Sodium-glucose cotransporter 2 inhibitors (SGLT2i), a new class of glucose-lowering drugs traditionally used to control blood glucose levels in patients with type 2 diabetes mellitus, have been proven to reduce major adverse cardiovascular events, including cardiovascular death, in patients with heart failure irrespective of ejection fraction and independently of the hypoglycemic effect. Because of their favorable effects on the kidney and cardiovascular outcomes, their use has been expanded in all patients with any combination of diabetes mellitus type 2, chronic kidney disease and heart failure. Although mechanisms explaining the effects of these drugs on the cardiovascular system are not well understood, their effectiveness in all these conditions suggests that they act at the intersection of the metabolic, renal and cardiac axes, thus disrupting maladaptive vicious cycles while contrasting direct organ damage. In this systematic review we provide a state of the art of the randomized controlled trials investigating the effect of SGLT2i on cardiovascular outcomes in patients with chronic kidney disease and/or heart failure irrespective of ejection fraction and diabetes. We also discuss the molecular targets and signaling pathways potentially explaining the cardiac effects of these pharmacological agents, from a clinical and experimental perspective.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults and is associated with significant morbidity and mortality, including an increased risk of stroke, heart failure, dementia, and recurrent hospitalizations. As life expectancy rises, both the incidence and prevalence of AF continue to grow. Stroke prevention remains a cornerstone of AF management, with oral anticoagulation being the primary strategy to reduce thromboembolic risk. However, despite their advantages, direct oral anticoagulants do not completely eliminate the risk of bleeding complications. For patients in whom anticoagulation is contraindicated, poorly tolerated, or ineffective at preventing AF-related stroke, interventional alternatives have gained traction. The left atrial appendage (LAA), a primary site of thrombus formation in AF, can be occluded through a catheter-based procedure known as left atrial appendage closure (LAAC) or left atrial appendage occlusion (LAAO). This review aims to provide imaging specialists with a comprehensive understanding of their role in LAAC, underscoring the importance of a multidisciplinary approach to enhance patient selection, procedural success, and long-term efficacy.

Myocardial injury is a recognized complication of acute pancreatitis, whereas myocarditis has only been occasionally reported and has not been systematically evaluated. We systematically reviewed PubMed literature published up to January 2024 for studies including both “myocarditis” and “pancreatitis” as keywords. Relevant data regarding patient characteristics and outcomes were collected and analyzed. A total of 31 patients from 31 independent studies were included. The etiology of pancreatitis was viral in 52%, bacterial in 20%, toxic in 16%, autoimmune in 9%, and idiopathic in 3%. 23% of patients were immunocompromised. Median high sensitivity-cardiac troponin T was 342 (IQR 73-890) ng/L and N-terminus-pro-brain natriuretic peptide was 11053 (IQR 1397-26150) pg/mL. The average left ventricular ejection fraction was 33±13%. Fulminant myocarditis, presenting with cardiogenic shock and/or malignant ventricular arrhythmias occurred in 48% of patients, more frequently in men than in women (P=0.026). Severe myocarditis occurred in 42% of edematous and 60% of necrotizing pancreatitis (P=0.56). No association was found between the severity of myocarditis and plasma levels of amylase (P=0.98) and lipase (P=0.83). The relative frequency of severe myocarditis was 80% in pancreatitis due to Leptospirosis, and 40% in pancreatitis due to viral infections. The mortality rate was 22%: 13% died during hospitalization and 9% after. Myocarditis is a potentially lethal complication of pancreatitis and is more frequently associated with viral etiology in immunocompromised individuals. Based on such findings, cardiac troponin measurements and an electrocardiogram are advisable to exclude myocardial involvement in selected patients. Confirmatory diagnosis and prognostic assessments should be based on cardiac magnetic resonance imaging.

Aims: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of clinical entities requiring further investigation to assess aetiology. The European Society of Cardiology guidelines recommend advanced tests to establish an underlying mechanism. We evaluated advanced diagnostic testing utilization and real-world adherence to the current guideline in an international MINOCA registry. Methods and results: DOMINO is a prospective, multicentre, non-commercial registry enrolling 365 patients with MINOCA across 17 centres in 13 countries. Advanced testing was defined as cardiac magnetic resonance (CMR), intracoronary imaging, and/or invasive coronary functional assessment. The association between advanced testing and diagnostic resolution was assessed by multivariable logistic regression, with standard, cluster-robust, and generalized estimating equation (GEE) approaches to account for clustering by centre. Guideline-directed testing was performed in 254/365 (69.6%) and varied markedly by country (0–100%, P < 0.0001). A specific etiologic diagnosis was reached in 337/365 patients (92.3%). Advanced testing was associated with diagnostic resolution in the standard and GEE models, with a directionally consistent but non-significant cluster-robust estimate [standard odds ratio (OR) 3.94, 95% confidence interval (CI) 1.59–10.06; cluster-robust OR 3.75, 95% CI 0.95–14.72, P = 0.058; GEE OR 3.69, 95% CI 1.04–13.11]. Diagnostic resolution increased progressively with the extent of testing performed, from 85.6% with no advanced testing to 97.1% with CMR plus invasive/functional assessment (trend P = 0.02). Discharge pharmacotherapy varied significantly by etiologic diagnosis (P = 0.0001). Conclusion: Advanced diagnostic testing was associated with a higher likelihood of a determined etiologic diagnosis in MINOCA, despite marked international variability in its use; however, this association is partly definitional, as advanced testing directly contributes to diagnostic ascertainment for several etiologic categories. These findings nonetheless support closing the guideline-practice gap in advanced testing, while underscoring the need to distinguish mechanistically confirmed diagnoses from presumptive ones.

Aims: Late gadolinium enhancement (LGE) quantification by cardiovascular magnetic resonance is central to risk stratification in hypertrophic cardiomyopathy (HCM). Conventional techniques require contour tracing and region of interest (ROI) placement, which may reduce reproducibility and increase analysis time. We developed a novel visual approach, the visual standardized quantification (VISTAQ) of LGE, that does not require myocardial contouring, arbitrary ROI positioning, or dedicated post-processing software. Methods and results: LGE images from 400 patients (100 prior myocardial infarction, 250 HCM, and 50 other non-ischaemic heart diseases) were analysed. Reproducibility was assessed using the intra-class correlation coefficients (ICC) and Bland–Altman analysis. VISTAQ was compared with conventional methods [mean+2SD, +5SD, +6SD, full-width-at-half-maximum (FWHM), visual thresholding]. Prognostic performance was evaluated in 250 HCM patients. VISTAQ demonstrated excellent intra- and inter-observer reproducibility (ICC up to 0.98 and 0.97, respectively), consistent across disease subtypes. VISTAQ showed similar ICC to FWHM but significantly lower net and absolute inter-observer differences (median absolute difference: 1.3%). Mean+2SD markedly overestimated LGE, whereas mean+6SD slightly underestimated LGE compared with VISTAQ, mean+5SD, FWHM, and visual thresholding. Analysis time was shorter with VISTAQ (median 105 vs. 375 s, P < 0.0001). During follow-up, 21 hard cardiac events occurred in HCM population. An LGE threshold >10% predicted events with higher accuracy using VISTAQ [area under the curve (AUC): 0.90; sensitivity: 85%; specificity: 94%) compared with mean+6SD (AUC: 0.75; sensitivity: 57%; specificity: 93%). Conclusion: VISTAQ provides highly reproducible, time-efficient LGE quantification without dedicated software and demonstrates non-inferior prognostic discrimination in HCM compared with conventional threshold-based techniques.