Abstract Introduction Transthoracic echocardiography (TTE) identifies a hypercontractile phenotype (HP) in chronic coronary syndromes (CCS), characterized by elevated resting left ventricular (LV) elastance (force = systolic blood pressure/end-systolic volume). To evaluate the prognostic significance and functional correlates of HP. Methods In a prospective multicentre study, 10 677 patients with CCS underwent resting TTE to assess LV ejection fraction (EF), stroke volume, and force by quantitative volumetric echocardiography. All patients were followed for the endpoint of all-cause mortality. In a subset of 5834 patients, stress echocardiography (exercise or dobutamine) was performed for LV contractile reserve and heart rate reserve. Results Patients were stratified into Force quintiles (Q1–Q5). Patients with hypercontractile phenotype exhibited lower stroke volume at rest (Q5 = 34.8 ± 12.3 vs Q1–Q4 = 57.4 ± 19.1 mL; P < .01) and higher EF at rest (Q5 = 64.8 ± 6.9% vs Q1–Q4 = 58.1 ± 8.7%, P < .01). During a median follow-up of 24 months (interquartile range = 12–40 months), 509 deaths occurred. The exposure-adjusted death rate was lowest in Q3 (3.53–4.51 mmHg/mL; 1.03 per 100 person/years) and higher in Q1 (≤2.62 mmHg/mL, 2.88), Q2 (2.63–3.52 mmHg/mL, 1.86), Q4 (4.52–6.11 mmHg/mL, 1.56), and Q5 (HP, >6.11 mmHg/mL; 1.88; P < .0001 vs Q1 and Q3). Multivariable analysis identified HP (Q5; HR 1.531 vs Q3, 95% CI 1.116–2.099; P = .006) and EF (HR 0.963, 95% CI 0.953–0.972; P < .0001) as independent predictors of death. During exercise or dobutamine stress, HP showed reduced LV contractile reserve (ΔEF: Q5 = 4.3 ± 9.4% vs Q1–Q4 = 7.0 ± 9.3%; P < .001) and blunted heart rate reserve (Q5 = 1.77 ± 0.33 vs Q1–Q4 = 1.85 ± 0.39; P < .01). All patients with force-based LV contractile reserve >4.1 (present in 185, 3.2% of the population) survived. Conclusion Patients with CCS with HP assessed by resting TTE demonstrate higher mortality and multilayered functional impairment, including reduced LV contractile and chronotropic reserves. Hypercontractile phenotype improved the prediction of mortality by EF. A ‘stronger’ heart is, in fact, functionally and prognostically weaker.

Stress echocardiography (SE) has evolved beyond its traditional role of detecting coronary artery disease (CAD) through a single marker-regional wall motion abnormality (RWMA). This conventional approach, while guideline-embedded, faces a declining positivity rate and reduced prognostic power in today's diverse patient population. In response, SE has undergone a conceptual transformation into a multi-marker, comprehensive functional assessment of patient vulnerability. The modern multi-marker protocol, known as the ABCDE-SE, integrates five steps during a single stress test: Step A assesses RWMA for ischemia; Step B quantifies pulmonary congestion via B-lines and E/e'; Step C evaluates left ventricular volume response; Step D measures coronary flow velocity reserve for microvascular function; and Step E determines heart rate reserve for autonomic function. Each step identifies distinct pathophysiological mechanisms and actionable therapeutic targets, significantly refining risk stratification.Developed and validated over the past decade with the SE 2030 study (2016-2030), the flagship project of SIECVI, Italian Society of Echocardiography and Cardiovascular Imaging, and adopted by 50 laboratories from 20 countries, the ABCDE protocol represents a universal and widely accessible platform, applicable to all patients with suspected cardiac disease. It paves the way for personalized medicine by enabling tailored therapies targeted to the specific vulnerabilities.

ABSTRACT Introduction: Repaired TOF (rTOF) is a common condition in adult congenital heart disease care. The aim of this article is to investigate how inflammatory markers and volume overload affect rTOF, and how these factors correlate with echocardiographic findings in the right heart cavities. Methods: This study included 32 adult patients (mean age, 27.44 ± 6.22 years) who had undergone surgical correction of TOF during infancy. All participants underwent transthoracic echocardiography, and laboratory assessments included measurements of N-terminal pro-B-type natriuretic peptide (NT-proBNP; reference range ≤125 pg/mL) and high-sensitivity C-reactive protein (hs-CRP; reference range ≤2.0 mg/L). Results: Significant correlations were found between NT-proBNP levels and right ventricular (RV) fractional area change (FAC) (r = −0.55, P = 0.001), tricuspid annular plane systolic excursion (TAPSE) (r = −0.35, P = 0.04), RV basal diameter (r = 0.47, P = 0.006), and right atrium (RA) area (r = 0.50, P = 0.003). Similarly, hs-CRP levels showed strong associations with RV FAC (r = −0.58, P < 0.001), TAPSE (r = −0.45, P = 0.009), RV basal diameter (r = 0.43, P = 0.01), and RA area (r = 0.43, P = 0.01). NT-proBNP had a significant impact (P = 0.017; EXP B = 0.982) on RV FAC. A decrease of 10 units in NT-proBNP was associated with a 17% reduction likelihood of having RV FAC <35%. Conclusion: The proinflammatory response (hs-CRP) and volume load (NT-proBNP) are directly correlated with echocardiographic parameters of the right heart cavities in patients with rTOF, suggesting that patients may benefit from treatment with anti-inflammatory drugs, as well as medications targeting diastolic dysfunction.

Objectives. Our objective was to study the ecological relationship of many risk factors and personal characteristics with mean age at death (AD) after a 50-year follow-up of nearly extinct cohorts. Material and Methods. There were 16 cohorts totaling 12,763 middle-aged men enrolled in the Seven Countries Study (SCS), and 58 variables were measured, including traditional risk factors, dietary nutrition and anthropometric variables. A follow-up of 50 years allowed the use of AD as the end-point. Analysis included simple linear regression correlation and multivariate modelling using Principal Component Analysis and regression and Ridge regression. Results. Out of 58 variables, only 11 (10 nutrition-dietary items plus age) showed a significant linear correlation coefficient (R) ≥ 0.50 and a p value ≤ 0.05. Linear regression was computed by using as a predictor the dietary factor score derived from a Principal Component Analysis of the 11 significant variables, which were used as independent variables, whose coefficients were significantly related with AD, and the final R2 was 0.52. The Principal Component regression and Ridge regression documented the direct relationship of food groups of vegetable origin (including olive oil) with the AD and the inverse relationship for food groups of animal origin. Conclusions. A few variables, all related to diet and nutrition, were able to statistically explain about 50% of the different AD in 16 cohorts of men followed up with nearly until death. Other variables, including traditional cardiovascular disease risk factors, did not contribute in a significant way for this purpose.

ObjectiveTo evaluate the predictive value of LA strain parameters and LASI for AF recurrence following electrical CV, and to compare them to conventional echocardiographic, biochemical, and clinical markers.MethodsIn this prospective, observational pilot study, 31 patients with persistent AF underwent electrical CV and were followed for six months. Echocardiographic evaluation included LA reservoir, conduit, and contractile strain, left atrial stiffness index, left atrial volume index (LAVI), left atrial appendage (LAA) morphology, left ventricular ejection fraction (LVEF), right atrial (RA) area, and right ventricular systolic pressure (RVSP). AF recurrence was assessed at three and six months.ResultsAt three months post-CV, LA reservoir, conduit, and contractile strain values were significantly negatively associated with AF recurrence (p < 0.001), while LASI and E/E' ratios were positively associated (p < 0.001). At six months, only contractile strain retained prognostic significance (p = 0.008). LVEF showed a positive correlation with recurrence at six months (p = 0.003), potentially reflecting the role of diastolic dysfunction.ConclusionLA strain parameters and LASI are valuable tools for predicting AF recurrence after CV, particularly in the early post-procedural period. Contractile strain may serve as a more reliable long-term predictor, emphasizing the importance of longitudinal atrial function assessment in rhythm outcome prediction. However, given the small sample size and single-center design, these results should be considered hypothesis-generating, requiring validation in larger studies.

BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous entity including patients with different phenotypes of near normal, normal, and supernormal left ventricular (LV) function. OBJECTIVES To assess the value of resting LV elastance (also known as force) with transthoracic echocardiography (TTE) to identify HFpEF phenotypes. METHODS In a prospective, observational, multicenter study, 2380 HFpEF patients were recruited from July 2016 to May 2024. Systolic blood pressure (SBP) was measured. We assessed LV end-diastolic volume (EDV), end-systolic volume (ESV), EF, force (SBP/ESV), stroke volume (SV), arterial elastance (AE), ventricular-arterial coupling (VAC), and left atrial volume index (LAVI). Global longitudinal strain (GLS) was available in 1164 (48.9%) patients. 680 patients finished follow-up with a composite end-point of major adverse cardiac events (MACEs). Patients were divided into three groups: low force (< 25th percentile, Group 1, < 3.24 mmHg/ml), intermediate force (≥ 25th percentile and ≤ 75 th percentile, Group 2, 3.24-5.48 mmHg/ml), and high force (> 75 th percentile, Group 3, >5.48 mmHg/ml). RESULTS The 3 groups showed a gradient with descending values (Group 3>2>1) for SBP, EF, GLS, AE, and VAC, with the opposite gradient (Group 1> 2> 3) for EDV, ESV, SV, and LAVI values (all P<0.01). After a median follow-up of 16 months, 205 MACEs occurred in 138 patients. Cumulative MACEs rate was lowest in group 2 (14.7% person-year), higher in group 1 (16.1% person-year) and 3 (22.9% person-year, log rank p = 0.036). CONCLUSIONS HFpEF patients present with different LV contractile phenotypes, easily identified with resting LV force and volumetric TTE. The dominant hemodynamic feature of hypocontractile phenotype is a preload recruitment with larger LV EDV and normal SV, while the hypercontractile phenotype is characterized by a small LV with reduced SV. The hypercontractile and hypocontractile phenotypes are associated with a higher risk of subsequent events.

Over the past decade, stress echocardiography has evolved from a test for assessing epicardial artery stenosis to a comprehensive functional test, targeting multiple cardiovascular parameters. The new approach includes several structured steps: (a) evaluating regional wall motion abnormalities to detect epicardial artery stenosis or vasospasm; (b) assessing pulmonary congestion and diastolic function via B-lines with lung ultrasound; (c) gauging preload and contractile reserve with volumetric echocardiography; (d) measuring coronary microvascular reserve using Doppler-based coronary flow velocity in the middistal left anterior descending artery; and (e) determining cardiac sympathetic reserve by tracking heart rate reserve on an ECG. This evolution was supported extensively by the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI), which played a key role in five areas: (1) developing the initial, curiosity-driven project; (2) disseminating protocols and results at national and international conferences, supporting logistic infrastructure and publication expenses; (3) establishing a digital platform (customized Redcap) for data entry and storage; (4) facilitating patient recruitment across 19 Italian centers; and (5) offering formal endorsement through six presidencies, adding credibility and reach beyond any single institution. The protocol quickly advanced from concept to high-impact publications, earning inclusion in 2024 specialty guidelines. Initially Italian-led, the study now includes 50 centers across 20 countries (e.g. USA and China). Beyond the 50 peer-reviewed papers published in 2016–2024, this study offers a novel, sustainable approach to cardiac stress testing, providing more information at lower costs, with zero radiation and minimal environmental impact. SIECVI’s endorsement was instrumental in amplifying the study’s rigor and outreach.

Introduction/Objective. Introduction/Objective Following the failure of the single-wire technique in percutaneous coronary intervention (PCI) for chronic total occlusions (CTO), two principal anterograde escalation strategies are commonly employed: the parallel-wire technique and antegrade wire escalation (AWE). Despite their widespread use, comparative data on the procedural characteristics and long-term clinical outcomes of these strategies remain scarce. This study aims to compare the procedural parameters and long-term outcomes of the parallel-wire and AWE techniques after single-wire failure in CTO PCI. Methods. This retrospective, single-center study included patients who underwent successful CTO PCI between January 2018 and December 2023 using either the parallel-wire or AWE technique following single-wire failure. The primary endpoint was a composite of cardiac death, myocardial infarction, stroke, or target vessel revascularization (TVR). Secondary outcomes included procedure duration, fluoroscopy time, contrast volume, and total radiation dose. Median follow-up duration was 1222 days (IQR 580-1969 days). Results. Among 270 CTO PCI procedures, 112 (41.5%) required escalation: 90with AWE and 22 with the parallel-wire technique. Baseline clinical and angiographic characteristics were comparable. The primary composite outcome occurred in 14.4% of the parallel-wire group and 9.1% of the AWE group (p = 0.73). No significant differences were observed in individual clinical events. Procedure duration was longer (95.5 ? 43.6 vs. 77.0 ? 30.7 min; p = 0.064) and contrast volume higher (336.4 ? 113.3 vs. 271.6 ? 90.6 mL; p = 0.014) in the AWE group, with similar fluoroscopy time and radiation dose. No clinically or ?ngiographically significant complications occurred during the periprocedural period. Conclusion. Both AWE and parallel-wire techniques demonstrate comparable safety and efficacy following single-wire failure in CTO PCI. While procedural efficiency slightly favored the parallel-wire strategy, overall outcomes support either approach, pending further prospective validation.

Introduction. When considering revascularization modalities, for patients with stable presentation, with appropriate coronary anatomy suitable for both PCI and CABG and low predicted surgical mortality, the recommendations are specifically focused on patients with main stem stenosis. In these cases, patients should be individually assessed according to the complexity of the anatomical disease, as determined by the anatomical SYNTAX score. In the last few years, the results of four randomized studies have been published comparing PCI with newer-generation DES and CABG in patients with left-main stenosis. The latest 2024 ESC guidelines for the management of chronic coronary syndromes recommend CABG over PCI when the anatomical SYNTAX score exceeds 22, as indicated by recent trials. The aim of this study was to examine whether the indications for CABG or PCI, as determined by the well-informed intuitive judgment of PCI operators in everyday clinical practice, align with the treatment recommendations outlined in the recently published ESC guidelines. Methods. Between January 1, 2023, and December 31, 2023, patients were recruited from the University Clinical Centre of the Republic of Srpska in Banja Luka, Bosnia and Herzegovina, utilizing the hospital information system. The study included consecutive patients diagnosed with significant unprotected left main coronary artery disease (≥50% diameter stenosis) confirmed through angiography, who did not exhibit major hemodynamic instability and received PCI at our facility. Patients were divided into two groups, based on the anatomical SYNTAX score i.e. those with SYNTAX ≤ 22 and those with SYNTAX > 22. Results. Following inclusion criteria, a total number of 38 patients were included in the analysis. The included patients had either previously diagnosed coronary artery disease or a high suspicion of coronary artery disease. The majority of the participants were male, with an average age of 65.6 years, with the youngest participant being 31 years old and the oldest 83 years old. A large majority of both sexes suffered from arterial hypertension, dyslipidemia, and type 2 diabetes. Participants in whom SYNTAX score was ≤ 22 were younger (p=0.049) and had less complex coronary artery disease i.e. fewer MEDINA 1,1,1 (p< 0.001) with less stents implanted (p=0.040). Over the course of one year of follow-up, three patients passed away, two of whom had a SYNTAX score exceeding 22. Additionally, two patients were lost to follow-up. Conclusion. The present study demonstrates that an intuitive decision-making process by experienced interventional cardiologists for choosing the optimal myocardial revascularization method for the individual patient with left main stenosis led to a discordance of the definitely chosen methods vs. the recommended method based on the SYNTAX score and ESC guidelines. This discordance between the recommended and the finally performed revascularization strategy led to a higher shortterm mortality.

Introduction. A modified imaging technique for the right coronary artery (RCA) has been developed to reduce radiation dose and fluoroscopy time. Methods. This study compared patient and operator exposure to ionizing radiation (mGy) and fluoroscopy time(s) during RCA imaging using standard and modified methods. Results. The modified technique resulted in significantly lower radiation dose (23.78 vs. 34.78 mGy; p < 0.001). Conclusion. The modified RCA imaging technique substantially decreases radiation exposure, fluoroscopy duration, and contrast volume, improving safety for both patients and staff. Keywords: Right Coronary Artery, Ionizing Radiation, Coronary Angiography, Fluoroscopy, Radiation Protection.

Medical professionals have a responsibility to inform the public about contemporary research on alcohol consumption. Earlier health recommendations focused primarily on the link between alcohol and cardiovascular diseases. Over time, these guidelines have expanded to consider the broader impact of alcohol on all-cause morbidity and mortality. Unlike the tobacco industry, which remains profitable but faces strict regulations on marketing and lobbying, the alcohol industry benefits from fewer regulations. This allows alcohol manufacturers to freely promote their products and influence both federal and state policies. Clear emphasis on the importance of ceasing alcohol consumption is crucial, particularly in primary and secondary prevention efforts. Keywords: cardiovascular diseases, alcoholics, prevention.

Atrial cardiomyopathy is closely associated with atrial fibrillation (AF), and some patients exhibit no dysfunction at rest but demonstrate evident changes in left atrial (LA) function and LA volume during exercise. This study aimed to identify distinguishing signs during exercise stress echocardiography (ESE) among patients in sinus rhythm (SR), with and without history of paroxysmal/persistent AF (PAF). A prospective cohort of 1055 patients in SR was enrolled across 12 centers. The main study cohort was divided into two groups: the modeling group (n = 513) and the verification group (n = 542). All patients underwent ESE, which included B-lines, LA volume index (LAVi), and LA strain of the reservoir phase (LASr). Age, resting and stress LAVi and LASr, and B-lines were identified as a combination of detectors for PAF in both groups. In the entire cohort, aside from resting and stress LAVi and LASr, additional parameters differentiating PAF and non-PAF patients were the presence of systemic hypertension, exercise E/e’ > 7, worse right ventricle (RV) contraction during exercise (∆ tricuspid annular plane systolic excursion < 5 mm), a lower left ventricular contractile reserve (< 1.6), and a reduced chronotropic reserve (heart rate reserve < 1.64). The composite score, summing all 9 items, yielded a score of > 4 as the best sensitivity (79%) and specificity (65%). ESE can complement rest echocardiography in the identification of previous PAF in patients with SR through the evaluation of LA functional reservoir and volume reserve, LV chronotropic, diastolic, and systolic reserve, and RV contractile reserve. A scoring system predicting the probability of PAF. The score was computed using the cutoff values as in the illustration. The score >4 demonstrated a sensitivity of 79% and a specificity of 65% of PAF.