AIMS:Globally, nearly 20% of cardiovascular disease deaths were attributable to air pollution. Out-of-hospital cardiac arrest (OHCA) represents a major public health problem; therefore, the identification of novel OHCA triggers is of crucial relevance. The aim of the study was to evaluate the association between air pollution (short-, mid-, and long-term exposures) and OHCA risk, during a 7-year period in a highly polluted urban area in northern Italy, with a high density of automated external defibrillators (AEDs). METHODS AND RESULTS:Out-of-hospital cardiac arrests were prospectively collected from the 'Progetto Vita Database' between 1 January 2010 and 31 December 2017; day-by-day air pollution levels were extracted from the Environmental Protection Agency stations. Electrocardiograms of OHCA interventions were collected from the AED data cards. Day-by-day particulate matter (PM) 2.5 and 10, ozone (O3), carbon monoxide (CO), and nitrogen dioxide (NO2) levels were measured. A total of 880 OHCAs occurred in 748 days. A significant increase in OHCA risk with a progressive increase in PM2.5, PM10, CO, and NO2 levels was found. After adjustment for temperature and seasons, a 9% and 12% increase in OHCA risk for each 10 μg/m3 increase in PM10 (P < 0.0001) and PM2.5 (P < 0.0001) levels was found. Air pollutant levels were associated with both asystole and shockable rhythm risk, while no correlation was found with pulseless electrical activity. CONCLUSION:Short- and mid-term exposures to PM2.5 and PM10 are independently associated with the risk of OHCA due to asystole or shockable rhythm.

BACKGROUND:Cardiovascular comorbidities are a common cause of death in COVID-19 and the aim of this study is to evaluate the effect of comorbidities on mortality in COVID-19 patients.METHODS:In this retrospective observational study we enrolled 1049 patients hospitalized with confirmed SARS-CoV-2 infection in a single Italian Center from 21 February to 20 March 2020 Evaluated risk factors (RFs) were: advanced age, gender, hypertension, diabetes, atrial fibrillation, hyperlipidemia, chronic kidney disease, thyroid disease, chronic obstructive pulmonary disease, malignancy, stroke, cardiovascular disease, and peripheral vascular disease. Endpoint of the study was death from any cause. A multivariate logistic regression model was built using covariates that showed as statistically significant at univariate regression analysis.RESULTS:Median age at presentation was 71.1 years (IQR: 59.1-80.5); 244 (72.2%) were males. Primary outcome occurred in 338 patients (32.2%). In decedents, median survival from Hospitalization was 6 (IQR: 3-10) days. 264 decedents had 1 RF, 120 had 2 RFs and 39 had ≥3 RFs. At multivariate logistic regression model, variables associated with primary outcome were: age class (64-69 years) (OR 3.03, CI: 1.75-5.31, P<0.001), age class (70-88 years) (OR 10.08, CI: 6.67-15.72, P<0.001), age class (≥88 years) (OR 23.99, CI: 13.21-44.82, P<0.001), male gender (OR 1.88, CI: 1.36-2.62, P<0.001), diabetes (OR 1.56, CI: 1.07-2.26, P=0.02), stroke (OR 3.41, CI: 1.33-9.91, P=0.015).CONCLUSIONS:Age, male gender, presence of diabetes and stroke appeared as independent predictors of mortality in COVID-19 patients. A table for risk of 30 days-mortality in SARS-CoV-2 infection was built, based on odds ratios derived from multivariate regression analysis.

AIMS:The clinical and prognostic importance of functional mitral regurgitation (FMR) in heart failure patients with reduced ejection fraction (HFrEF) has been highly debated. This study aims to define FMR linkage to cardiovascular (CV) outcomes and the interplay with left atrial (LA) function in a prospective cohort of consecutive HFrEF outpatients. METHODS AND RESULTS:Overall, 286 consecutive outpatients with chronic HFrEF were prospectively enrolled. FMR was quantified by effective regurgitant orifice area (EROA). Global peak atrial longitudinal strain (PALS) was measured by speckle tracking echocardiography. The primary endpoint was a composite of congestive heart failure hospitalization or CV death. During a mean follow-up of 4.1 ± 1.5 years, the primary endpoint occurred in 99 patients (35%). The spline modelling of the risk by FMR severity showed an excess event risk starting at about the EROA value of 0.1 cm2 . There was a remarkable graded association between the EROA strata, even if tested per 0.1 cm2 increase, and the risk of CV events (hazard ratio [HR] EROA per 0.10 cm2 increase: 1.42, 95% confidence interval [CI] 1.19-1.68; p < 0.0001). EROA ≥0.30 cm2 was associated with CV events regardless of LA function (HR 2.34, 95% CI 1.29-4.19; p = 0.005). Less severe FMR (EROA ≥0.10 cm2 ) was associated with a dismal outcome only in patients with reduced LA function (PALS <14%) (5-year CV event rate 51 ± 4%); conversely, the risk of events was relative reduced when preserved global PALS and FMR coexisted (5-year CV event rate 38 ± 6%). CONCLUSIONS:Our results refine the independent association between FMR and CV outcome among HFrEF outpatients. Within a moderate EROA range, LA function mitigates the clinical consequences of mitral regurgitation, providing measurable proof of the interplay between regurgitation and LA compliance.

In recent years, the left atrial (LA) function has emerged to be of clinical value.1Pernigo M. Benfari G. Geremia G. Noni M. Borio G. Mazzali G. et al.Atrial function as an independent predictor of postoperative atrial fibrillation in patients undergoing aortic valve surgery for severe aortic stenosis.J Am Soc Echocardiogr. 2017; 30: 956-965Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Methodologies for the accurate assessment of LA function by echocardiography have significantly improved, and the peak atrial longitudinal strain (PALS) by two-dimensional speckle-tracking seems to be the most promising. Despite its established independent prognostic role, whether PALS has a linear relationship with outcome in patients with heart failure (HF) and reduced ejection fraction (HFrEF) remains unknown. Indeed, PALS-related risk of cardiovascular (CV) events has never been analyzed across the whole spectrum of values. Its association with events could reach a plateau as with E/e’ or LA volume rather than being linear.2Benfari G. Miller W.L. Antoine C. Rossi A. Lin G. Oh J.K. et al.Diastolic determinants of excess mortality in heart failure with reduced ejection fraction.JACC Heart Fail. 2019; 7: 808-817Crossref PubMed Scopus (21) Google Scholar,3Essayagh B. Antoine C. Benfari G. Messika-Zeitoun D. Michelena H. Le Tourneau T. et al.Prognostic implications of left atrial enlargement in degenerative mitral regurgitation.J Am Coll Cardiol. 2019; 74: 858-870Crossref PubMed Scopus (11) Google Scholar Furthermore, whether PALS could modulate the prognostic effect of functional mitral regurgitation (FMR) has not yet been explored. To investigate this issue, we extended the long-term follow-up of our previously published cohort of 286 outpatients with stable HFrEF.4Malagoli A. Rossi L. Bursi F. Zanni A. Sticozzi C. Piepoli M.F. et al.Left atrial function predicts cardiovascular events in patients with chronic heart failure with reduced ejection fraction.J Am Soc Echocardiogr. 2019; 32: 248-256Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The primary endpoint was a composite of CV mortality or HF hospitalization. The mean age was 68 ± 11 years, and most of the patients were male (81%) with ischemic heart disease (64%). Left ventricular ejection fraction was 32% ± 6%. During a median follow-up of 6.4 years (interquartile range, 3.92-7.70), 61 (21%) patients died from CV causes and 80 (28%) were hospitalized for HF (61% of them later experienced CV death). To assess the association between PALS as a continuous variable and composite endpoint, we created a spline modeling of the hazard ratio within the study cohort (Figure 1A). The curve begins to rise for PALS values below 30%, with a steady increase from higher to lower PALS values in an almost linear fashion. Excess event risk within the study population (risk ratio >1) appears at about the PALS value of 14%, without a definite plateau effect. Recently, the PALS value of 15.5% has been proposed as a prognostic predictor, using time-dependent receiver operating characteristic analysis.5Carluccio E. Biagioli P. Mengoni A. Cerasa M.F. Lauciello R. Zuchi C. et al.Left atrial reservoir function and outcome in heart failure with reduced ejection fraction.Circ Cardiovasc Imaging. 2018; 11: e007696Crossref PubMed Scopus (48) Google Scholar Our results are supportive of such a threshold, adding the concept of linearity to the relationship. Left atrial strain seems to be less dependent on loading conditions than traditional echocardiographic parameters. However, caution needs to be applied concerning the possible confounding effects of FMR. Figure 1B shows the relationship between the different degrees of FMR (no-mild vs moderate-severe) and outcome across the spectrum of the PALS values. At higher PALS values there is a low absolute rate of events regardless of FMR severity. At lower PALS, event rates are high and significantly increased by the FMR (P = .03) as demonstrated by the progressive divergence between the curves. Thus, reduced PALS shows a multiplicative effect on the dismal outcome carried by FMR in this clinical setting. In conclusion, quantifying LA function by strain should be part of clinical decision-making in patients with HFrEF. The linear relationship with events makes it appropriate for incorporating into HF risk scores. Functional mitral regurgitation severity combined with impaired LA function seems to have a major impact on prognosis, as if the buffering effect of the LA compliance with respect to the hemodynamic effects of FMR is lost. Future studies aimed at the interaction between these two variables are warranted. Moreover, LA function should always be taken into account when analyzing the effect of FMR treatments as well as in designing future FMR trials. Left Atrial Function Predicts Cardiovascular Events in Patients With Chronic Heart Failure With Reduced Ejection FractionJournal of the American Society of EchocardiographyVol. 32Issue 2PreviewHeart failure (HF) is known to be the most widespread epidemic of cardiovascular disease. Among several factors with prognostic value for the clinical course of HF, left atrial (LA) function has not yet been fully examined. The aim of this prospective study was to evaluate LA function for the prediction of major cardiovascular outcomes in stable patients with chronic HF with reduced ejection fraction. Additionally, as secondary end points, cardiovascular mortality and atrial fibrillation were analyzed separately. Full-Text PDF

Abstract Aims The debate about the independent prognostic responsibility of functional mitral regurgitation (FMR) is still in turmoil. Growing findings about the predictive role of left atrial (LA) function are emerging in several scenarios. This study aims to define FMR linkage to cardiovascular (CV) outcomes and the interplay with LA function in a prospective cohort of consecutive heart failure patients with reduced ejection fraction (HFrEF). Methods and results 286 consecutive outpatients with chronic HFrEF were enrolled. FMR was quantified by effective regurgitant orifice area (EROA). Global peak atrial longitudinal strain (PALS) was measured by speckle tracking echocardiography (STE). The primary endpoint was defined as a composite of congestive HF hospitalization and CV death. The majority (81%) of patients were men (mean age: 67 ± 11 years, mean LVEF: 32 ± 6%). The median global PALS was 17.7% ranging from 2.7% to 49.2%. FMR was quantifiable in 240 (84%) patients. During a median follow-up period of 6.4 (IQR: 3.9–7.7) years, the primary endpoint occurred in 88 (31%) patients (35 HF admissions, and 53 deaths). EROA showed independent prediction for the primary endpoint [HR: 1.30 (1.05–1.57), P = 0.01]. The spline modelling of the risk by EROA values showed an excess event risk starting at about the EROA value of 0.1 cm2 (Figure 1). There was a remarkable graded association between the EROA strata, even if tested per 0.1 cm2 increase, and the risk of congestive HF hospitalization and CV death (P = 0.0004). Any FMR grade presenting with reduced LA function (PALS < 14%) was associated with dismal outcome (event rate of 63 ± 10% for EROA exceeding 0.3 cm2 and 49 ± 6% for EROA ≥0.1 cm2 at 5 years). Conversely, the presence of EROA ≥0.1 in the context of preserved global PALS showed a better outcome (Figure 2). 47 Figure 1 47 Figure 2 Conclusions Our results refine the independent association between FMR and CV outcome among HFrEF outpatients. The risk of CV events starts at a low EROA value, reaching a severe level above the threshold of 0.3 cm2. Within a moderate EROA range, the LA function mitigates the clinical consequences of the mitral regurgitation, providing measurable proof of the interplay between the regurgitation and the LA compliance.

Background: Patients with coronavirus disease 2019 (COVID-19) exhibit high thrombotic risk. The evidence on a potential independent prognostic role of antiplatelet treatment in those patients is limited. The aim of the study was to evaluate the prognostic impact of pre-admission low-dose acetylsalicylic acid (ASA) in a wide series of hospitalized patients with COVID-19. Methods: This cohort study included 984 COVID-19 patients stratified according to ASA intake before hospitalization: ASA(+) (n = 253) and ASA(-) (n = 731). Patients were included in ASA(+) group if they received it daily in the 7 days before admission. 213 (83%) were on ASA 100 mg daily. Primary endpoint was a composite of in-hospital death and/or need for respiratory support upgrade, secondary endpoints were in-hospital death and need for respiratory support upgrade. Results: Mean age was 72 [62; 81] with 69% of male patients. ASA(+) patients were significantly older, with higher prevalence of comorbidities. No significant differences regarding the degree of respiratory dysfunction were observed. At 30-day Kaplan-Meier analysis, ASA(+) patients had higher survival free from the primary endpoint and need for respiratory support upgrade, conversely in-hospital death did not significantly differ between groups. At multivariate analysis ASA intake was independently associated with a lower probability of reaching primary endpoint (HR 0.697, 95% C.I. 0.525-0.924; p = 0.012). Conclusions: In COVID-19 patients undergoing hospitalization, pre-admission treatment with ASA is associated with better in-hospital outcome, mainly driven by less respiratory support upgrade.

Studies have described clinical features of patients with coronavirus disease (COVID‐19). However, limited data concerning the clinical characteristics of the Italian deaths are available. We aim to describe the clinical and epidemiological characteristics of 320 deceased from the Italian experience. We retrospectively collected all consecutive non‐survivor patients with laboratory‐confirmed COVID‐19 infection admitted to the Emergency Rooms (ERs) Piacenza Hospital Network during the first month of COVID‐19 pandemic in Italy. Clinical history, comorbidities, laboratory findings and treatment were recorded for each patient. A total of 1050 patients with confirmed COVID‐19 pneumonia were admitted to the ERs between 24 February and 22 March 2020. Three hundred and twenty (30.5%) patients died with a median age of 78.0 years, 205 (64%) non‐survivors were above 65 years old, 230 (71.9%) were male. Non‐survivor patients showed frequently several coexisting medical conditions, with hypertension being the most common comorbidity (235 patients, 73.4%). The in‐hospital mortality did not change during the progression of the pandemic. In this retrospective Italian study, most of COVID‐19 deceased patients were elderly male aged over than 65 years. Hypertension was the most common coexisting disease. In‐hospital mortality was high and showed no variation during the first month of the COVID‐19 italian epidemic.

Association of renin–angiotensin system inhibitors with risk of death in patients with hypertension (HTN) and coronavirus disease 2019 (COVID-19) is not well characterized. The aim of this study was to evaluate the outcomes of patients with HTN and COVID-19 with respect to different chronic antihypertensive drug intake. We performed a retrospective, observational study from a large cohort of patients with HTN and with a laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection admitted to the Emergency Rooms (ER) of the Piacenza Hospital network from February 21, 2020 to March 20, 2020. There were 1050 patients admitted to the ERs of the Piacenza Hospital network with COVID-19. HTN was present in 590 patients [median age, 76.2 years (IQR 68.2–82.6)]; 399 (66.1%) patients were male. Of them, 248 patients were chronically treated with ACEi, 181 with ARBs, and 161 with other drugs (O-drugs) including beta blockers, diuretics and calcium-channel inhibitors. With respect to the antihypertensive use, there was no difference between comorbid conditions. During a follow-up of 38 days (IQR 7.0–46.0), 256 patients (43.4%) died, without any difference stratifying for antihypertensive drugs. Of them, 107 (43.1%) were in ACEi group vs 67 (37%) in ARBs group vs 82 (50.7%) in O-drugs group, (log-rank test: p = 0.066). In patients with HTN and COVID-19, neither ACEi nor ARBs were independently associated with mortality. After adjusting for potential confounders in risk prediction, the rate of death was similar. Our data confirm Specialty Societal recommendations, suggesting that treatment with ACEIs or ARBs should not be discontinued because of COVID-19.

Background Mobile computing and communication technologies in health services and information (so-called mHealth) have modified the traditional approach in the follow-up of patients with implantable cardiac devices, increased patient engagement and empowerment, reduced healthcare costs and improved patients' outcome. Recent developments in mobile technology, with the introduction of smartphone-compatible devices that can measure various health parameters and transfer automatically generated data, have increased the potential application of remote monitoring and the interest towards mHealth. However, little is known about the patients' interest and expectations of this new technology. Objective The patients' interest in the possibility of receiving data from their implantable cardiac device, clinical and health advice via remote monitoring on their smartphones were investigated. Methods A questionnaire entitled ‘Expectations for future possibility of self-management of device data’ (Likert scale scored) was submitted to 300 consecutive implantable cardiac device outpatients. The questionnaire was focused on collecting patients’ expectations in receiving direct information regarding their implantable cardiac device status (item 1, five questions), their own clinical status (item 2, seven questions) and advice on healthy lifestyle promotion (item 3, nine questions). Patient characteristics associated with greater interest towards mHealth were also investigated. Results Questionnaires were completed by 268 patients (221 men, aged 69 ± 14 years). The Cronbach test reported an alpha value of 0.98 for item 1, 0.94 for item 2 and 0.97 for item 3. Patients declared to be mainly interested in the device interventions (62%) and in severe arrhythmia occurrence (61%), followed by data on heart failure severity (54%) and their performed physical activity (48%). Patients showed very little interest in ECG tracing (37%), but the lowest interest was expressed towards healthy lifestyle promotion advice (<40%). A higher education degree and the presence of the caregiver positively affected the interest towards remote monitoring information (P < 0.001). Conclusions The patients' interests were mainly directed at receiving information related to technical data of the implantable cardiac device and not to the overall management of the disease, underlying the insufficient awareness of patients towards the key role of self-control health status and the promotion of a healthy lifestyle.

OBJECTIVES:This study sought to assess speckle-tracking-derived parameters as predictors of first and subsequent ventricular events in patients with structural heart disease and implantable cardioverter-defibrillators (ICD). BACKGROUND:Left ventricular ejection fraction (LVEF), the current primary parameter of risk stratification for ventricular arrhythmias (VAs) in structural heart diseases is burdened by many limitations. METHODS:In this retrospective, observational study, all consecutive patients with structural heart disease were admitted for ICD implantation. Patients not followed by a home-monitoring system were excluded. Two-dimensional (2D) speckle-tracking analysis was used to derive global longitudinal strain (GLS), mechanical dispersion (MD), and delta contraction duration (DCD) of all patients at enrollment. Home monitoring was checked weekly to detect all VAs and ICD therapies. A recurrent event statistical approach (Prentice, Williams, and Peterson model) was applied to evaluate subsequent events after the first ones. RESULTS:A total of 203 patients were consecutively enrolled and followed for a median of 2.2 years. Kaplan-Meier curves showed an increased risk of antitachycardia pacing or shock (log-rank p = 0.003) and VAs (log-rank p = 0.001) associated with lower quartiles of GLS. An impaired GLS was independently associated with an increased risk for the first ICD therapy (hazard ratio [HR]: 1.94; 95% confidence interval [CI]: 1.30 to 2.91; p = 0.001) and (HR: 1.42; 95% CI: 1.01 to 1.98; p = 0.04) for the first VA. GLS impairment was not significantly associated with an increased risk of recurrent ICD therapies or VAs. LVEF, MD, and DCD were not associated with an increased risk of first, second, and third ICD therapies or VA. CONCLUSIONS:Impaired GLS is associated with an increased risk of VAs and appropriate ICD therapies in a consecutive "real-world," unselected population of remotely monitored patients with structural heart disease, although it does not seem reliable in predicting further arrhythmic events after the first one. MD and DCD do not predict first or subsequent arrhythmic events in ICD patients with structural heart disease.

Background: Heart failure (HF) is known to be the most widespread epidemic of cardiovascular disease. Among several factors with prognostic value for the clinical course of HF, left atrial (LA) function has not yet been fully examined. The aim of this prospective study was to evaluate LA function for the prediction of major cardiovascular outcomes in stable patients with chronic HF with reduced ejection fraction. Additionally, as secondary end points, cardiovascular mortality and atrial fibrillation were analyzed separately. Methods: The predictive value of LA function evaluated by speckle-tracking echocardiography was assessed in a population of 286 outpatients referred to the authors' institution for routine evaluation of chronic HF. Global peak atrial longitudinal strain was measured at the end of the reservoir phase and calculated by averaging in all LA segments. Results: During a median follow-up period of 48 6 11 months, major adverse cardiac events occurred in 98 patients (34%). In a multivariate model, global peak atrial longitudinal strain (hazard ratio, 0.95; 95% CI, 0.94-0.96; P =.02), left ventricular ejection fraction (hazard ratio, 0.95; 95% CI, 0.93-0.97; P =.01), and renal failure (hazard ratio, 0.98; 95% CI, 0.97-0.99; P =.01) were independent predictors of an adverse outcome. Sixty-six patients (23%) died of cardiac causes. Fifty-four patients (19%) developed atrial fibrillation. Patients with lower global peak atrial longitudinal strain showed worse event-free survival and developed atrial fibrillation more frequently than those with higher levels. Conclusions: LA function assessed by speckle-tracking echocardiography is an independent prognostic marker in patients with HF with reduced ejection fraction.

Purpose: The study aimed to investigate the patient wishes in Remote Monitoring (RM) feedbacks from their cardiac implantable device. In particular the study aimed to highlight patient expectations to receive direct information about device functions, control the own clinical status and tips on lifestyle on their smartphone.