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Heart failure with preserved ejection fraction (HFpEF) is a growing epidemiologic problem affecting more than half of the patients with heart failure (HF). HFpEF has a significant morbidity and mortality and so far no treatment has been clearly demonstrated to improve the outcomes in HFpEF, in contrast to the efficacy of treatment in heart failure with reduced ejection fraction (HFrEF).The failure of proven beneficial drugs in HFrEF to influence the outcome of patients with HFpEF could be related to the heterogeneity of the disease, its various phenotypes and multifactorial pathophysiology, incompletely elucidated yet. The diagnosis of HFpEF could be demanding or even inaccurate. Moreover, the therapeutic strategies were influenced by different cut-offs used to define preserved ejection fraction (EF). From this perspective, the current guidelines have classified HFpEF by an EF ≥ 50%, together with a distinct entity, heart failure with mid-range ejection fraction (HFmrEF), defined by an EF ranging from 41-49%.New therapies have been developed to interfere with the mediator pathways of HFpEF at the cellular and molecular level, including mineralocorticoid receptor antagonists, soluble guanylate cyclase stimulators, or angiotensin receptor-neprilysin inhibitors. A number of antidiabetic drugs, such as sodium/glucose cotransporter 2 inhibitors and dipeptidyl peptidase-4 inhibitors are promising options, being under research in large clinical trials. Until the results of ongoing trials shed light on these therapies, guidelines recommend empirical treatment for established HFpEF, and emphasize the crucial role of addressing cardiovascular comorbidities leading to HFpEF, in particular arterial hypertension.

Background. Oxidative stress (OS) and inflammation are major mechanisms involved in the progression of chronic heart failure (CHF (E/e' ≥ 13) had higher sUA (8.6 ± 2.3 vs. 7.3 ± 1.4, p=0.08) and NT-proBNP levels (643±430 vs. 2531±709, p=0.003) and lower EF (29.8 ± 3.9 % vs. 36.3 ± 4.4 %, p=0.001). p<0.001), MDA (r= 0.49, p= 0.001), MPO (r=0.34, p=0.001) and p= 0.003).Conclusion. In CHF, hyperuricemia is associated with disease severity. High sUA levels in CHF with normal renal function may reflect increased xanthine-oxidase activity linked with chronic inflammatory response.

696levels, associated with gas within the biliary tree (FIGURE 1A). Abdominal computed tomography (CT) confirmed the acute occlusive distention of the je junum and proximal ileum, as well as pneumobi lia. There was no presence of a gallstone in the air filled gallbladder, but a concentric intraluminal ring was present in the right iliac fossa, suggest ing a migrated gallstone in the bowel lumen, with a secondary ileoileal intussusception (FIGURE 1B -1E). The clinical diagnosis was acute intestinal obstruc tion probably due to gallstone ileus associated with secondary ileoileal intussusception, bilio enteric fistula, and pneumobilia.The emergent surgery revealed a jejunal ob struction by a gallstone of 2.5 cm in diameter, a spontaneous cholecystoduodenal fistula, and a secondary ileoileal intussusception due to gall stone displacement. The gallstone was extracted An 84 year old woman with a history of choleli thiasis was admitted for abdominal pain and per sisting vomiting, which had started more than a week earlier, as well as symptoms of acute small bowel obstruction, which she noted 3 days ear lier. On physical examination, she appeared dis tressed and dehydrated, while her abdomen was distended, diffusely painful, and soft, without re bound tenderness. A laboratory analysis revealed neutrophilic inflammation and mild cholestasis (increased conjugated bilirubin and serum alka line phosphatase levels). The levels of pancreat ic enzymes were normal, and other laboratory test results were unremarkable. Abdominal ul trasound revealed a shrunken gallbladder with the air inside, but without stones, and a nondi lated common bile duct. Plain abdominal X ray showed dilated small bowel loops with air fluid

Worsening chronic heart failure (HF) is responsible for recurrent hospitalization and increased mortality risk after discharge, irrespective to the ejection fraction. Symptoms and signs of pulmonary and systemic congestion are the most common cause for hospitalization of acute decompensated HF, as a consequence of increased cardiac filling pressures. The elevated cardiac filling pressures, also called hemodynamic congestion, may precede the occurrence of clinical congestion by days or weeks. Since HF patients often have comorbidities, dyspnoea, the main symptom of HF, may be also caused by respiratory or other illnesses. Recent studies underline the importance of the diagnosis and treatment of hemodynamic congestion before HF symptoms worsen, reducing hospitalization and improving prognosis. In this paper we review the role of integrated evaluation of biomarkers and imaging technics, i.e., echocardiography and pulmonary ultrasound, for the diagnosis, prognosis and treatment of congestion in HF patients.

Purpose of the study: echocardiographic evaluation of the form of degenerative aortic stenosis (DAS) with preserved ejection fraction (EF) and low transvalvular gradient, in order to formulate the indication of valvular prosthesis as early as possible; retrospective observational study that includes patients admitted or sent for ambulatory evaluation by other medical services. The echocardiographic parameters used: systolic and diastolic indices, tissue and spectral, mitral and tricuspid veins, aortic orifice area, maximal aortic systolic velocity, maximal and medium aortic transvalvular gradient, myocardial mass index, volume of left atrium, left ventricular (LV) thickness. 42 patients with severe DAS and preserved EF, average age 71.7�3.85 years. Two groups were isolated: A - with increased gradient (22 patients) and B - with low gradient (20 patients). The gender distribution was comparable: women representing 33% in group A versus 30% in group B. The average age of women in both groups was higher than that of the men: in group A: 72�8 years in the case of women vs. 67�6 years in the case of men and in group B 72�3.5 years in women vs. 68�6 years in men. Apical displacement of the mitral ring: 14�2mm in lot A vs. 11�2mm in lot B. Myocardial mass index: 120 � 9g/m2 in lot A vs. 126 � 12g/m2 in lot B. Left ventricular filling ratio E/e�: 8�2 in lot A vs. 13�2 in lot B; maximum aortic systolic velocity: 4.3�0.9m/s in lot A vs. 3.1�0.8m/s in lot B; maximum gradient: 73.9�10mmHg in lot A vs. 37�12mmHg in lot B; aortic orifice area: 0.80�10.5 in lot A vs. 0.79�0.07 in lot B. Statistical analysis shows the Pearson correlation index r with the highest values of 95% at the significance threshold between the aortic orifice area and the valve opening (r=0.87), the ratio E/e� (r=-0.85) and diastolic thickness of the posterior wall of the aortic left ventricle (r = 0.78). Aortic stenosis with preserved ejection fraction and low gradient was more common in men. The filling ratio E/e� was increased (13 � 2) in group B, suggesting the increase of filling pressures of LV in patients with DAS and low transvalvular gradient. Tissue spectral systolic and longitudinal velocities were lower in group B, suggesting the onset of systolic LV dysfunction. The aortic valve opening and the E/e� ratio showed the highest correlation coefficient with the area of the aortic orifice in both groups. The myocardial mass index and the thickness of the walls of the LV cavity are similar in the two groups, suggesting that the reduction of the LV cavity through hypertrophy may not explain, at least in totality, the form of DAS with low gradient and preserved ejection fraction.

Background: The association between hypertension (HTN) and type 2 diabetes mellitus (DM) frequently leads to left ventricular diastolic dysfunction (DD). Methods: We aim to test whether DD can readily be unveiled as early as in the subclinical stage in diabetic hypertensive asymptomatic patients, even before echocardiography can do so. We compared the values of NT-pro BNP (as a marker of increased filling pressures) before and after the treadmill stress test in hypertensive patients with and without diabetes mellitus (DM) and normal subjects. All had normal systolic and diastolic functions at rest and after the stress test, according to the recommendations of the ESC. Results: The results from our study showed a significant increase inNT-pro BNP after the stress test, but only in hypertensive patients with diabetes. Conclusion: Compared with echocardiography, measuring the changes inNT-pro BNP after the stress test in hypertensive and diabetic patients with class A heart failure could be a tool for diagnosing DD much earlier in the evolution of the disease. This is an important finding because these patients are difficult to distinguish from those with normal left ventricle function, based only on restingNT-pro BNP or echocardiography. In this way, they can benefit much earlier from specific therapies to mitigate future cardiovascular events.

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