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.

A BSTRACT 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. 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). 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%. 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.

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.

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.