Phenotyping congestion in acute heart failure by renal flow and right heart to pulmonary circulation coupling.

AIMS: In acute heart failure (AHF), kidney congestion is basic to treatment and prognosis. Its aetiology is manifold and quite unexplored in details mainly regarding the right heart to pulmonary circulation (Pc) coupling. We investigated the right heart to kidney interrelationship by Doppler renal flow pattern, right atrial dynamics, and right ventricular (RV) function to Pc coupling in AHF. METHODS AND RESULTS: In 119 AHF patients, echocardiographic and renal Doppler data were analysed. Univariate and multivariate regression models were performed to define the determinants of a quantitative parameter of renal congestion, the renal venous stasis index (RVSI). When grouped according to different intra-renal venous flow patterns, no differences were observed in haemodynamics and baseline renal function. Nonetheless, patients with renal Doppler evidence of congestion showed a reduced RV function [tricuspid annular plane systolic excursion (TAPSE), S'-wave velocity, and fractional area change], impaired RV to Pc coupling [TAPSE/pulmonary artery systolic pressure (PASP) ratio], and right atrial peak longitudinal strain (RAPLS), along with signs of volume overload [increased inferior vena cava (IVC) diameters and estimated right atrial pressure]. Univariate and multivariate regression analyses confirmed TAPSE/PASP, RAPLS, and IVC diameter as independent determinants of the RVSI. RVSI was the only variable predicting the composite outcome (cardiac death, heart failure hospitalization, and haemodialysis). An easy-to-use echo-derived right heart score of four variables provided good accuracy in identifying kidney congestion. CONCLUSIONS: In AHF, the renal venous flow pattern combined with a right heart study phenotypes congestion and clinical evolution. Keys to renal flow disruption are an impaired right atrial dynamics and RV-Pc uncoupling. Integration of four right heart echocardiographic variables may be an effective tool for scoring the renal congestive phenotype in AHF.

Breast cancer diagnostic methods: screen-detected and clinical cases. An Italian survey of women's experiences.

AIMS AND BACKGROUND: The real practice of breast cancer diagnosis and treatment is often very different from guideline recommendations. Screening programs should minimize deviations from "best practice". The aim of the study was to compare cases detected by screening programs with cases that were not part of the public screening program, analyzing the diagnostic pathways from the first suspected breast problem to therapeutic intervention for breast cancer. METHODS: We interviewed a random sample of 268 women aged 49-70 years in three Italian regions (Lazio, Tuscany, Basilicata) who were treated for breast cancer, stratified by screening participation. RESULTS: In the nonscreened group, 48% of women were symptomatic and 50% were diagnosed by preventive tests. The proportion of women treated within 30 days of diagnosis was significantly lower in the screened group, 21.3% vs 35.8% (P = 0.0003). The mean number of tests (mammography, ultrasonography, cytology and histology) performed in the screened group was significantly higher than in the nonscreened group, 3.7 vs 2.8 (P = 0.001). The percentage of women treated without a preoperative histological or cytological diagnosis was lower in the screened group than in the nonscreened group, 14% vs 25% (P = 0.024). CONCLUSION: Participation in screening programs seems to lead to more appropriate disease management even for breast cancer cases treated at the same hospital.