Background Whether orthostatic hypotension (OH) is a risk factor for cardiovascular morbidity and death is uncertain. Currently available evidence derives from non-homogeneous and partly ambiguous studies. Objective We aimed at assessing the relationship between OH and death or major adverse cardiac and cerebrovascular events (MACCEs) by integrating results of previous studies. Methods We performed a meta-analysis of prospective observational studies reporting on the association between prevalent OH, mortality, and incident MACCE, published from 1966 through 2013. Mantel–Haenszel pooled estimates of relative risk (RR) and 95% confidence intervals (CIs) for all-cause death were assessed as the primary endpoint at the longest follow-up; incident coronary heart disease (CHD), heart failure (HF), and stroke were assessed as secondary endpoints. We also performed post hoc subgroup analyses stratified by age and a meta-regression analysis. Results We identified a total of 13 studies, including an overall population of 121 913 patients, with a median follow-up of 6 years. Compared with the absence of OH, the occurrence of OH was associated with a significantly increased risk of all-cause death (RR 1.50; 95% CI 1.24–1.81), incident CHD (RR 1.41; 95% CI 1.22–1.63), HF (RR 2.25; 95% CI 1.52–3.33), and stroke (RR 1.64; 95% CI 1.13–2.37). When analysed according to age, pooled estimates of RR (95% CI) for all-cause death were 1.78 (1.25–2.52) for patients <65 years old, and 1.26 (0.99–1.62) in the older subgroup. Conclusion Orthostatic hypotension is associated with a significantly increased risk of all-cause death, incident CHD, HF, and stroke.

In patients receiving permanent cardiac electrical stimulation, a high burden of apical right ventricular pacing is associated with an increased incidence of heart failure. Despite the large body of electrocardiographic, echocardiographic, and pathological data, mechanisms underlying this serious complication are not fully understood. Moreover, the empirical use of alternative right ventricular pacing sites, both in the experimental and in the clinical setting, has not provided better results in terms of clinical outcome. Recent data derived by echocardiographic particle image velocimetry of intracardiac flows have shown abnormal flow patterns in patients with dyssynchrony of left ventricular wall contraction, and the reversion to normal flow dynamics after successful electrical cardiac resynchronization therapy. This suggests that a normal intraventricular flow pattern is strongly dependent on the highly coordinated contraction of the ventricular wall segments and that an abnormal sequence of wall contraction may trigger the development of overt heart failure. This review summarizes the state of the art on this topic, highlighting postulated underlying basic mechanisms linking abnormal flow with the development of pacing-induced heart failure. This research line suggests the importance of studying intraventricular fluid dynamics as a new powerful tool for a more complete understanding of mechanisms involved, and ultimately to prevent pacing-related heart failure.

Lung ultrasonography is an emerging, user-friendly and easy-to-use technique that can be performed quickly at the patient’s bedside to evaluate several pathologic conditions affecting the lung. Ultrasound lung comets (ULCs) are an echographic sign of uncertain biophysical characterisation mostly attributed to water-thickened subpleural interlobular septa, but invariably associated with increased extravascular lung water. ULCs have thus been proposed as a complementary tool for the assessment and monitoring of acute heart failure and are now entering into statements in international recommendation documents. Adding lung ultrasonography to conventional echocardiography allows for performing an integrated cardiopulmonary ultrasound examination, and this is an important opportunity for the cardiologist. The technique allows the simultaneous gathering of considerable information about the heart and the lungs to investigate acute and chronic cardio-pulmonary conditions within a non-invasive, radiation-free, single-probe, all-in-one examination. We have here reviewed the pertinent literature on the physical origin of ULCs and on their role and importance in intensive and acute cardiac care settings. We also here propose a new algorithm aimed at implementing evaluation in the diagnostic work-up of patients with suspected acute heart failure.

The exercise electrocardiographic stress test (ExET) is the most widely used non-invasive diagnostic method to detect coronary artery disease. However, the sole ST depression criteria (ST-max) have poor specificity for coronary artery disease in patients with left ventricular hypertrophy. We hypothesised that ST-segment depression/heart rate hysteresis, depicting the relative behaviour of ST segment depression during the exercise and recovery phase of the test might increase the diagnostic accuracy of ExET for coronary artery disease detection in such patients. In three cardiology centres, we studied 113 consecutive patients (mean age 66 ± 2 years; 88% men) with hypertension-related left ventricular hypertrophy at echocardiography, referred to coronary angiography after an ExET. The following ExET criteria were analysed: ST-max, chronotropic index, heart rate recovery, Duke treadmill score, ST-segment depression/heart rate hysteresis. We detected significant coronary artery disease at coronary angiography in 61 patients (53%). At receiver-operating characteristic analysis, ST-segment depression/heart rate hysteresis had the highest area under the curve value (0.75, P < 0.001 when compared with the ‘neutral’ receiver-operating characteristic curve value of 0.5). Area under the curve values were 0.68 (P < 0.01) for the chronotropic index, 0.58 (P = NS) for heart rate recovery, 0.57 (P = NS) for ST-max and 0.52 (P = NS) for the Duke treadmill score. Among currently available ExET diagnostic variables, ST-segment depression/heart rate hysteresis offers a substantially better diagnostic accuracy for coronary artery disease than conventional criteria in patients with hypertension-related left ventricular hypertrophy.