To evaluate potential effects of adenosine (ADO) administration on global longitudinal strain (GLS) and mechanical dispersion (MD) in ST-segment elevation myocardial infarction (STEMI), as ischemia-reperfusion injury may be reduced by ADO. At 7 ± 2 days after successfully treated STEMI, 49 patients (age 63 ± 11 years, 35 male) underwent rest/stress echocardiography by intravenous administration of ADO at 140 mcg/Kg/minute for 90 s. Resting echocardiography was repeated after 6-months. Thirty sex and age-matched subjects were considered as controls to set normal response of GLS and MD to ADO. GLS and MD were assessed in all time points. Contractile recovery at follow-up was defined by GLS values ≥ 20

Background:Invasive coronary functional tests (I-CFTs) can identify the mechanism(s) of angina in patients with non-obstructed coronary arteries (ANOCA). In this study, we assessed whether non-invasive coronary functional tests (NI-CFTs) can also produce reliable results when assessing these mechanisms. Methods:We performed NI-CFTs by recording coronary blood flow velocity (CBFV) in the left anterior descending coronary artery by transthoracic Doppler echocardiography in 18 patients with ANOCA who had undergone I-CFTs (an acetylcholine provocation test and an adenosine stress test) and 13 healthy controls. The NI-CFTs included hyperventilation, a dipyridamole stress test and a cold pressor test. Results:Acetylcholine induced epicardial or coronary microvascular spasm in 11 patients (61.1%), whereas adenosine coronary flow reserve (CFR) was reduced (<2.5) in seven (39%). Hyperventilation-induced coronary vasoconstriction produced a reduction in CBFV >10% compared to baseline in eight patients (44.4%) and none in the control group (p=0.005). Dipyridamole-CFR was lower in the patient group than in the control group (2.25 ± 0.49 versus 2.76±0.49; p=0.01) and correlated with adenosine-CFR (r=0.75; p<0.001). Full agreement in coronary abnormalities detected during I-CFTs and NI-CFTs (hyperventilation/dipyridamole stress test) was found in 14 patients (77.8%). Furthermore, cold pressor test-CFR was lower in patients than in the control group (1.33 ± 0.18 versus 1.52 ± 0.22; p=0.019); cold pressor test-CFR <1.35 identified three patients who showed both normal I-CFTs and a normal response to hyperventilation and dipyridamole at NI-CFTs. Conclusion:In ANOCA patients, the results of NI-CFTs performed with transthoracic Doppler echocardiography of the left anterior descending coronary artery showed a high correlation with coronary function abnormalities detected using I-CFTs. Our data suggest that NI-CFTs deserve investigation in larger multicentre studies to assess their usefulness in guiding clinical management of ANOCA patients.

BackgroundEarly-stage heart failure with preserved ejection fraction (HFpEF) is like hypertensive heart disease (HHD) at resting echocardiography, but increases left ventricular (LV) filling pressure during stress. Coronary microvascular dysfunction (CMD) is a pathogenetic mechanism of HFpEF. Whether CMD actively increases LV filling pressure when LV stiffness is not yet established at rest remains unknown. LV mechanics were evaluated using dipyridamole stress echocardiography (DipSE) in suspected early-stage HFpEF.MethodsA total of 30 patients (mean age: 76 years; 80% female) with suspected early-stage HFpEF and 33 with HHD and normal NT-proBNP underwent DipSE. Systolic and diastolic indexes of LV myocardial function, particularly E/e′, isovolumic contraction and relaxation times (IVCT and IVRT), and ejection time (ET), were measured at rest and during stress. The myocardial performance index (MPI) was calculated as IVCT + IVRT/ET.ResultsE/e′ ratio increased in suspected early-stage HFpEF patients (p < 0.001), but not in HHD patients. During stress, the IVRT reduced in HHD patients (p = 0.002), whereas remained significantly higher in suspected early-stage HFpEF patients (p < 0.001). Thus, MPI improved during DipSE in HHD patients (p = 0.005), but not in suspected early-stage HFpEF patients. Particularly, MPI was worse in suspected early-stage HFpEF patients with ST-segment depression than in those without it (p = 0.05).ConclusionsIn suspected early-stage HFpEF, increased LV filling pressure during DipSE is associated with abnormal active myocardial relaxation. Myocardial performance is particularly impaired in patients with ST-segment depression during DipSE.

BACKGROUND:Left atrioventricular coupling index (LACI) has emerged as a powerful marker of cardiac remodeling across a variety of cardiac diseases, however its prognostic value in the setting of transthyretin amyloid cardiomyopathy (ATTR-CM) remains largely unexplored. METHODS:Patients with ATTR-CM who underwent prospective evaluation comprising full echocardiographic assessment between 2021 and 2025 were included. LACI was measured as the ratio between the left atrial (LA) and the left ventricular (LV) end-diastolic volumes. The population was stratified based on LACI terciles. The study endpoint was all-cause mortality. RESULTS:A total of 202 patients (median age 80 years, 80% male) were included, with a predominance of wild-type subtype (70%). LACI terciles cutoffs were: ≤59.5% (first tercile), from 59.5% to 88.1% (second tercile) and > ≥88.1% (third tercile). Higher LACI terciles were associated with a greater prevalence of wild-type disease and atrial fibrillation (AF) and more advanced NAC stage. Higher LACI terciles were associated with significantly smaller LV volumes and larger LA volumes, as well as worse parameters of LV systolic and diastolic function. Three-year survival rates progressively declined across increasing LACI terciles (97%, 68% and 55%, p < 0.001). LACI demonstrated higher discriminatory power for predicting 3-year mortality (AUC 0.789, 95% CI 0.717-0.861), in comparison to LA dimensional parameters. After adjusting for age, NAC stage, AF and LV longitudinal strain, LACI terciles remained significantly associated with all-cause mortality (adjusted HR 1.942, 95% CI 1.078-3.499; p = 0.027). CONCLUSIONS:In patients with ATTR-CM, increasing LACI is associated with markers of disease severity and worse long-term survival.

Purpose:To compare the clinical impact and operational efficiency of exercise electrocardiography (ex-ECG) and coronary CT angiography (CCTA) in the diagnostic-therapeutic care pathway of patients presenting to the Emergency Department (ED) with acute chest pain (ACP) and suspected non-ST-elevation acute coronary syndrome (NSTE-ACS). Methods:This single-center retrospective cohort study enrolled 428 consecutive patients presenting with ACP between January 2022 and December 2023. After propensity score matching (PSM) for age, sex, Heart Score, and triage code, two balanced groups of 214 patients each underwent either -ex-ECG or CCTA. Primary outcomes included diagnostic test positivity, hospital admission rate, and ED length-stay. Secondary outcomes included need for invasive coronary angiography (ICA) and revascularization rates. Results:No statistically significant differences were found in test positivity (42 vs 31 patients, p = 0.157) or hospital admission rates (42 vs 30 patients, p = 0.121) between ex-ECG and CCTA groups. The ICA rates were similar (36 vs 32 patients, p = 0.597), as were revascularization rates (13 patients each, p = 1.000). However, discharged patients undergoing CCTA had significantly shorter total ED length-stay compared to ex-ECG (1710 vs 1841 min, p < 0.001), representing a 7.12 % reduction. Conclusion:Both ex-ECG and CCTA demonstrate comparable clinical impact and operational efficiency in patients with ACP and suspected NSTE-ACS. CCTA offers effective advantages with significantly reduced ED length-stay for a safe discharge of the patients, improving resource management without compromising diagnostic quality. These findings support the increasing adoption of CCTA in the diagnostic pathway for ACP and suspected NSTE-ACS in the ED setting.

Myocardial infarction with non-obstructive coronary artery disease (MINOCA) occurs in up to 14% of patients presenting with acute myocardial infarction. Initially considered a favorable clinical diagnosis, MINOCA is now recognized as a condition that significantly impairs quality of life and is associated with an unfavorable prognosis, including significant risks of mortality, rehospitalization, disability, and recurrent angina, all contributing to high socioeconomic costs. MINOCA is a heterogeneous condition, with multiple identified underlying mechanisms, including epicardial or microvascular spasm, rupture or erosion of an atherosclerotic coronary plaque, coronary embolism, and spontaneous coronary artery dissection. Given this complexity, a comprehensive diagnostic workup that integrates clinical assessment, advanced imaging modalities, and invasive testing is necessary for the accurate identification of the specific cause of MINOCA and to guide the selection of an appropriate, individualized therapeutic strategy for each patient. This narrative review aims to explore the etiologies of MINOCA and provide clinicians with an up-to-date overview of therapeutic advances and targeted strategies for each underlying mechanism.

Due to its significant prevalence and clinical implications, angina with non-obstructive coronary arteries (ANOCA) has become a major focus in modern cardiology. In fact, diagnosing ANOCA presents a significant challenge. The final diagnosis is often difficult, delayed, and frequently necessitates an invasive assessment through coronary angiography. However, recent improvements in non-invasive cardiac imaging allow a diagnosis of ANOCA using a combination of clinical evaluation, anatomical coronary imaging, and functional testing. This narrative review aims to critically assess various non-invasive diagnostic methods and propose a multimodal approach to diagnose ANOCA and tailor appropriate treatments.

Adult survivors of haematological malignancies are at increased risk of long-term cardiovascular sequelae. Several echocardiographic metrics have been tested to detect subclinical myocardial dysfunction before it progresses toward cardiac events. Myocardial work (MW) is a load-independent echocardiographic index that conjugates non-invasive arterial blood pressure and global longitudinal strain (GLS). Sixty-three disease-free survivors of Hodgkin Lymphoma (HL) [49

Background: Pharmacologic therapy guided by invasive coronary function tests (CFTs) may improve symptomatic outcomes in patients with angina and non-obstructive coronary artery disease (ANOCA). In this study, we specifically aimed to investigate whether the induction of coronary microvascular spasm (CMVS) by the acetylcholine (Ach) test predicts a better therapeutic effect of calcium-channel blocker therapy compared to beta-blocker therapy. Methods: We enrolled 31 ANOCA patients, who were divided into two groups according to the result of Ach testing: 16 patients with CMVS (CMVS group) and 15 patients with a negative test (NEG group). Patients with Ach-induced epicardial spasm were excluded. In an open-label crossover trial, patients were randomly assigned to each receive, for a period of 4 weeks, either metoprolol (50 mg twice daily) or diltiazem (120 mg twice daily). At the end of each 4-week period, patients underwent an ECG–exercise stress test (EST) and were invited to fill out the Seattle Angina Questionnaire (SAQ). Results: No significant differences were found between metoprolol and diltiazem in terms of SAQ scores, and ECG-EST results were also largely comparable with the two drug treatments, both in the CMVS group and the NEG group. In particular, the SAQ summary score was 63.1 ± 24 and 66.0 ± 25 (p = 0.59) for metoprolol and diltiazem, respectively, in the CMVS group, and 70.9 ± 17 and 74.3 ± 16 (p = 0.37) with the two drugs, respectively, in the NEG group. Conclusions: Our small open-label study shows that patients with ANOCA with negative Ach test or Ach-induced CMVS show largely comparable short-term symptomatic outcomes and ECG-EST results when treated with either metoprolol or diltiazem.

Background: An extensive use of transesophageal echocardiography (TEE) has recently been suggested for the diagnosis of infective endocarditis (IE). In this study, we investigated whether among patients with negative transthoracic echocardiography (TTE), subgroups can be identified among whom TEE can be avoided/delayed. Methods: We conducted a retrospective study of 637 consecutive patients who underwent TEE for suspected IE. We selected 375 patients with negative TTE. For each patient, we obtained age, sex, blood culture (BC), blood exams, evidence of embolism, presence of moderate/severe heart valve disease, valve prostheses, and intracardiac devices. Results: IE was eventually diagnosed in 56 patients. Variables independently associated with IE at multivariate analysis included positive BC (OR 3.45; p = 0.006), evidence of embolism (OR 13.0; p < 0.001), bioprosthetic heart valves (OR 4.31; p < 0.001) and platelet count < 150,000/mL (OR 2.47; p = 0.014). In patients without any of these predictors for IE (n = 81), only 1 had a diagnosis of IE and no in-hospital IE-related deaths occurred. Among patients with negative BC (n = 127), IE prevalence increased with the number of other predictors, but IE-related mortality was 0%. IE prevalence (10.8%) and IE related in-hospital mortality (2.7%) were also rather low in patients with a positive blood culture without any other independent predictors for IE but were 20% (IE-related mortality 3.8%) and 71% (IE-related mortality 28.6%) in those with only one or 2-3 other IE predictors, respectively. Conclusions: Our data suggest that, among patients with suspected IE and negative TTE, subgroups can be identified in whom TEE might be safely avoided or delayed.

BACKGROUND:Takotsubo syndrome (TTS) is an acute condition characterized by a reversible left ventricular (LV) systolic dysfunction leading to serious in-hospital complications (IHC). The aim of our study is to investigate the prognostic impact of right ventricular-to-pulmonary artery (RV-PA) coupling in patients with TTS. METHODS:Consecutive TTS patients were prospectively enrolled. In all patients, standard and speckle tracking transthoracic echocardiography was performed within 48 h from hospital admission. RV function was evaluated by RV global longitudinal strain (RV-GLS) and RV free wall strain (RV-FWS) and RV-PA coupling was measured as the ratio of either tricuspid annular plane systolic excursion (TAPSE), RV-GLS or RV-FWS to pulmonary artery systolic pressure (PASP). Data about IHC (acute heart failure, life-threatening arrhythmias and death) were collected. RESULTS:A total of 80 patients were analyzed (71 ± 11 years, female 77.5 %) and IHC occurred in 33 (41 %). Patients who experienced IHC had lower LV ejection fraction (LVEF), lower left atrial (LA) reservoir strain, TAPSE/PASP, RV-FWS/PASP and RV-GLS/PASP and higher left atrial volume indexed (LAVi) values. At multivariate analysis, only LVEF (OR 0.913, 95 % CI [0.858-0.971], p = 0.004) was an independent predictor of IHC. Receiver operating characteristics (ROC) curve analysis showed an additional prognostic value of a combined model including RV-GLS/PASP and LVEF compared to LVEF alone in the prediction of IHC (AUC of 0.756 vs 0.736, differences between AUCs: 0.02 [p = 0.73]). CONCLUSION:RV-PA coupling assessed by RV-GLS/PASP may help in identifying TTS patients at higher risk of cardiovascular complications with an additional prognostic value to LVEF alone.

BackgroundTo date, only limited data are available on right atrium (RA) morphofunctional remodeling in Fabry disease (FD).PurposeWe aimed to investigate RA structural and functional remodeling in patients with FD vs. healthy controls using 2D speckle tracking echocardiography (STE) and to explore whether any differences exist in FD patients with and without left ventricular hypertrophy (LVH).MethodsWe prospectively enrolled patients with FD and controls matched for age, sex, and cardiovascular risk factors. Patients with FD were divided in two groups according to the presence/absence of LVH (LVH+: left ventricular wall thickness >12 mm). All patients underwent standard echocardiography and STE analysis investigating the mechanics of all cardiac chambers, including RA reservoir, contractile and conduit strain.ResultsA total of 64 patients with FD (50% males; mean age 50 ± 17 years; 51.5% LVH+) and 64 control patients were included in the study. Focusing on right chambers, RA and right ventricular (RV) dimensions were similar between FD and controls. No differences were found for tricuspid annular plane systolic excursion (p = 0.073) and RV fractional area change (p = 0.461), while RV systolic Tissue Doppler velocity was reduced in patients with FD (p = 0.041). STE analysis revealed impaired strain values for all cardiac chambers in FD vs controls, specifically: left ventricular global longitudinal strain (LV-GLS, p < 0.001), left atrial (LA) reservoir strain (p = 0.001), conduit strain (p = 0.012), and contractile strain (p < 0.001), RV-GLS and RV free wall strain (p < 0.001). Similarly, all RA strain phases were significantly reduced in patients with FD compared with control patients (RA reservoir 27.4 ± 11.1 vs. 41.9 ± 8.3%, p < 0.001; RA contractile 9.9 ± 5.1 vs. 18.0 ± 4.9%, p < 0.001; RA conduit 19.1 ± 8.1 vs. 24.1 ± 8.1%, p = 0.001). When comparing FD patients without LVH to controls, it was found that RA reservoir and contractile strains were significantly reduced in the former (p < 0.001). In multivariable linear regression analyses, LA reservoir strain (p = 0.010) and LV-GLS (p = 0.044) emerged as independent correlates of RA mechanics after adjustments were made for RA dimensions, RV systolic function parameters and hypertrophy, and LV maximal wall thickness.ConclusionsIn FD impaired RA strain is a common finding. RA reservoir and contractile strains are reduced in FD patients even before LVH ensues, as compared to controls. LA reservoir strain and LV-GLS show an independent correlation with RA reservoir strain.

Background: This study aimed to evaluate the effectiveness of right and left atrial strain reservoir (RASr and LASr) in predicting the recurrence of atrial arrhythmias (AAs) following cavotricuspid isthmus ablation (CTIA) for typical atrial flutter (AFL). Methods: We retrospectively enrolled consecutive patients with AFL who had undergone CTIA. Transthoracic echocardiography was conducted within one month before the procedure, and atrial two-dimensional speckle tracking analysis was performed offline. Results: Sixty-two subjects were evaluated (mean age 64.8 ± 13.2 years, 29% females). At a median follow-up of 12.1 months, AA recurrence occurred in 21 subjects (33.8%). The study endpoint occurred mainly among females (p = 0.021) and patients with lower RASr and LASr values (both p < 0.001). In Cox regression analysis, RASr and LASr remained independent predictors of AA recurrence (p = 0.02 and p = 0.03, respectively). In ROC curve analysis, RASr and LASr showed a similar and satisfactory ability to predict AA recurrence with optimal cut-off values of 16.8% and 17.7%, respectively. In survival analysis, RASr > 16.8% and LASr > 17.7% were associated with significantly higher freedom from AAs during follow-up (log rank p = 0.001 and p = 0.002, respectively). Conclusions: The results of this study suggest that pre-CTIA atrial speckle tracking analysis may aid in identifying AFL patients at an increased risk of AA recurrence, allowing for more frequent follow-up visits and extended antiarrhythmic therapy.

Coronary artery disease (CAD) has traditionally been diagnosed and managed based on anatomical assessments of the epicardial coronary arteries. However, a growing body of evidence highlights the limitations of coronary angiography in evaluating the ischemic burden of atherosclerotic plaques. The coronary microcirculation is increasingly recognized for its pivotal role in myocardial ischemia. Coronary microvascular dysfunction (CMD) contributes significantly to both acute and chronic coronary syndromes, even in the absence of obstructive epicardial disease. Despite its clinical significance, CMD remains underdiagnosed due to the lack of routine assessment in contemporary cardiac catheterization practices. Emerging invasive and noninvasive techniques now enable comprehensive evaluation of coronary microvascular dysfunction (CMD) by assessing microvascular resistance, coronary flow reserve, and tissue-level perfusion. Advances in thermodilution-based indices, intracoronary Doppler, and functional coronary angiography continue to provide quantitative insights into microvascular physiology, whereas noninvasive modalities-including cardiac magnetic resonance (MRI), positron-emitted tomography (PET), transthoracic Doppler echocardiography, and computed tomography-based perfusion imaging-offer powerful tools for diagnosing CMD without the need for catheter-based assessment. Integrating these complementary approaches into clinical practice enhances risk stratification and supports personalized management strategies, particularly in patients with ischemia and nonobstructive coronary arteries (INOCA). This review explores in-depth the diagnostic tools and the quantitative metrics used or the invasive assessment of CMD, emphasizing their clinical utility and impact on patient management.

Background:The ability of the electrocardiogram exercise stress test (ECG-EST) in excluding the presence of left main (LM) coronary artery disease (CAD) has been poorly investigated. Methods:We retrospectively selected patients who underwent both ECG-EST and elective invasive coronary angiography (ICA) at our Institution between January 2018 and December 2023 due to angina pain suspected of obstructive CAD. Preventively defined individual and combined ECG-EST variables suggesting no/mild myocardial ischemia were assessed as predictors of the absence of LM disease. Some ECG-EST variables suggesting extensive/severe myocardial ischemia were instead assessed as predictors of the presence of LM disease, defined as a stenosis ≥50% of the left main artery. Results:Overall, 515 patients were included (age 66.2 ± 11 years; 74% men). LM disease at ICA was found in 26 patients (5%). Individual and combined ECG-EST variables showed low positive predictive values for LM-CAD [maximum 15% for a combination of ST-segment depression (STD) in ≥ 5 leads and ECG-EST duration <360 s]. The negative predictive value, however, was very high for some combined ECG-EST variables. Very low risk of LM disease (≤2.5%) was particularly shown in patients with peak heart rate (HR) ≥ 75% of maximal predicted HR for age and STD < 2 mm (prevalence 63.1%; risk 2.2%) and peak HR ≥85% of maximal predicted HR for age and maximal STD < 2 mm (prevalence 46.2%; risk 2.5%). Conclusions:Among patients with angina chest pain suspected of obstructive CAD, ECG-EST results can reliably identify those at very low risk of LM disease at coronary angiography.

BACKGROUND AND METHODS:Previous studies suggested that patients with myocardial infarction and non-obstructive coronary arteries (MINOCA) may have adverse clinical outcomes, but long-term follow-up has not hitherto been investigated. In this study we assessed whether non-invasive assessment of coronary functional abnormalities may help predicting long-term prognosis. We assessed coronary blood flow velocity (CBFV) response to ergonovine, adenosine and cold pressor test (CPT) by transthoracic Doppler echocardiography and performed exercise stress test (EST) in 30 patients (67 ± 10 years, 19 female) with MINOCA and 10 patients with non-cardiac acute chest pain (control group). Clinical conditions were assessed at a median follow-up of 10.3 years (interquartile interval, 8.4-10.5). Clinical endpoints included major adverse cardiovascular events (MACE) and all-cause mortality. RESULTS:MACE occurred in 10 patients (33.3 %) and 1 control (9.1 %) (HR 4.20, 95 % C.I. 0.54-32.9, p = 0.17). Death occurred in 6 MINOCA patients (20 %), mainly from non-cardiovascular causes, whereas no death occurred in the control group (p = 0.37). In MINOCA patients, CBFV response to CPT was significantly associated with all-cause mortality (p = 0.046), whereas age (p = 0.084), CBFV response to adenosine (p = 0.096) and EST duration (p = 0.099) were of borderline statistical significance. At multivariable analysis, EST duration emerged as the only independent variable associated with mortality (p = 0.041). No variable was found to be predictive of long-term MACE in MINOCA patients. CONCLUSIONS:MINOCA patients present a sizeable global, but low cardiovascular mortality at long-term follow-up. Functional capacity seems the only variable independently predictive of global mortality, whereas non-invasive coronary functional tests seem unable to predict mortality and MACE.