Background: Evaluation of coronary flow velocity reserve (CFVR) is the physiological approach to assess the severity of coronary stenosis and microvascular dysfunction. Impaired CFVR occurs frequently in women with suspected or known coronary artery disease. The aim of this study was to assess the role of CFVR to predict long-term cardiovascular event rate in women with unstable angina (UA) without obstructive coronary artery stenosis. Methods: CFVR in left anterior descending coronary artery was assessed by adenosine transthoracic echocardiograhy in 161 women admitted at our Department with UA and without obstructive coronary artery disease. Results: During a mean FU of 32.5 ± 19.6 months, 53 cardiac events occurred: 6 nonfatal acute myocardial infarction, 22 UA, 7 coronary revascularization by percutaneous transluminal coronary angioplasty, 1 coronary bypass surgery, 3 ischemic stroke, and 8 episodes of congestive heart failure with preserved ejection fraction and 6 cardiac deaths. Using a ROC curve analysis, CFVR 2.14 was the best predictor of cardiac events and was considered as abnormal CFVR. Abnormal CFVR was associated with lower cardiac event-free survival (30 vs 80%, p < 0.0001). During FU, 70% of women with reduced CFVR had cardiac events whereas only 20% with normal CFVR (p = 0.0001). At multivariate Cox analysis, smoke habitus (p = 0.003), metabolic syndrome (p = 0.01), and CFVR (p < 0.0001) were significantly associated with cardiac events at FU. Conclusion: Noninvasive CFVR provides an independent predictor of cardiovascular prognosis information in women with UA without obstructive coronary artery disease whereas, impaired CFVR seems to be associated with higher CV events at FU.

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Background In the evaluation of specific non MINOCA, the differential diagnosis between Takotsubo syndrome and myocarditis can be challenging. Purpose The aim of our study was to evaluate the parameters that can be more useful to distinguish the pathologies. Methods All the patients with specific non MINOCA admitted to our service were enrolled. Informations about clinical characteristic, in-hospital outcome and complications were collected. All the patients have made several blood samples for hS-troponin, CRP, NT-proBNP, ECG with calculation of QTc, cardiac echocardiogram at the admission and at the discharge and diagnosis has always been confirmed by CMR. Results Between October 2018 and October 2021 51 specific non MINOCA have been hospitalized in our service (26 Takotsubo and 25 myocarditis). Patients affected by Takotsubo syndrome were more frequent older, females (p&lt;0,0001), had a higher global cardiovascular risk (p=0,046) and had more frequently neurological disorders (p=0,041), autoimmune thyroiditis (p=0,02) and have experienced stressful triggers before hospital admission (p=0,003); patients with myocarditis had, instead, more often an infection before hospital admission (p&lt;0,0001). No differences have been found in clinical or electrocardiographic presentation, although observing the evolution of the ECG, a significative prolongation of the QTc in Takotsubo have been noticed (QTc 552 ± 75,1 vs 409,8 ± 27,7 p&lt;0,0001). Peak troponins, NT-proBNP and CRP were significantly different (p=0,002; p=0,008; p=0,003), as were LVEF and WMSI at the admission (p=0,004 and p&lt;0,0001). From the CMR data LGE and T2 mapping were useful to distinguish the two pathologies (p&lt;0,0001; p=0,001). From the analysis of ROC curves a T2 mapping value superior to 62 msec was able to distinguish the two pathologies with a sensibility of 70%, a specificity of 73%, a positive predictive value of 73% and a negative predictive value of 70%. Conclusion There are many parameters useful to distinguish the specific non MINOCA: clinical characteristics; blood sample parameters like troponins, CRP and NT-proBNP; ECG, echocardiographic and CRM. T2 mapping can distinguish the two pathologies with a good sensibility and specificity.

Aims Takotsubo Syndrome (TTS), also known as stress cardiomyopathy, is an important form of acute reversible myocardial damage characterized by a transient systolic dysfunction of the left ventricle, which generally occurs following intense emotional or physical stress. The availability of new imaging techniques broadened knowledge about TTS and allowed for more accurate risk stratification and their use as a potential guide to clinical management. The aims of our study was that of evaluating changes in myocardial tissue characterization on cardiac magnetic resonance imaging in patients diagnosed with TTS admitted to our center. Methods and Results From December 2018 to December 2021, 52 patients diagnosed with TTS according to the 2018 InterTAK diagnostic criteria were admitted to our ICU; only 27 patients who underwent cardiac magnetic resonance imaging were included in our study. Cardiac magnetic resonance was performed after an average of 7 days from admission to the ward, therefore not in all patients the regional wall motion abnormalities of the left ventricle found on the first echocardiogram performed were then still evident. Despite this, at the evaluation of the T2-STIR sequences, the presence of myocardial edema in the segments with previous regional dissynergies was highlighted in all patients included in the study, indicating a greater sensitivity of tissue characterization techniques. Furthermore, the analysis of T2 mapping, for the quantification of edema, also showed a significant lengthening of the average values ​​of the global T2 mapping, compared to the reference values ​​at our center [65.9 +/- 7.7 msec, vn T2 mapping = 53 ± 3 msec; mean baseline T2 mapping value: 60.4 +/- 5.5 msec, mean T2 mapping value: 65 +/- 7.1 msec, apical T2 mapping: 71 +/- 7.7 msec], with evidence of a clear base-apex gradient on 19/23 patients (82.6%) compatible with the greater involvement of the mid-apical segments typical of the classic form of "apical ballooning" TTS. Finally, the evaluation of the systolic strain also showed a significant reduction in the values ​​both in the radial component and in the circumferential and longitudinal components, especially in the mid-apical segments, even in the absence of significant regional wall motion abnormalities or with preserved left ventricular EF [mean values global radial strain (GRS) of 28.6 +/- 9.5; global circumferential strain (GCS) of 15.4 +/- 7.9; global longitudinal strain (GLS) of 12.6 +/- 3.2]. Conclusions Our study confirms that tissue characterization and functional evaluation techniques using myocardial strain with cardiac magnetic resonance appear to be more accurate, compared to the evaluation of regional wall motion abnormalities and left ventricular EF alone, in identifying pathophysiological changes and in diagnostic framework of TTS patients.

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