Association between Inflammation and New-Onset Atrial Fibrillation in Acute Coronary Syndromes.

Acute coronary syndrome (ACS) is a complex clinical syndrome that encompasses acute myocardial infarction (AMI) and unstable angina (UA). Its underlying mechanism refers to coronary plaque disruption, with consequent platelet aggregation and thrombosis. Inflammation plays an important role in the progression of atherosclerosis by mediating the removal of necrotic tissue following myocardial infarction and shaping the repair processes that are essential for the recovery process after ACS. As a chronic inflammatory disorder, atherosclerosis is characterized by dysfunctional immune inflammation involving interactions between immune (macrophages, T lymphocytes, and monocytes) and vascular cells (endothelial cells and smooth muscle cells). New-onset atrial fibrillation (NOAF) is one of the most common arrhythmic complications in the setting of acute coronary syndromes, especially in the early stages, when the myocardial inflammatory reaction is at its maximum. The main changes in the atrial substrate are due to atrial ischemia and acute infarcts that can be attributed to neurohormonal factors. The high incidence of atrial fibrillation (AF) post-myocardial infarction may be secondary to inflammation. Inflammatory response and immune system cells have been involved in the initiation and development of atrial fibrillation. Several inflammatory indexes, such as C-reactive protein and interleukins, have been demonstrated to be predictive of prognosis in patients with ACS. The cell signaling activation patterns associated with fibrosis, apoptosis, and hypertrophy are forms of cardiac remodeling that occur at the atrial level, predisposing to AF. According to a recent study, the presence of fibrosis and lymphomononuclear infiltration in the atrial tissue was associated with a prior history of AF. However, inflammation may contribute to both the occurrence/maintenance of AF and its thromboembolic complications.

Echocardiographic assessment of epicardial adipose tissue thickness as independent predictor in coronary artery disease.

This study aimed to assess the utility of echocardiography-measured epicardial adipose tissue (EAT) thickness (EATT) as an independent predictor for coronary artery disease (CAD), examining its correlation with oxidative stress levels in epicardial tissue and the complexity of the disease in patients undergoing open-heart surgery. This study included a total of 25 patients referred for cardiac surgery with 14 in the CAD group and 11 in the non-CAD group. Epicardial fat was sampled from patients subjected to open-heart surgery. EATT was higher in the CAD group compared to the non-CAD group (8.15 ± 2.09 mm vs. 5.12 ± 1.8 mm, p = 0.001). The epicardial reactive oxygen species level was higher in the CAD group compared to the non-CAD group (21.4 ± 2.47 nmol H2O2/g tisssue/h vs. 15.7 ± 1.55 nmol H2O2/g tisssue/h, p < 0.001). EATT greater than 6.05 mm was associated with CAD, with a sensitivity of 86% and specificity of 73%. Echocardiographically measured EATT is a significant, independent predictor of CAD. Its relationship with increased EAT oxidative stress levels suggests a potential mechanistic link between EATT and CAD pathogenesis. These findings highlight the importance of EATT as a diagnostic tool in assessing the complexity of CAD in patients undergoing cardiac surgery.

Radial Artery Spasm-A Review on Incidence, Prevention and Treatment.

Radial artery spasm (RAS) is a common complication associated with transradial access (TRA) for coronary interventions, particularly affecting elderly patients in whom radial access is preferred due to its benefits in reducing bleeding complications, improving clinical outcomes, and lowering long-term costs. This review examines the incidence, prevention, and treatment of RAS. Methods included an online search of PubMed and other databases in early 2024, analyzing meta-analyses, reviews, studies, and case reports. RAS is characterized by a sudden narrowing of the radial artery due to psychological and mechanical factors with incidence reports varying up to 51.3%. Key risk factors include patient characteristics like female sex, age, and small body size as well as procedural factors such as emergency procedures and the use of multiple catheters. Preventive measures include using distal radial access, hydrophilic sheaths, and appropriate catheter sizes. Treatments involve the intraarterial administration of nitroglycerine and verapamil as well as mechanical methods like balloon-assisted tracking. This review underscores the need for standardizing RAS definitions and emphasizes the importance of operator experience and patient management in reducing RAS incidence and improving procedural success.

Left Atrium Reverse Remodeling in Fusion CRT Pacing: Implications in Cardiac Resynchronization Response and Atrial Fibrillation Incidence.

Background: When compared to biventricular pacing, fusion CRT pacing was linked to a decreased incidence of atrial fibrillation (AF). There is a gap in the knowledge regarding exclusive fusion CRT without interference with RV pacing, and all the current data are based on populations of patients with intermittent fusion pacing. Purpose: To assess left atrium remodeling and AF incidence in a real-life population of permanent fusion CRT-P. Methods: Retrospective data were analyzed from a cohort of patients with exclusive fusion CRT-P. Device interrogation, exercise testing, transthoracic echocardiography (TE), and customized medication optimization were all part of the six-monthly individual follow-up. Results: Study population: 73 patients (38 males) with non-ischemic dilated cardiomyopathy aged 63.7 ± 9.3 y.o. Baseline characteristic: QRS 159.8 ± 18.2 ms; EF 27.9 ± 5.1%; mitral regurgitation was severe in 38% of patients, moderate in 47% of patients, and mild in 15% of patients; 43% had type III diastolic dysfunction (DD), 49% had type II DD, 8% had type I DD. Average follow-up was 6.4 years ± 27 months: 93% of patients were responders (including 31% super-responders); EF increased to 40.4 ± 8.5%; mitral regurgitation decreased in 69% of patients; diastolic profile improved in 64% of patients. Paroxysmal and persistent AF incidence was 11%, with only 2% of patients developing permanent AF. Regarding LA volume, statistically significant LA reverse remodeling was observed. Conclusions: Exclusive fusion CRT-P was associated with important LA reverse remodeling and a low incidence of AF.

From ECG to Imaging: Challenges in the Diagnosis of Adult Congenital Heart Diseases.

Congenital heart diseases (CHD) are one of the most common birth defects and the main leading cause of death in children. Many patients with CHD are reaching adulthood due to the success of improved contemporary surgical procedures. Understanding the etiology of CHD remains important for patient clinical management. Both genetic and environmental factors are involved in the development and progression of CHD. Variations in many different genes and chromosomal anomalies can be associated with CHD, by expression of different mechanisms. Sporadic cases are the most frequently encountered in these patients. Atrial septal defect is a common congenital heart disease that refers to direct communication between atrial chambers, found isolated or associated with other syndromes. Imaging techniques, especially transthoracic and transesophageal echocardiography (TOE) represent the key for diagnosis and management of ASD. The disease has a major incidence in adulthood, due to late symptomatology, but assessment and treatment are important to avoid time-related complications. Ebstein's anomaly is a rare congenital disease, with a dominant genetic participation, characterized by an abnormal displacement of the tricuspid valve and right ventricular myopathy, often requiring surgical intervention. Alongside echocardiography, cardiac magnetic resonance (CMR) imaging is the gold standard tool for the assessment of ventricular volumes. Early diagnosis and adequate treatment are mandatory to avoid possible complications of CHD, and thus, ECG, as well as imaging techniques, are important diagnostic tools. However, patients with CHD need a special healthcare team for the entire monitorization in various life stages.

Heart Rate Recovery: Up to Date in Heart Failure-A Literature Review.

The rising prevalence of cardiovascular disease underscores the growing significance of heart failure (HF). Pathophysiological insights into HF highlight the dysregulation of the autonomic nervous system (ANS), characterized by sympathetic overactivity and diminished vagal tone, impacting cardiovascular function. Heart rate recovery (HRR), a metric measuring the heart's ability to return to its baseline rate post-exertion, plays a crucial role in assessing cardiovascular health. Widely applied across various cardiovascular conditions including HF, coronary artery disease (CAD), and arterial hypertension (HTN), HRR quantifies the difference between peak and recovery heart rates. Given its association with elevated sympathetic tone and exercise, HRR provides valuable insights into the perspective of HF, beyond effort tolerance, reaching toward prognostic and mortality indicators. Incorporating HRR into cardiovascular evaluations enhances our understanding of autonomic regulation in HF, offering potential implications for prognostication and patient management. This review addresses the significance of HRR in HF assessment, analyzing recently conducted studies, and providing a foundation for further research and clinical application.

Importance of Multimodality Cardiac Imaging in the Diagnosis of Lipomatous Hypertrophy of the Interatrial Septum-A View beyond Standard Situations.

Lipomatous hypertrophy of the interatrial septum (LHIAS) represents a benign proliferation of lipoid cells at the level of the interatrial septum (IAS) inducing an important thickening of this structure. It respects the fossa ovalis (FO) region, having a typical "hourglass" echocardiographic appearance. There are certain cases though, with unusual appearances and/or with associated pathologies that may induce similar lesions in the heart, in which the differential diagnosis cannot be guaranteed using only the standard methods. The final diagnosis has important implications in these patients' treatment plan. In this paper, we present an unusual case of a female patient undergoing chemotherapy for lung carcinoma, suspected of right atrial thrombosis/metastasis. As the diagnosis was unclear after transthoracic echocardiography (TTE), inducing the suspicion of an IAS mass with atrial wall infiltration, bi- and tridimensional transesophageal echocardiography (TOE) was performed, revealing a severely and homogenously hypertrophied IAS respecting the FO, but lacking a clear visualization of the atrial wall. The diagnosis of LHIAS was established by cardiac magnetic resonance (CMR) that certified the adipose nature of the structure, excluding the need for invasive investigations and/or treatment options. Multimodality imaging is very important for the clinician in adopting the best management plan for each individual patient.

Short-Term Changes in Weather Conditions and the Risk of Acute Coronary Syndrome Hospitalization with and without ST-Segment Elevation: A Focus on Vulnerable Subgroups.

Background and Objectives: Acute coronary syndrome (ACS), a prevalent global cardiovascular disease and leading cause of mortality, is significantly correlated with meteorological factors. This study aims to analyze the impact of short-term changes in meteorological factors on the risk of ACS, both with and without ST-segment elevation, and to identify vulnerable subgroups. Materials and Methods: Daily ACS admissions and meteorological variables were collected from October 2016 to December 2021. A generalized linear model (GLM) with a Poisson distribution was employed to examine how short-term fluctuations in meteorological parameters influence ACS hospitalizations. Subgroup analyses were conducted to identify the populations most vulnerable to climate change. Results: Multiple regression analyses showed that short-term fluctuations in atmospheric pressure (≥10 mbar) and air temperature (≥5 °C) seven days prior increased the number of ACS hospitalizations by 58.7% (RR: 1.587; 95% CI: 1.501-1.679) and 55.2% (RR: 1.552; 95% CI: 1.465-1.644), respectively, notably impacting ST-segment elevation myocardial infarctions (STEMIs). The least pronounced association was observed between the daily count of ACS and the variation in relative air humidity (≥20%), resulting in an 18.4% (RR: 1.184; 95% CI: 1.091-1.286) increase in the risk of hospitalization. Subgroup analysis revealed an increased susceptibility among men and older adults to short-term variations in weather parameters. Conclusions: The findings indicate that short-term changes in weather conditions are associated with an increased risk of ACS hospitalizations, particularly STEMIs. Male and older adult patients exhibit heightened susceptibility to variations in climatic factors. Developing effective preventive strategies is imperative to alleviate the adverse consequences of these environmental risk factors.

Casting Light on Early Heart Failure: Unveiling the Prognostic Potential of the E/(e' × s') Index.

It has been shown that patients with NYHA class I and II have a high morbidity and mortality burden. We investigated the value of a new tissue Doppler index, E/(e' × s'), to predict cardiac events in the long-term follow-up of patients at an early stage of heart failure (HF). Sequential echocardiography was conducted on a consecutive cohort of 212 hospitalized HF patients, pre-discharged and with three-month follow-up. The primary end point consisted of cardiac death or readmission due to HF worsening. During follow-up, cardiac events occurred in 99 patients (46.7%). The first cardiac event was represented by cardiac death in 8 patients (3.8%) and readmission for HF in 91 patients (42.9%). A Kaplan-Meier analysis did not show a significantly different event-free survival rate between patients with NYHA class I and II. The composite end point was significantly higher in patients with an E/(e' × s') >1.6. The E/(e' × s') at discharge was the best independent predictor of cardiac events. Those exhibiting an E/(e' × s') > 1.6 at discharge, with a subsequent deterioration after three months, displayed the poorest prognosis concerning cardiac events, HF-related rehospitalization, and cardiac mortality (all p < 0.05). In early-stage HF patients, an E/(e' × s') > 1.6 emerged as a robust predictor of clinical outcomes, especially when coupled with a deterioration in condition.

Echocardiographic Myocardial Work: A Novel Method to Assess Left Ventricular Function in Patients with Coronary Artery Disease and Diabetes Mellitus.

Myocardial ischemia caused by coronary artery disease (CAD) and the presence of metabolic abnormalities and microvascular impairments detected in patients with diabetes mellitus (DM) are a common cause of left ventricular (LV) dysfunction. Transthoracic echocardiography is the most-used, non-invasive imaging method for the assessment of myocardial contractility. The accurate evaluation of LV function is crucial for identifying patients who are at high risk or may have worse outcomes. Myocardial work (MW) is emerging as an alternative tool for the evaluation of LV systolic function, providing additional information on cardiac performance when compared to conventional parameters such as left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) because it incorporates deformation and load into its analysis. The potential of MW in various conditions is promising and it has gained increased attention. However, larger studies are necessary to further investigate its role and application before giving an answer to the question of whether it can have widespread implementation into clinical practice. The aim of this review is to summarize the actual knowledge of MW for the analysis of LV dysfunction caused by myocardial ischemia and hyperglycemia.

Comprehensive imaging in patients with suspected pulmonary arterial hypertension.

Currently, several imaging techniques are being used for a comprehensive evaluation of patients with suspected pulmonary hypertension (PH), in order to provide information that may clarify the presence and identify the aetiology of this complex pathology. The current paper is focused on recent updates regarding the importance of comprehensive imaging techniques for patients with suspected PH. Transthoracic echocardiography that can mainly detect right ventricle pressure overload and dysfunction is the cornerstone of imaging evaluation, while right heart catheterisation remains the gold standard assessment method. Chest radiography that may exclude pleuroparenchymal lung diseases, CT, the primary imaging modality for the assessment of lung parenchyma and CT pulmonary angiography, that allows for the non-invasive assessment of the pulmonary arteries, are equally important. Imaging techniques like dual-energy CT, single photon emission CT and ventilation perfusion scan may provide accurate diagnostic information for patients with chronic thromboembolic PH. Cardiac MRI provides the most accurate three-dimensional characterisation of the right ventricle. Accurate use of diagnostic imaging algorithms allows early detection of the disease, with the constant goal of improved PH patients prognosis.

Reduced Left Ventricular Twist Early after Acute ST-Segment Elevation Myocardial Infarction as a Predictor of Left Ventricular Adverse Remodelling.

BACKGROUND: The left ventricular (LV) remodelling process represents the main cause of heart failure after a ST-segment elevation myocardial infarction (STEMI). Speckle-tracking echocardiography (STE) can detect early deformation impairment, while also predicting LV remodelling during follow-up. The aim of this study was to investigate the STE parameters in predicting cardiac remodelling following a percutaneous coronary intervention (PCI) in STEMI patients. METHODS: The study population consisted of 60 patients with acute STEMI and no history of prior myocardial infarction treated with PCI. The patients were assessed both by conventional transthoracic and ST echocardiography in the first 12 h after admission and 6 months after the acute phase. Adverse remodelling was defined as an increase in LVEDV and/or LVESV by 15%. RESULTS: Adverse remodelling occurred in 26 patients (43.33%). By multivariate regression equation, the risk of adverse remodelling increases with age (by 1.1-fold), triglyceride level (by 1.009-fold), and midmyocardial radial strain (mid-RS) (1.06-fold). Increased initial twist decreases the chances of adverse remodelling (0.847-fold). The LV twist presented the largest area under the receiver operating characteristic (ROC) curve to predict adverse remodelling (AUROC = 0.648; 95% CI [0.506;0.789], p = 0.04). A twist value higher than 11° has a 76.9% specificity and a 72.7% positive predictive value for reverse remodelling at 6 months.

Considering Diastolic Dyssynchrony as a Predictor of Favorable Response in LV-Only Fusion Pacing Cardiac Resynchronization Therapy.

Background: CRT improves systolic and diastolic function, increasing cardiac output. Aim of the study: to assess the outcome of LV diastolic dyssynchrony in a population of fusion pacing CRT. Methods: Diastolic dyssynchrony was measured by offline speckle-tracking-derived TDI timing assessment of the simultaneity of E″ and A″ basal septal and lateral walls. New parameters introduced: E″ and, respectively, A″ time (E″T/A″T) as the time difference between E″ (respectively, A″) peak septal and lateral wall. Patients were divided into super-responders (SR), responders (R), and non-responders (NR). Results: Baseline characteristics: 62 pts (62 ± 11 y.o.) with idiopathic DCM, EF 27 ± 5.2%; 29% type III diastolic dysfunction (DD), 63% type II, 8% type I. Average follow-up 45 ± 19 months: LVEF 37 ± 7.9%, 34%SR, 61%R, 5%NR. The E″T decreased from 90 ± 20 ms to 25 ± 10 ms in SR with significant LV reverse remodeling (LV end-diastolic volume 193.7 ± 81 vs. 243.2 ± 82 mL at baseline, p < 0.0028) and lower LV filling pressures (E/E' 13.2 ± 4.6 vs. 11.4 ± 4.5, p = 0.0295). DD profile improved in 65% of R with a reduction in E/E' ratio (21 ± 9 vs. 14 ± 4 ms, p < 0.0001). Significant cut-off value calculated by ROC curve for LV diastolic dyssynchrony is E″T > 80 ms and A″T > 30 msec. Conclusions: The study identifies the cut-off values of diastolic dyssynchrony parameters as predictors of favorable outcomes in responders and super-responder patients with fusion CRT pacing. These findings may have important implications in patient selection and follow-up.

Considering Both GLS and MD for a Prognostic Value in Non-ST-Segment Elevated Acute Coronary Artery Syndrome.

Global longitudinal strain (GLS) and mechanical dispersion (MD), as determined by 2D speckle tracking echocardiography, have been demonstrated to be reliable indicators of prognosis in a variety of cardiovascular illnesses. There are not many papers that discuss the prognostic significance of GLS and MD in a population with non-ST-segment elevated acute coronary syndrome (NSTE-ACS). Our study objective was to examine the predictive utility of the novel GLS/MD two-dimensional strain index in NSTE-ACS patients. Before discharge and four to six weeks later, echocardiography was performed on 310 consecutive hospitalized patients with NSTE-ACS and effective percutaneous coronary intervention (PCI). Cardiac mortality, malignant ventricular arrhythmia, or readmission owing to heart failure or reinfarction were the major end points. A total of 109 patients (35.16%) experienced cardiac incidents during the follow-up period (34.7 ± 8 months). The GLS/MD index at discharge was determined to be the greatest independent predictor of composite result by receiver operating characteristic analysis. The ideal cut-off value was -0.229. GLS/MD was determined to be the top independent predictor of cardiac events by multivariate Cox regression analysis. Patients with an initial GLS/MD > -0.229 that deteriorated after four to six weeks had the worst prognosis for a composite outcome, readmission, and cardiac death according to a Kaplan-Meier analysis (all p < 0.001). In conclusion, the GLS/MD ratio is a strong indicator of clinical fate in NSTE-ACS patients, especially if it is accompanied by deterioration.

Pacemaker Implantation in a Patient with Isolated Persistent Left Superior Vena Cava Draining into the Left Atrium: A Case Report and Brief Literature Review.

Anomalies of the thoracic venous system are rare and usually discovered incidentally, but they become clinically relevant in the case of patients requiring cardiac device implantation. Persistent left superior vena cava is considered the most common venous drainage abnormality, with several anatomical variants that generate technical difficulties during pacemaker or defibrillator lead placement. We report a case of an isolated persistent left superior vena cava with abnormal drainage into the left atrium, associated with a hypoplastic right-sided superior vena cava, in a patient scheduled for permanent pacemaker implantation. Considering the patient's anatomical characteristics, a transvenous approach proved unfeasible and the procedure was successfully accomplished via the surgical placement of a left ventricle epicardial lead. We aim to emphasize the clinical importance of such venous anomalies and to discuss the practical implications and challenges derived from these types of conditions, especially in the field of electrophysiology.

Nonischemic Super-Responders in Fusion CRT Pacing with Normal Atrioventricular Conduction.

Background: Fusion CRT pacing (FCRT) is noninferior to biventricular pacing, according to the current data. The aim of this study is to assess the response to FCRT and to identify predictors of super-responders (SRs) in a nonischemic population with normal AV conduction. Methods: LV-only CRT patients (pts) with a right atrium/left ventricle pacing system implanted in two CRT centers in Romania were included. Device interrogation, exercise tests, echocardiography, and individualized drug optimization were performed every 6 months during close follow-up. SRs pts were defined as those with left ventricular end-systolic volume (LVESV) improvement ≥30% and stable ejection fraction (LVEF) ≥45%. Results: A total of 25 out of 83 pts (31%) were SRs, with nonischemic LBBB low EF cardiomyopathy (50 male, 62 ± 9 y.o.) initially included. Mean follow-up was 5 years ± 27 months. Patients were divided in two groups: SRs and non-SRs (52 responders/6 hypo-responders). Two predictors were found in the SRs group: a higher baseline LVEF (SRs 29 ± 5% vs. non-SRs 26 ± 5%, p = 0.02) and a lower pulmonary arterial systolic pressure (SRs 38 ± 11 mm Hg vs. non-SRs 50 ± 15 mmHg, p = 0.003). Baseline severe mitral regurgitation was found in 11% of SRs vs. 64% in the non-SRs group. Conclusions: SRs in the selected NICM-FCRT group are significative high. Higher baseline LVEF and mild pulmonary arterial hypertension were independently associated with super-response.

Betablockers and Ivabradine Titration According to Exercise Test in LV Only Fusion CRT Pacing.

Background: Betablockers (BB)/ivabradine titration in fusion CRT pacing (CRTP) is understudied. Aim: To assess drug optimization using systematic exercise tests (ET) in fusion CRTP with preserved atrioventricular conduction (AVc). Methods: Changes in drug management were assessed during systematic follow-ups in CRTP patients without right ventricle lead. Shorter AVc (PR interval) allowed BB up-titration, while longer AVc needed BB down-titration, favoring ivabradine. Constant fusion pacing was the goal to improve outcomes. Results: 64 patients, 62.5 ± 9.5 y.o divided into three groups: shorter PR (<160 ms), normal (160−200 ms), longer (200−240 ms); follow-up 59 ± 26 months. Drugs were titrated in case of: capture loss due to AVc shortening (14%), AVc lengthening (5%), chronotropic incompetence (11%), maximum tracking rate issues (9%), brady/tachyarrhythmias (8%). Interventions: BB up-titration (78% shorter PR, 19% normal PR, 5% longer PR), BB down-titration (22% shorter PR, 14% normal PR), BB exclusion (16% longer PR), adding/up-titration ivabradine (22% shorter PR, 19% normal PR, 5% longer PR), ivabradine down-titration (22% shorter PR, 3% normal PR), ivabradine exclusion (11% normal PR, 5% longer PR). Drug strategy was changed in 165 follow-ups from 371 recorded (42% patients). Conclusions: BBs/ivabradine titration and routine ET during follow-ups in patients with fusion CRTP should be a standard approach to maximize resynchronization response. Fusion CRTP showed a positive outcome with important LV reverse remodeling and significant LVEF improvement in carefully selected patients.

The Incremental Prognostic Value of E/(e'×s') Ratio in Non-ST-Segment Elevated Acute Coronary Syndrome.

It has been shown that the E/(e'×s') index, which associates a marker of diastolic function (E/e', early transmitral/diastolic mitral annulus velocity ratio) and a parameter that explores LV systolic performance (s', systolic mitral annulus velocity), is a good predictor of outcome in acute anterior myocardial infarction. There are no studies that have investigated the prognostic value of E/(e'×s') in a non-ST-segment elevated acute coronary syndrome (NSTE-ACS) population. Echocardiography was performed in 307 consecutive hospitalized patients with NSTE-ACS and succesful percutaneous coronary intervention, before discharge and six weeks after. The primary endpoint consisted of cardiac death or readmission due to re-infarction or heart failure. During the follow-up period (25.4 ± 3 months), cardiac events occurred in 106 patients (34.5%). Receiver operating characteristic (ROC) analysis identified E/(e'×s') at discharge as the best independent predictor of composite outcome. The optimal cut-off value was 1.63 (74% sensitivity, 67% specificity). By multivariate Cox regression analysis, E/(e'×s') was the only independent predictor of cardiac events. Kaplan-Meier analysis identified that patients with an initial E/(e'×s') > 1.63 that worsened after six weeks presented the worst prognosis regarding composite outcome, readmission, and cardiac death (all p < 0.001). In conclusion, in NSTE-ACS, E/(e'×s') is a powerful predictor of clinical outcome, particularly if it is accompanied by worsening after 6-weeks.

Arterial Hypertension: Individual Therapeutic Approaches-From DNA Sequencing to Gender Differentiation and New Therapeutic Targets.

The aim of this paper is to provide an accurate overview regarding the current recommended approach for antihypertensive treatment. The importance of DNA sequencing in understanding the complex implication of genetics in hypertension could represent an important step in understanding antihypertensive treatment as well as in developing new medical strategies. Despite a pool of data from studies regarding cardiovascular risk factors emphasizing a worse prognosis for female patients rather than male patients, there are also results indicating that women are more likely to be predisposed to the use of antihypertensive medication and less likely to develop uncontrolled hypertension. Moreover, lower systolic blood pressure values are associated with increased cardiovascular risk in women compared to men. The prevalence, awareness and, most importantly, treatment of hypertension is variable in male and female patients, since the mechanisms responsible for this pathology may be different and closely related to gender factors such as the renin-angiotensin system, sympathetic nervous activity, endothelin-1, sex hormones, aldosterone, and the immune system. Thus, gender-related antihypertensive treatment individualization may be a valuable tool in improving female patients' prognosis.

Impending Aortic Rupture in a Patient with Syphilitic Aortitis.

We report the case of a 48-year-old man, admitted for atrial fibrillation with rapid heart rate and intense chest pain. A quick evaluation revealed a giant aortic aneurysm with severe aortic regurgitation and pericardial fluid without a trace of aortic dissection. Because of high suspicion of aortic rupture, an emergency surgery was planned, and a Bentall procedure was performed. On examination of the aortic wall revealing vertical wrinkling with a tree bark aspect, suspicion of syphilitic aortitis arose. The diagnosis was confirmed through postoperative serologic testing and histological examination. Histopathologic differential diagnosis, special treatment and follow-up are presented.