.013), delayed recall (P 0.024) and logical memory (P 0.028). By comparing the Doppler velocities sampled on the MCA with QMCI scores, a statistically significant inverse relationship was found between mean flow velocity and orientation at QMCI (P 0.023), between PSV and orientation (P 0.017) and between EDV and orientation (P 0.049) (Figure).

Conclusions

In conclusion, our study demonstrates for the first time the existence of a significant association between the QMCI and the sampling of the MCA at the ultrasound Doppler. Studies on a larger population will be needed to confirm this association and to test the translational relevance, in particular to tailor therapeutic approach in patients with abnormal MCA Doppler.

The Role of Oxidative Stress in Cardiovascular Aging and Cardiovascular Diseases

Aging can be seen as process characterized by accumulation of oxidative stress induced damage. Oxidative stress derives from different endogenous and exogenous processes, all of which ultimately lead to progressive loss in tissue and organ structure and functions. The oxidative stress theory of aging expresses itself in age-related diseases. Aging is in fact a primary risk factor for many diseases and in particular for cardiovascular diseases and its derived morbidity and mortality. Here we highlight the role of oxidative stress in age-related cardiovascular aging and diseases. We take into consideration the molecular mechanisms, the structural and functional alterations, and the diseases accompanied to the cardiovascular aging process.

Artificial Intelligence as a Business Partner in Cardiovascular Precision Medicine: an Emerging Approach for Disease Detection and Treatment Optimization

BACKGROUND

In the real world, medical practice is changing hand in hand with the development of new Artificial Intelligence (AI) systems and problems from different areas have been successfully solved using AI algorithms. Specifically, the use of AI techniques in setting up or building precision medicine is significant in terms of the accuracy of disease discovery and tailored treatment. Moreover, with the use of technology, clinical personnel can deliver a very much efficient healthcare service.

OBJECTIVE

This article reviews AI state-of-the-art in cardiovascular disease management, focusing on diagnostic and therapeutic improvements.

METHODS

To that end, we conducted a detailed PubMed search on AI application from distinct areas of cardiology: heart failure, arterial hypertension, atrial fibrillation, syncope and cardiovascular rehabilitation. Particularly, to assess the impact of these technologies in clinical decision-making, this research considers technical and medical aspects.

RESULTS

On one hand, some devices in heart failure, atrial fibrillation and cardiac rehabilitation represent an inexpensive, not invasive or not very invasive approach to long-term surveillance and management in these areas. On the other hand, the availability of large datasets (big data) is a useful tool to predict the development and outcome of many cardiovascular diseases. In summary, with this new guided therapy, the physician can supply prompt, individualised, and tailored treatment and the patients feel safe as they are continuously monitored, with a significant psychological effect.

CONCLUSION

Soon, tailored patient care via telemonitoring can improve the clinical practice because AI-based systems support cardiologists in daily medical activities, improving disease detection and treatment. However, the physician-patient relationship remains a pivotal step.

Serum Uric Acid and Left Ventricular Mass in Essential Hypertension

Serum uric acid (sUA) has been associated with cardiovascular risk. Although the recent mechanistic hypothesis poses the basis for the association between sUA and left ventricular mass index (LVMi), the issue remains poorly investigated in a clinical setup. Through a retrospective analysis of the database of the departmental Hypertension Clinic of University Hospital of Salerno Medical School, we identified 177 essential hypertensives (age 60.3 ± 13.3 years; 85 men), free from uric acid-modulating medications and severe chronic kidney disease, and whose sUA values, anthropometric, clinical, and echocardiographic data were available. In the studied cohort, the average duration of hypertension was 8.4 ± 7.1 years. LVMi associated with classical determinants, such as age, blood pressure, and kidney function, although after multivariate correction, only age remained significant. Also, sUA correlated positively with LVMi, as well as body size, metabolism, and kidney function. In a multivariate analysis, sUA confirmed the independent association with LVMi. Also, levels of sUA >5.6 mg/dl are associated with larger cardiac size. We confirmed our data in a replicate analysis performed in a larger population (1,379 hypertensives) from an independent clinic. Our results demonstrate that sUA increases with LVMi, and a cutoff of 5.6 mg/dl predict larger LV sizes. Our data suggest that hyperuricemia might help to stratify the risk of larger cardiac size in hypertensives.

It is easy to see, but it is better to foresee: a case report on the favourable alliance between CardioMEMS and levosimendan

Background

In the past years, different devices have been investigated to help in identifying early decompensation events in patients with heart failure (HF) and reduced ejection fraction (EF), reducing hospital admissions. In this report, we present the first patient experience with levosimendan infusion led by CardioMEMS.

Case summary

A 68-year-old man with HF and reduced EF with more than 20 hospitalizations for exacerbation of HF was enrolled in our HF Clinic from October 2017. Echocardiogram showed a dilated left ventricle with severely reduced EF (29%) and increased pulmonary artery systolic pressure (40 mmHg). From October 2017 to May 2019, the patient went through numerous hospitalizations, despite optimal medical therapy; subsequently, was adopted a strategy of levosimendan infusions guided by CardioMEMS. Levosimendan infusions improved haemodynamic and pressure profiles. The patient was monitored daily by CardioMEMS, and from June to December 2019, he had only two hospitalizations scheduled for levosimendan infusion and none for HF exacerbation.

Discussion

Our case supports the combination of CardioMEMS and levosimendan for the optimal management of patients with advanced HF. These results further strengthen the development of a randomized clinical trial to demonstrate the clinical usefulness of this device in combination with the levosimendan infusion programme in advanced HF patients.

We are What We Eat: Impact of Food from Short Supply Chain on Metabolic Syndrome

Food supply in the Mediterranean area has been recently modified by big retail distribution; for instance, industrial retail has favored shipments of groceries from regions that are intensive producers of mass food, generating a long supply chain (LSC) of food that opposes short supply chains (SSCs) that promote local food markets. However, the actual functional role of food retail and distribution in the determination of the risk of developing metabolic syndrome (MetS) has not been studied hitherto. The main aim of this study was to test the effects of food chain length on the prevalence of MetS in a population accustomed to the Mediterranean diet. We conducted an observational study in Southern Italy on individuals adhering to the Mediterranean diet. We examined a total of 407 subjects (41% females) with an average age of 56 ± 14.5 years (as standard deviation) and found that being on the Mediterranean diet with a SSC significantly reduces the prevalence of MetS compared with the LSC (SSC: 19.65%, LSC: 31.46%; p: 0.007). Our data indicate for the first time that the length of food supply chain plays a key role in determining the risk of MetS in a population adhering to the Mediterranean diet.

Vitamin D, parathyroid hormone and cardiovascular risk: the good, the bad and the ugly

25-Hydroxyvitamin D insufficiency and increased cardiovascular risk (CVR) association is still debated. The vitamin D (VitD)-dependent parathyroid hormone (PTH) is considered as the possible actuator of VitD effects on CVR. To investigate the association of CVR, PTH and VitD, we carried out blood pressure measurements and blood samples and collected information on dietary habits, anamnestic, clinical and metabolic data of 451 participants in the Salerno area (Southern Italy) during the World Hypertension Day (17 May). CVR was calculated according to the Framingham CVR charts. The overall population mean age was 51.6 ± 0.7 years, and female sex was slightly prevalent (55%). VitD deficiency (<20 ng/ml) was most frequent (59.7%). In this population, VitD and CVR did not correlate. VitD and PTH inversely correlated (r = −0.265, P < 0.001) as expected. PTH was in direct correlation (r = 0.225, P < 0.001) with CVR. Elevated PTH (75 percentile; ≥49.5 pg/ml) levels identify a population with higher CVR (11.8 ± 0.5 vs. 8.5 ± 0.3, P < 0.001). In a multivariate analysis, both age and PTH correlate to CVR, but not VitD. In conclusion, VitD does not directly affect CVR in the overall population. Rather, increased PTH might be a better predictor of CVR.

Abstract P197: Vitamin D, Paratohormone and Cardiovascular Risk: The Good, the Bad and the Ugly

25OH Vitamin D (VitD) insufficiency and increased cardiovascular risk (CVR) association is still debated. The VitD dependendent paratohormone (PTH), is considered as the possible actuator of VitD effects on CVR. In an overall population observational study, we assessed the role of PTH in predicting CVR. We recruited 412 persons during the World Hypertension Day, in the area of Salerno, Southern Italy. Through means of dedicated questionnaires, blood pressure measurements and a blood draught, we collected dietary habits, anamnestic, clinical and metabolic data. CVR was calculated according to the Framingham CVR charts. The overall population mean age±SD was 49.9±20 yrs, and female sex was slightly prevalent (53.2%). VitD deficiency (<20 uMol/ml) was most frequent (65.4%). In this population VitD and CVR did not correlate. VitD and PTH inversely correlated (r=-0.236, p<0.001) as expected. PTH was in direct linear regression with CVR (F=14,982, p<0.0001).

Elevated PTH (>=56 mg/dl) levels identify a population with higher CVR (11.9±6.2 vs 9.2±7.1, p<0.01) and larger prevalence of cardiovascular events (10,2 vs 4.1, p<0,04). Since PTH increases with age and kidney function, we selected a 41-60 years old population (N=150). Also in this homogenous group, people with elevated PTH present a larger cardiovascular risk (8.4±10.5 vs 4.1±4.8, p<0,01) due to higher systolic blood pressure (137.2±20.4 vs 130.1±16.0, p<0.05). In conclusion, VitD deficiency causes PTH elevation that in the overall population increases the CVR. Our data let hypothesize that VitD supplementation may represent a major presidium to reduce PTH level and consequently CVR.

Larger Blood Pressure Reduction by Fixed-Dose Compared to Free Dose Combination Therapy of ACE Inhibitor and Calcium Antagonist in Hypertensive Patients

The introduction of fixed combination of ACEi+CCB (Fixed) has significantly increased patients compliance and adherence to therapy. At the moment, however, there are no data suggesting the better control of once-daily fixed (Fixed) over free doses in separate administrations combination therapy in hypertensives. In a population of 39 consecutive outpatient patients referred to the departmental Hypertension clinic of the University Hospital of Salerno Medical School with the first diagnosis of arterial hypertension, we tested the hypothesis that the Fixed achieve a better control of blood pressure than the Free combination. Patients were randomized to either strategy and after 3 months patients underwent a clinical assessment to evaluate the antihypertensive effect. The two groups, matched for anthropometric and clinical parameters, received Amlodipine (5-10 mg/daily) and Perindopril (5-10 mg/daily). Perindopril and Amlodipine doses did not significantly differ between the two groups. After 3 months BP control was improved in both groups and BP targets were similarly reached in both groups (SBP; Fixed: 61.54%; Free 69.23%; n.s. DPB; Fixed: 80.77%; Free 84.62%; n.s.). The reduction in systolic blood pressure was similar in both groups (Fixed:7.64±2.49%; Free: 7.81±4.00%, n.s.), while the reduction of diastolic blood pressure was greater in the Fixed group (Fixed: 14.22±2.03%; Free: 4.92±5.00%, p<0.05). Although both strategies are effective in reducing BP, the use of Fixed dose has an advantage in the reduction of BP. The present study does not allow to identify the mechanisms of this difference, which can be assumed to be due to the pharmacokinetics of the drugs administered in once-daily fixed combination.

Abstract P124: “Beyond Silos” Model of Homecare Improves Blood Pressure Control in Multimorbid Hypertensive Patients

Introduction: Less than 40% of hypertensive on antihypertensive treatment have pressure <140/90 mmHg. Among the most common causes is poor adherence to therapy, in particular in multimorbid, polytreated patients. ICT based new models of care like Smartcare or Beyond Silos (www.beyondsilos.eu) that offer patient-centered home care including telemonitoring, represent a new tool to strengthen the doctor-patient interaction, and improve compliance of chronic patients.

Methods: To verify the impact of home care strategy to improve pressure control, from February 1 to March 31 2016 we selected patients who accessed the Outpatient Clinic for Hypertension at the AOU San Giovanni e Ruggi in Salerno, those with 1) poor BP control >140 and/or DBP>90 mmHg) after at least three follow-up visits in the last year, 2) optimal drug therapy, 3) poor adherence to therapy, 4) at least one concurrently treated chronic condition. Patients who signed informed consent received “Beyond Silos” home care program, including a weekly nurse access, for four weeks, and telemonitoring through 3G-connected devices of systolic (SBP) and diastolic (DBP) blood pressure, heart rate (HR) and body weight measuring and Oxygen Saturation. Each patient was instructed to scheduled self-assesment of the above parameters that were stored on the Local Health Authority server of Salerno. Treatment compliance was verified weekly by the nurse through drug blister count. After 4 weeks, patients were evaluated at the hospital premises.

Results: We selected seven patients (M/F=5/2; age 73.4 ± 2.3 years). In this population BP control that went from ambulatory SBP/DBP 155±5/74±4mmHg to 111±1.7/95.9±2.7mmHg, p <0.001). Adherence scores assessed at the home of the patients also were improved. No changes were observed in HR, weight and oxygen saturation.

Conclusion: Our data show that patients with a hitory of loose BP control despite optimal therapy can achieve controlled BP through Beyond Silos home care program within a month. This suggest that strategies of ICT based home care might represent a real breackthrough in the management of chronic conditions, in particular for multimorbid, poor compliant patients. Future large scale studies are needed for assessing long term effects on cardiovascular outcome.

Ultrastructural ciliary findings in nasal obstructive diseases

Specific ultrastructural findings have widely been described in case of obstructive nasal diseases due to congenital defects. Ciliary impairment has in particular been observed as the main pathological feature in these conditions. In this study, nasal mucosal samples from different pathologies have been collected via the "brushing" technique and analysed by transmission electron microscopy. TEM analysis was focused on specific features, such as the numerical array of peripheral and central doublets of the cilium axoneme, including eventual microtubular disarrangement; partial or total loss of inner and/or outer dynein arms; defects of radial spokes and nexin links; disorientation of the ciliary axis in closely adjacent cilia, calculating the angle between the line crossing the central microtubular core and the horizontal ciliary axis and compound cilia (CC). Statistical comparison was carried out between study and control groups. A significant incidence of organic ciliary defects was found not only in patients with inflammatory processes, but mostly in those supposed to have a long-lasting nasal respiratory disease due to mechanical stenosis in relation to septum deviation and turbinate hypertrophy. Prevalence and percentage of compound cilia were instead more related to inflammatory conditions. The "brushing" technique can be considered an easy and reliable method for the assessment of the condition of the nasal mucosa. According to the findings derived from this study, mechanical nasal obstruction seems to cause major alterations on the nasal ciliary arrangement, thus determining a functional impairment on the whole nasal function.

Fibroblast growth factor 10 induces proliferation and differentiation of human primary cultured keratinocytes

Fibroblast growth factor 10 is a novel member of the fibroblast growth factor family, which is involved in morphogenesis and epithelial proliferation. It is highly homologous to the keratinocyte growth factor (or fibroblast growth factor 7), a key mediator of keratinocyte growth and differentiation. Both fibroblast growth factor 10 and keratinocyte growth factor bind with high affinity to the tyrosine kinase keratinocyte growth factor receptor. Here we analyzed the effect of fibroblast growth factor 10 on primary cultures of human keratinocytes, grown in chemically defined medium, and we compared the proliferative and differentiative cell responses to fibroblast growth factor 10 with those induced by keratinocyte growth factor and epidermal growth factor. Cell counting, 5-bromo-2'-deoxyuridine incorporation, and western blot analysis showed that fibroblast growth factor 10, similarly to keratinocyte growth factor, not only is a potent mitogen for human keratinocytes, but also promotes the expression of both early differentiation markers K1 and K10 and late differentiation marker filaggrin in response to the Ca2+ signal, and seems to sustain the proliferative activity in suprabasal stratified cells. Immunoprecipitation/western blot analysis revealed that fibroblast growth factor 10, similarly to keratinocyte growth factor, is able to induce tyrosine phosphorylation of keratinocyte growth factor receptor and of cellular substrates such as PLCgamma.

Up-modulation of the expression of functional keratinocyte growth factor receptors induced by high cell density in the human keratinocyte HaCaT cell line

Keratinocyte growth factor (KGF) is involved in the control of proliferation and differentiation of human keratinocytes. It binds to, and activates, the tyrosine kinase KGF receptor (KGFR), a splicing transcript variant of the fibroblast growth factor receptor 2. We have previously shown (C. Marchese et al., Cell Growth Differ., 8: 989-997, 1997) that differentiation of primary cultured keratinocytes triggered by high Ca2+ concentrations in the growing medium induced up-regulation of KGFR expression, which suggested that KGFR may play a crucial role in the control of the proliferative/differentiative program during transition from basal to suprabasal cells. Here we analyzed the process of modulation of the expression of KGFRs in the human keratinocyte cell line HaCaT, widely used as a model to study keratinocyte differentiation. Western blot and double immunofluorescence for KGFR and the K1 differentiation marker showed that cell differentiation and stratification induced by confluence and high cell density correlated with an increase in KGFR expression. KGFRs, present on suprabasal differentiated cells, appeared to be efficiently tyrosine-phosphorylated by KGF, which indicated that the receptors up-regulated by differentiation can be functionally activated by ligand binding. Bromodeoxyuridine incorporation assay revealed that a significant portion of suprabasal differentiated cells expressing KGFR seemed to be still able to synthesize DNA and to proliferate in response to KGF, which suggested that increased KGFR expression may be required for retention of the proliferative activity.

ErbB2 immune response in breast cancer patients with soluble receptor ectodomain

Investigation of ErbB2 immunity in human breast cancer employing recombinant expression sources in immunoblot analysis revealed ErbB2-specific antibodies of the IgG isotype in sera of 14 of 71 cancer patients and 1 of 31 normal donors. Reactivity was confirmed on ErbB2-specific immunoprecipitates. Independent evidence of existing ErbB2 immunity was obtained after in vitro transformation of peripheral blood leukocytes from six positive patients. Furthermore, in vitro immortalization of B-lymphocytes unmasked existent ErbB2 immunity in 1 of 8 patients negative for ErbB2 serum antibodies. Determining shed ErbB2 extracellular domain as an indirect measure of tumor burden in ErbB2-positive malignancy, elevated serum levels were observed in 16 of 71 breast cancer and 1 of 31 normal donor sera. Strikingly, existing ErbB2 immunity correlated significantly with elevated shed ErbB2 ectodomain among the patients analyzed. Incidence of both ErbB2 immunity and elevated ErbB2 extracellular domain increased with a progressed disease stage and was significantly associated with metastatic breast cancer. These observations implicate soluble ErbB2 amounts in vivo in the development of ErbB2 immunity in breast cancer. They further project serum analysis of ErbB2 immunity and soluble ectodomain as potential markers of disease progression in ErbB2-positive malignancy.

Molecular characterization of human IgG monoclonal antibodies specific for the major birch pollen allergen Bet v 1. Anti-allergen IgG can enhance the anaphylactic reaction

We report the molecular characterization of five human monoclonal antibodies, BAB1-5 (BAB1: IgG(1); BAB4: IgG(2); BAB2, 3, 5: IgG(4)), with specificity for the major birch pollen allergen, Bet v 1. BAB1-5 were obtained after immunotherapy and contained a high degree of somatic mutations indicative of an antigen-driven affinity maturation process. While BAB1 inhibited the binding of patients IgE to Bet v 1, BAB2 increased IgE recognition of Bet v 1, and, even as Escherichia coli-expressed Fab, augmented Bet v 1-induced immediate type skin reactions. The demonstration that IgG antibodies can enhance allergen-induced allergic reactions is likely to explain the unpredictability of specific immunotherapy.

Expression of GM3 microdomains on the surfaces of murine fibroblasts correlates with inhibition of cell proliferation

The expression and surface distribution of monosialoganglioside GM3 on the plasma membranes of NIH3T3 fibroblasts cultured at semiconfluence were analyzed by immunofluorescence as well as by immunogold electron microscopy on thin sections and surface replicas. The GM3 expression was highly variable from cell to cell and the distribution of the ganglioside on the positive cells appeared punctate. Quantitative immunogold electron microscopy showed the existence of well-defined GM3 clusters of different sizes scattered all over the cell surfaces. Double immunofluorescence analysis of 5-bromo-2'-deoxyuridine incorporation to identify proliferating cells and of GM3 expression indicated that most of the GM3-positive cells appear unable to synthesize DNA and demonstrated a growth-dependent expression of GM3.

Expression of keratinocyte growth factor receptor compared with that of epidermal growth factor receptor and erbB-2 in endometrial adenocarcinoma

Immunohistochemical analysis of the expression of keratinocyte growth factor receptor (KGFR) was performed in human endometrial carcinomas from 18 patients and in normal proliferative and secretory endometrium. The level of immunostaining was correlated with the clinico-pathological characteristics of the endometrial carcinoma patients and with the parallel expression of the epidermal growth factor receptor (EGFR) and erbB-2. The results showed that KGFR expression increased with the stage of the tumor and that the simultaneous overexpression of the three growth factor receptors appeared to be related to the depth of myometrial invasion. Taken together, these observations suggest that KGFR may represent an additional prognostic indicator in endometrial cancer.

Immune responses to all ErbB family receptors detectable in serum of cancer patients

Employing NIH3T3 transfectants with individual human ErbB receptor coding sequences as recombinant antigen sources, we detected by immunoblot analysis specific immunoreactivity against all four ErbB receptors among 13 of 41 sera obtained from patients with different types of epithelial malignancies. Overall, serum positivity was most frequently directed against ErbB2 followed by EGFR, ErbB3 and ErbB4. Specificity patterns comprised tumor patients with unique serum reactivity against ErbB2 or ErbB4. Moreover, approximately half of the positive sera exhibited concomitant reactivity with multiple ErbB receptors including EGFR and ErbB2, EGFR and ErbB4, ErbB2 and ErbB3 or EGFR, ErbB2 and ErbB3. Serum reactivity was confirmed for the respective ErbB receptors expressed by human tumor cells and corroborated on receptor-specific immunoprecipitates. Positive sera contained ErbB-specific antibodies of the IgG isotype. Representative immunohistochemical analysis of tumor tissues suggested overexpression of ErbB receptors for which serum antibodies were detectable in five of six patients. These findings implicate multiple ErbB receptors including ErbB3 and ErbB4 in addition to EGFR and ErbB2 in primary human cancer. Heterogeneity of natural ErbB-specific responses in cancer patients warrants their evaluation in light of immunotherapeutic approaches targeting these receptors.

Expression of a human IgG4 antibody, BAB2, with specificity for the major Birch pollen allergen, Bet v 1 in Escherichia coli: recombinant BAB2 Fabs enhance the allergic reaction

BACKGROUND

Antigen recognition by antibodies of different isotypes can result in completely different effects as exemplified by Type I allergy. While the IgE-antibody-mediated release of biological mediators constitutes the immunopathological basis for the immediate symptoms observed in allergic patients, allergen-specific IgG antibodies are thought to have protective effects.

METHODS

Cell lines secreting five human monoclonal IgG antibodies (BAB1-BAB5) with specificity for the major birch pollen allergen Bet v 1 were established from a birch-pollen-allergic patient who had received birch- pollen-specific immunotherapy. The influence of the Bet v 1-specific IgG antibodies on IgE binding to Bet v 1 was investigated. BAB2 was expressed in Escherichia coli as recombinant Fab, purified and tested for its ability to modulate Bet v 1-induced immediate-type skin reactions.

RESULTS

The BAB antibodies belonged to different IgG subclasses (BAB1: IgG1; BAB2, BAB3, BAB5: IgG4; and BAB4: IgG2) reflecting a tendency towards Th2. BAB1 represented the only antibody which strongly blocked IgE binding to Bet v 1, whereas BAB 3-BAB5 had little effect on IgE binding. Surprisingly, natural BAB2 antibodies as well as recombinant BAB2 Fabs strongly enhanced IgE binding to Bet v 1 and Bet v 1-induced immediate-type skin reactions and thus represent 'enhancing antibodies'.

CONCLUSION

The demonstration that anti-allergen IgG antibodies can also enhance IgE binding to a given allergen explains the unpredictability of specific immunotherapy as well as the controversy on the role of IgG in atopy.

Immunologic characterization of monoclonal antibodies that modulate human IgE binding to the major birch pollen allergen Bet v 1

BACKGROUND

Bet v 1 and homologous proteins represent major allergens for almost 95% of patients allergic to tree pollen and approximately 70% of those allergic to fruits and vegetables. As yet, no continuous (sequential) IgE epitopes have been determined for Bet v 1, and evidence has accumulated that Bet v 1 IgE epitopes belong to the conformational (discontinuous) type.

OBJECTIVE

A panel of 85 mouse monoclonal anti-Bet v 1 antibodies was raised as a tool with which to study the interaction of human IgE antibodies with Bet v 1.

METHODS

The epitopes of selected monoclonal antibodies (mAbs) were characterized by mapping with synthetic overlapping peptides and by cross-competition experiments. Cross-reactivity of Bet v 1-specific mAbs with tree and plant food allergens was investigated by Western blotting. The influence of Bet v 1-specific mAbs on the IgE-Bet v 1 interaction was studied by competition assays with immobilized purified recombinant Bet v 1 and by basophil histamine release experiments.

RESULTS

Antibodies that increased the IgE binding to Bet v 1 up to fivefold could be defined, whereas others inhibited IgE binding to Bet v 1 up to 99% and competed with the Bet v 1-induced histamine release from patients' basophils.

CONCLUSION

The activity of the enhancing antibodies is interpreted as a stabilization of Bet v 1 states/IgE epitopes, which are either more accessible for certain IgE antibodies or are recognized with higher affinity. Those mAbs that competed with the Bet v 1-IgE interaction, if humanized or produced as recombinant antibody fragments, might be considered as potential tools for local allergy therapy.

Human IgG monoclonal antibodies that modulate the binding of specific IgE to birch pollen Bet v 1

Birch pollen allergy is a very frequent pathology in Europe and North America. More than 95% of the tree pollen allergic patients display IgE reactivity against Bet v 1, the major birch pollen allergen. Starting with PBL from a patient desensitized by immunotherapy, we have generated five B cell lines (BAB1 to BAB5) that secrete human IgG mAbs of high affinity for Bet v 1. Although competition studies indicated that these human IgG mAb recognized different epitopes, broad cross-reactivity was found with Bet v 1 homologous allergens present in tree pollens and plant-derived foods. When tested for interference with allergic patients' IgE, BAB1 inhibited (by 80-100%) the binding of IgE to nitrocellulose-blotted Bet v 1, while BAB2 enhanced it. The biologic significance of the ability of BAB1 to interfere with patients' IgE binding is indicated by the finding that BAB1 completely inhibited Bet v 1-induced histamine release from allergic patients' basophils. Allergen-specific human IgG mAbs such as BAB1, which presents high blocking activity in both immunochemical and cellular IgE competition experiments, might have therapeutical application.

Human IgG monoclonal antibodies that modulate the binding of specific IgE to birch pollen Bet v 1

Birch pollen allergy is a very frequent pathology in Europe and North America. More than 95% of the tree pollen allergic patients display IgE reactivity against Bet v 1, the major birch pollen allergen. Starting with PBL from a patient desensitized by immunotherapy, we have generated five B cell lines (BAB1 to BAB5) that secrete human IgG mAbs of high affinity for Bet v 1. Although competition studies indicated that these human IgG mAb recognized different epitopes, broad cross-reactivity was found with Bet v 1 homologous allergens present in tree pollens and plant-derived foods. When tested for interference with allergic patients' IgE, BAB1 inhibited (by 80-100%) the binding of IgE to nitrocellulose-blotted Bet v 1, while BAB2 enhanced it. The biologic significance of the ability of BAB1 to interfere with patients' IgE binding is indicated by the finding that BAB1 completely inhibited Bet v 1-induced histamine release from allergic patients' basophils. Allergen-specific human IgG mAbs such as BAB1, which presents high blocking activity in both immunochemical and cellular IgE competition experiments, might have therapeutical application.