Analysis of carvedilol enantiomers in human plasma using chiral stationary phase column and liquid chromatography with tandem mass spectrometry

Carvedilol is an antihypertensive drug available as a racemic mixture. (-)-(S)-carvedilol is responsible for the nonselective beta-blocker activity but both enantiomers present similar activity on a1-adrenergic receptor. To our knowledge, this is the first study of carvedilol enantiomers in human plasma using a chiral stationary phase column and liquid chromatography with tandem mass spectrometry. The method involves plasma extraction with diisopropyl ether using metoprolol as internal standard and direct separation of the carvedilol enantiomers on a Chirobiotic T (R) (Teicoplanin) column. Protonated ions [M + H]+ and their respective ion products were monitored at transitions of 407 > 100 for the carvedilol enantiomers and 268 > 116 for the internal standard. The quantification limit was 0.2 ng ml-1 for both enantiomers in plasma. The method was applied to study enantioselectivity in the pharmacokinetics of carvedilol administered as a single dose of 25 mg to a hypertensive patient. The results showed a higher plasma concentration of (+)-(R)-carvedilol (AUC08 205.52 vs. 82.61 (ng h) ml-1), with an enantiomer ratio of 2.48. Chirality, 2012. (C) 2012 Wiley Periodicals, Inc.

THE FIRST DETERMINATION OF THE VISCOSITY PARAMETER IN THE CIRCUMSTELLAR DISK OF A Be STAR

Be stars possess gaseous circumstellar decretion disks, which are well described using standard alpha-disk theory. The Be star 28 CMa recently underwent a long outburst followed by a long period of quiescence, during which the disk dissipated. Here we present the first time-dependent models of the dissipation of a viscous decretion disk. By modeling the rate of decline of the V-band excess, we determine that the viscosity parameter alpha = 1.0 +/- 0.2, corresponding to a mass injection rate (M) over dot = (3.5 +/- 1.3) x 10(-8) M-circle dot yr(-1). Such a large value of a suggests that the origin of the turbulent viscosity is an instability in the disk whose growth is limited by shock dissipation. The mass injection rate is more than an order of magnitude larger than the wind mass-loss rate inferred from UV observations, implying that the mass injection mechanism most likely is not the stellar wind, but some other mechanism.

Non-neoplastic bulky mediastinal mass presentation in an adolescent patient: a case report

Abstract : Introduction Mediastinal masses in pediatric patients are very heterogeneous in origin and etiology. In the first decade of life, 70% of the mediastinal masses are benign whereas malignant tumors are more frequent in the second decade of life. Among the mediastinal masses, lymph nodes are the most common involved structures and could be enlarged due to a lymphoma, leukemia, metastatic disease, or due to infectious diseases as sarcoidosis, tuberculosis and others. Case presentation. We report a case of a 13-year-old Caucasian girl who came to the emergency room with a history of intermittent fever, weight loss and night sweating for at least 1 month. A radiologic image work-up presented an anterior and posterior mediastinal mass. The 18F-fluorodeoxyglucose positron emission tomography presented a high maximum standard uptake value, which directed our decision for mediastinal biopsy for diagnostic elucidation. Histologic examination described the mass as granulomatous tuberculosis. The patient was treated with anti-tuberculosis therapy and developed a full clinical recovery. Conclusions . The present case report demonstrates that a bulky mediastinal lymphadenopathy detected on 18F-fluorodeoxyglucose positron emission tomography is not always a malignant lesion, and in countries where tuberculosis is endemic, this etiology should not be forgotten during clinical investigations. There is a need for more accurate cut-off values for this technology; meanwhile, the further investigation of patients with bulky mediastinal masses with procedures such as the open biopsy is indispensable.

Mass spectrometry-based protein profiling strategies for biomarker discovery in liver and inflammatory bowel diseases

The study of protein expression profiles for biomarker discovery in serum and in mammalian cell populations needs the continuous improvement and combination of proteins/peptides separation techniques, mass spectrometry, statistical and bioinformatic approaches. In this thesis work two different mass spectrometry-based protein profiling strategies have been developed and applied to liver and inflammatory bowel diseases (IBDs) for the discovery of new biomarkers. The first of them, based on bulk solid-phase extraction combined with matrix-assisted laser desorption/ionization - Time of Flight mass spectrometry (MALDI-TOF MS) and chemometric analysis of serum samples, was applied to the study of serum protein expression profiles both in IBDs (Crohn’s disease and ulcerative colitis) and in liver diseases (cirrhosis, hepatocellular carcinoma, viral hepatitis). The approach allowed the enrichment of serum proteins/peptides due to the high interaction surface between analytes and solid phase and the high recovery due to the elution step performed directly on the MALDI-target plate. Furthermore the use of chemometric algorithm for the selection of the variables with higher discriminant power permitted to evaluate patterns of 20-30 proteins involved in the differentiation and classification of serum samples from healthy donors and diseased patients. These proteins profiles permit to discriminate among the pathologies with an optimum classification and prediction abilities. In particular in the study of inflammatory bowel diseases, after the analysis using C18 of 129 serum samples from healthy donors and Crohn’s disease, ulcerative colitis and inflammatory controls patients, a 90.7% of classification ability and a 72.9% prediction ability were obtained. In the study of liver diseases (hepatocellular carcinoma, viral hepatitis and cirrhosis) a 80.6% of prediction ability was achieved using IDA-Cu(II) as extraction procedure. The identification of the selected proteins by MALDITOF/ TOF MS analysis or by their selective enrichment followed by enzymatic digestion and MS/MS analysis may give useful information in order to identify new biomarkers involved in the diseases. The second mass spectrometry-based protein profiling strategy developed was based on a label-free liquid chromatography electrospray ionization quadrupole - time of flight differential analysis approach (LC ESI-QTOF MS), combined with targeted MS/MS analysis of only identified differences. The strategy was used for biomarker discovery in IBDs, and in particular of Crohn’s disease. The enriched serum peptidome and the subcellular fractions of intestinal epithelial cells (IECs) from healthy donors and Crohn’s disease patients were analysed. The combining of the low molecular weight serum proteins enrichment step and the LCMS approach allowed to evaluate a pattern of peptides derived from specific exoprotease activity in the coagulation and complement activation pathways. Among these peptides, particularly interesting was the discovery of clusters of peptides from fibrinopeptide A, Apolipoprotein E and A4, and complement C3 and C4. Further studies need to be performed to evaluate the specificity of these clusters and validate the results, in order to develop a rapid serum diagnostic test. The analysis by label-free LC ESI-QTOF MS differential analysis of the subcellular fractions of IECs from Crohn’s disease patients and healthy donors permitted to find many proteins that could be involved in the inflammation process. Among them heat shock protein 70, tryptase alpha-1 precursor and proteins whose upregulation can be explained by the increased activity of IECs in Crohn’s disease were identified. Follow-up studies for the validation of the results and the in-depth investigation of the inflammation pathways involved in the disease will be performed. Both the developed mass spectrometry-based protein profiling strategies have been proved to be useful tools for the discovery of disease biomarkers that need to be validated in further studies.

Anaerobic oxidation of ethanol over spinel mixed oxides: the first step in the steam-iron process for H2 production

The future hydrogen demand is expected to increase, both in existing industries (including upgrading of fossil fuels or ammonia production) and in new technologies, like fuel cells. Nowadays, hydrogen is obtained predominantly by steam reforming of methane, but it is well known that hydrocarbon based routes result in environmental problems and besides the market is dependent on the availability of this finite resource which is suffering of rapid depletion. Therefore, alternative processes using renewable sources like wind, solar energy and biomass, are now being considered for the production of hydrogen. One of those alternative methods is the so-called “steam-iron process” which consists in the reduction of a metal-oxide by hydrogen-containing feedstock, like ethanol for instance, and then the reduced material is reoxidized with water to produce “clean” hydrogen (water splitting). This kind of thermochemical cycles have been studied before but currently some important facts like the development of more active catalysts, the flexibility of the feedstock (including renewable bio-alcohols) and the fact that the purification of hydrogen could be avoided, have significantly increased the interest for this research topic. With the aim of increasing the understanding of the reactions that govern the steam-iron route to produce hydrogen, it is necessary to go into the molecular level. Spectroscopic methods are an important tool to extract information that could help in the development of more efficient materials and processes. In this research, ethanol was chosen as a reducing fuel and the main goal was to study its interaction with different catalysts having similar structure (spinels), to make a correlation with the composition and the mechanism of the anaerobic oxidation of the ethanol which is the first step of the steam-iron cycle. To accomplish this, diffuse reflectance spectroscopy (DRIFTS) was used to study the surface composition of the catalysts during the adsorption of ethanol and its transformation during the temperature program. Furthermore, mass spectrometry was used to monitor the desorbed products. The set of studied materials include Cu, Co and Ni ferrites which were also characterized by means of X-ray diffraction, surface area measurements, Raman spectroscopy, and temperature programmed reduction.

Development of a multi-species method by GC-coupling with inductively coupled plasma isotope dilution mass spectrometry for the simultaneous determination of alkylated lead, mercury and tin compounds

An accurate and sensitive species-specific GC-ICP-IDMS (gas chromatography inductively coupled plasma isotope dilution mass spectrometry) method for the determination of trimethyllead and a multi-species-specific GC-ICP-IDMS method for the simultaneous determination of trimethyllead, methylmercury, and butyltins in biological and environmental samples were developed. They allow the determination of corresponding elemental species down to the low ng g-1 range. The developed synthesis scheme for the formation of isotopically labeled Me3206Pb+ can be used for future production of this spike. The novel extraction technique, stir bar sorptive extraction (SBSE), was applied for the first time in connection with species-specific isotope dilution GC-ICP-MS for the determination of trimethyllead, methylmercury and butyltins. The results were compared with liquid-liquid extraction. The developed methods were validated by the analysis of certified reference materials. The liquid-liquid extraction GC-ICP-IDMS method was applied to seafood samples purchased from a supermarket. The methylated lead fraction in these samples, correlated to total lead, varied in a broad range of 0.01-7.6 %. On the contrary, the fraction of methylmercury is much higher, normally in the range of 80-98 %. The highest methylmercury content of up to 12 µg g-1 has been determined in shark samples, an animal which is at the end of the marine food chain, whereas in other seafood samples a MeHg+ content of less than 0.2 µg g-1 was found. Butyltin species could only be determined in samples, where anthropogenic contaminations must be assumed. This explains the observed broad variation of the butylated tin fraction in the range of <0.3-49 % in different seafood samples. Because all isotope-labelled spike compounds, except trimethyllead, are commercially available, the developed multi-species-specific GC-ICP-IDMS method has a high potential in future for routine analysis.

Pyrolysis-Gas Chromatography-Mass Spectometry and Chemometric Analysis for the Characterization of Complex Matrices

The present PhD thesis was focused on the development and application of chemical methodology (Py-GC-MS) and data-processing method by multivariate data analysis (chemometrics). The chromatographic and mass spectrometric data obtained with this technique are particularly suitable to be interpreted by chemometric methods such as PCA (Principal Component Analysis) as regards data exploration and SIMCA (Soft Independent Models of Class Analogy) for the classification. As a first approach, some issues related to the field of cultural heritage were discussed with a particular attention to the differentiation of binders used in pictorial field. A marker of egg tempera the phosphoric acid esterified, a pyrolysis product of lecithin, was determined using HMDS (hexamethyldisilazane) rather than the TMAH (tetramethylammonium hydroxide) as a derivatizing reagent. The validity of analytical pyrolysis as tool to characterize and classify different types of bacteria was verified. The FAMEs chromatographic profiles represent an important tool for the bacterial identification. Because of the complexity of the chromatograms, it was possible to characterize the bacteria only according to their genus, while the differentiation at the species level has been achieved by means of chemometric analysis. To perform this study, normalized areas peaks relevant to fatty acids were taken into account. Chemometric methods were applied to experimental datasets. The obtained results demonstrate the effectiveness of analytical pyrolysis and chemometric analysis for the rapid characterization of bacterial species. Application to a samples of bacterial (Pseudomonas Mendocina), fungal (Pleorotus ostreatus) and mixed- biofilms was also performed. A comparison with the chromatographic profiles established the possibility to: • Differentiate the bacterial and fungal biofilms according to the (FAMEs) profile. • Characterize the fungal biofilm by means the typical pattern of pyrolytic fragments derived from saccharides present in the cell wall. • Individuate the markers of bacterial and fungal biofilm in the same mixed-biofilm sample.

Mass measurements on neutron-deficient nuclides at SHIPTRAP and commissioning of a cryogenic narrow-band FT-ICR mass spectrometer

The dissertation presented here deals with high-precision Penning trap mass spectrometry on short-lived radionuclides. Owed to the ability of revealing all nucleonic interactions, mass measurements far off the line of ß-stability are expected to bring new insight to the current knowledge of nuclear properties and serve to test the predictive power of mass models and formulas. In nuclear astrophysics, atomic masses are fundamental parameters for the understanding of the synthesis of nuclei in the stellar environments. This thesis presents ten mass values of radionuclides around A = 90 interspersed in the predicted rp-process pathway. Six of them have been experimentally determined for the first time. The measurements have been carried out at the Penning-trap mass spectrometer SHIPTRAP using the destructive time-of-fligh ion-cyclotron-resonance (TOF-ICR) detection technique. Given the limited performance of the TOF-ICR detection when trying to investigate heavy/superheavy species with small production cross sections (σ< 1 μb), a new detection system is found to be necessary. Thus, the second part of this thesis deals with the commissioning of a cryogenic double-Penning trap system for the application of a highly-sensitive, narrow-band Fourier-transform ion-cyclotron-resonance (FT-ICR) detection technique. With the non-destructive FT-ICR detection method a single singly-charged trapped ion will provide the required information to determine its mass. First off-line tests of a new detector system based on a channeltron with an attached conversion dynode, of a cryogenic pumping barrier, to guarantee ultra-high vacuum conditions during mass determination, and of the detection electronics for the required single-ion sensitivity are reported.

Insights in the maturation of pathogenic bacteria vaccine candidates using mass spectrometry based approaches

The study of the maturation process that occurs to a protein is of pivotal importance for the understanding of its function. This is true also in the vaccine field but in this case is also important to evaluate if inappropriate protein conformation and maturation play roles in the impairment of the functional immunogenicity of protein vaccines. Mass spectrometry (MS) is the method of choice for the study of the maturation process since each modification that occurs during the maturation will lead to a change in the mass of the entire protein. Therefore the aim of my thesis is the development of mass spectrometry-based approaches to study the maturation of proteins and the application of these methods to proteic vaccine candidates. The thesis is divided in two main parts. In the first part, I focused my attention on the study of the maturation of different vaccine candidates using native mass spectrometry. The analyses in this case have been performed using recombinant proteins produced in E. coli. In the second part I applied different MS strategies for the identification of unknown PTMs on pathogenic bacteria surface proteins since modified surface proteins are now considered for vaccine candidate selection.

Characterization of circulating steroids and endocannabinoids levels in obese subjects by liquid chromatography tandem mass spectrometry

Nowadays obesity can be defined as a global epidemic. The precise identification of circulating biomarkers involved in this pathology could be essential to early diagnose potential co-morbidities and to better address the development of future therapeutic strategies. Published evidences show that circulating steroid hormones and endocannabinoids might have a role in the physiopathology of obesity; however, a precise and reliable quantification of these molecules is still lacking. In the first part of the present thesis, we developed a sensitive, specific and accurate quantification method for nine steroid hormones using a liquid chromatography tandem mass spectrometry (LC-MS/MS) system. This method has been used first for a comparative study with immunoassays, currently used in the clinical practice to quantify these molecules and then to redefine circulating reference intervals in healthy subjects. Furthermore, we measured circulating steroid hormones in three groups of subjects: normo-weight, over-weight and obese, defining different steroid hormones profiles depending on the obesity state. The role of circulating endocannabinoids in humans is still unclear, however there are several evidences concerning their involvement in obesity. In the second part of the thesis, we determined changes of circulating endocannabinoids in obese patients after a weight loss induced by bariatric surgery, currently the most effective long-term treatment for obesity, using LC/MS-MS. We measured basal and dynamic endocannabinoids plasma levels in 12 patients with severe obesity before, one month after and six months after the Roux-en-Y gastric bypass intervention, currently one of the most performed types of bariatric surgery. All together the findings illustrated in this thesis project will help better define the role of steroid hormones and endocannabinoids in the framework of obesity in humans and the role that each type of molecule might have in its pathophysiology.

Nuclear structure studies in the xenon and radon region and the discovery of a new radon isotope by Penning trap mass spectrometry

Heutzutage gewähren hochpräzise Massenmessungen mit Penning-Fallen tiefe Einblicke in die fundamentalen Eigenschaften der Kernmaterie. Zu diesem Zweck wird die freie Zyklotronfrequenz eines Ions bestimmt, das in einem starken, homogenen Magnetfeld gespeichert ist. Am ISOLTRAP-Massenspektrometer an ISOLDE / CERN können die Massen von kurzlebigen, radioaktiven Nukliden mit Halbwertszeiten bis zu einigen zehn ms mit einer Unsicherheit in der Größenordnung von 10^-8 bestimmt werden. ISOLTRAP besteht aus einem Radiofrequenz-Quadrupol zum akkumulieren der von ISOLDE gelieferten Ionen, sowie zwei Penning-Fallen zum säubern und zur Massenbestimmung der Ionen. Innerhalb dieser Arbeit wurden die Massen von neutronenreichen Xenon- und Radonisotopen (138-146Xe und 223-229Rn) gemessen. Für elf davon wurde zum ersten Mal die Masse direkt bestimmt; 229Rn wurde im Zuge dieses Experimentes sogar erstmalig beobachtet und seine Halbwertszeit konnte zu ungefähr 12 s bestimmt werden. Da die Masse eines Nuklids alle Wechselwirkungen innerhalb des Kerns widerspiegelt, ist sie einzigartig für jedes Nuklid. Eine dieser Wechselwirkungen, die Wechselwirkung zwischen Protonen und Neutronen, führt zum Beispiel zu Deformationen. Das Ziel dieser Arbeit ist eine Verbindung zwischen kollektiven Effekten, wie Deformationen und Doppeldifferenzen von Bindungsenergien, sogenannten deltaVpn-Werten zu finden. Insbesondere in den hier untersuchten Regionen zeigen deltaVpn-Werte ein sehr ungewöhnliches Verhalten, das sich nicht mit einfachen Argumenten deuten lässt. Eine Erklärung könnte das Auftreten von Oktupoldeformationen in diesen Gebieten sein. Nichtsdestotrotz ist eine quantitative Beschreibung von deltaVpn-Werten, die den Effekt von solchen Deformationen berücksichtigt mit modernen Theorien noch nicht möglich.

The construction of TRIGA-TRAP and direct high-precision Penning trap mass measurements on rare-earth elements and americium

Nuclear masses are an important quantity to study nuclear structure since they reflect the sum of all nucleonic interactions. Many experimental possibilities exist to precisely measure masses, out of which the Penning trap is the tool to reach the highest precision. Moreover, absolute mass measurements can be performed using carbon, the atomic-mass standard, as a reference. The new double-Penning trap mass spectrometer TRIGA-TRAP has been installed and commissioned within this thesis work, which is the very first experimental setup of this kind located at a nuclear reactor. New technical developments have been carried out such as a reliable non-resonant laser ablation ion source for the production of carbon cluster ions and are still continued, like a non-destructive ion detection technique for single-ion measurements. Neutron-rich fission products will be available by the reactor that are important for nuclear astrophysics, especially the r-process. Prior to the on-line coupling to the reactor, TRIGA-TRAP already performed off-line mass measurements on stable and long-lived isotopes and will continue this program. The main focus within this thesis was on certain rare-earth nuclides in the well-established region of deformation around N~90. Another field of interest are mass measurements on actinoids to test mass models and to provide direct links to the mass standard. Within this thesis, the mass of 241-Am could be measured directly for the first time.

Mass spectrometric identification of Varicella-Zoster Virus (VZV) proteins recognized by human T cells

Primary varicella-zoster virus (VZV) infection during childhood leads to varicella commonly known as chickenpox. After primary infection has occurred VZV establishes latency in the host. During subsequent lifetime the virus can cause reactivated infection clinically known as herpes zoster or shingles. In immunodeficient patients’ dissemination of the virus can lead to life-threatening disease. Withdrawal of acyclovir drug prophylaxis puts allogeneic hematopoietic stem-cell transplantation (HSCT) patients at increased risk for herpes zoster as long as VZV-specific cellular immunity is impaired. Although an efficient live attenuated VZV vaccine for zoster prophylaxis exists, it is not approved in immunocompromised patients due to safety reasons. Knowledge of immunogenic VZV proteins would allow designing a noninfectious nonhazardous subunit vaccine suitable for patients with immunodeficiencies. The objective of this study was to identify T cell defined virus proteins of a VZV-infected Vero cell extract that we have recently described as a reliable antigen format for interferon-gamma (IFN-γ) enzyme-linked immunosorbent spot (ELISpot) assays (Distler et al. 2008). We first separated the VZV-infected/-uninfected Vero cell extracts by size filtration and reverse-phase high performance liquid chromatography (RP-HPLC). The collected fractions were screened for VZV reactivity with peripheral blood mononuclear cells (PBMCs) of VZV-seropositive healthy individuals in the sensitive IFN-γ ELISpot assay. Using this strategy, we successfully identified bioactive fractions that contained immunogenic VZV material. VZV immune reactivity was mediated by CD4+ memory T lymphocytes (T cells) of VZV-seropositive healthy individuals as demonstrated in experiments with HLA blockade antibodies and T cell subpopulations already published by Distler et al. We next analyzed the bioactive fractions with electrospray ionization mass spectrometry (ESI-MS) techniques and identified the sequences of three VZV-derived proteins: glycoprotein E (gE); glycoprotein B (gB), and immediate early protein 62 (IE62). Complementary DNA of these identified proteins was used to generate in vitro transcribed RNA for effective expression in PBMCs by electroporation. We thereby established a reliable and convenient IFN-γ ELISPOT approach to screen PBMCs of healthy donors and HSCT patients for T cell reactivity to single full-length VZV proteins. Application in 10 VZV seropositive healthy donors demonstrated much stronger recognition of glycoproteins gE and gB compared to IE62. In addition, monitoring experiments with ex vivo PBMCs of 3 allo-HSCT patients detected strongly increased CD4+ T cell responses to gE and gB for several weeks to months after zoster onset, while IE62 reactivity remained moderate. Overall our results show for the first time that VZV glycoproteins gE and gB are major targets of the post-transplant anti-zoster CD4+ T cell response. The screening approach introduced herein may help to select VZV proteins recognized by memory CD4+ T cells for inclusion in a subunit vaccine, which can be safely used for zoster prophylaxis in immunocompromised HSCT patients.

New analytical LC-mass spectrometry methodologies for the quali-quantitative determination of natural substances and drugs in complex matrices

This thesis reports an integrated analytical and physicochemical approach for the study of natural substances and new drugs based on mass spectrometry techniques combined with liquid chromatography. In particular, Chapter 1 concerns the study of Berberine a natural substance with pharmacological activity for the treatment of hepatobiliary and intestinal diseases. The first part focused on the relationships between physicochemical properties, pharmacokinetics and metabolism of Berberine and its metabolites. For this purpose a sensitive HPLC-ES-MS/MS method have been developed, validated and used to determine these compounds during their physicochemical properties studies and plasma levels of berberine and its metabolites including berberrubine(M1), demethylenberberine(M3), and jatrorrhizine(M4) in humans. Data show that M1, could have an efficient intestinal absorption by passive diffusion due to a keto-enol tautomerism confirmed by NMR studies and its higher plasma concentration. In the second part of Chapter 1, a comparison between M1 and BBR in vivo biodistribution in rat has been studied. In Chapter 2 a new HPLC-ES-MS/MS method for the simultaneous determination and quantification of glucosinolates, as glucoraphanin, glucoerucin and sinigrin, and isothiocyanates, as sulforaphane and erucin, has developed and validated. This method has been used for the analysis of functional foods enriched with vegetable extracts. Chapter 3 focused on a physicochemical study of the interaction between the bile acid sequestrants used in the treatment of hypercholesterolemia including colesevelam and cholestyramine with obeticolic acid (OCA), potent agonist of nuclear receptor farnesoid X (FXR). In particular, a new experimental model for the determination of equilibrium binding isotherm was developed. Chapter 4 focused on methodological aspects of new hard ionization coupled with liquid chromatography (Direct-EI-UHPLC-MS) not yet commercially available and potentially useful for qualitative analysis and for “transparent” molecules to soft ionization techniques. This method was applied to the analysis of several steroid derivatives.

A simple voltage/mass index increases the suspicion of amyloidotic cardiomyopathy: an electrocardiographic and echocardiographic study of 767 patients with increased left ventricular wall thickness due to different causes

Background-Amyloidotic cardiomyopathy (AC) can mimic true left ventricular hypertrophy (LVH), including hypertrophic cardiomyopathy (HCM) and hypertensive heart disease (HHD). We assessed the diagnostic value of combined electrocardiographic/echocardiographic indexes to identify AC among patients with increased echocardiographic LV wall thickness due to either different etiologies of amyloidosis or HCM or HHD. Method-First, we studied 469 consecutive patients: 262 with biopsy/genetically proven AC (with either AL or transthyretin (TTR)-related amyloidosis); 106 with HCM; 101 with HHD. We compared the diagnostic performance of: low QRS voltage, symmetric LVH, low QRS voltage plus interventricular septal thickness >1.98 cm, Sokolow index divided by the cross-sectional area of LV wall, Sokolow index divided by body surface area indexed LV mass (LVMI), Sokolow index divided by LV wall thickness, Sokolow index divided by (LV wall/height^2.7); peripheral QRS score divided by LVMI, Peripheral QRS score divided by LV wall thickness, Peripheral QRS score divided by LV wall thickness indexed to height^2.7, total QRS score divided by LVMI, total QRS score divided by LV wall thickness; total QRS score divided by (LV wall/height^2.7). We tested each criterion, separately in males and females, in the following settings: AC vs. HCM+HHD; AC vs. HCM; AL vs. HCM+HHD; AL vs. HCM; TTR vs. HCM+HHD; TTR vs. HCM. Results-Low QRS voltage showed high specificity but low sensitivity for the identification of AC. All the combined indexes had a higher diagnostic accuracy, being total QRS score divided by LV wall thickness or by LVMI associated with the best performances and the largest areas under the ROC curve. These results were validated in 298 consecutive patients with AC, HCM or HHD. Conclusions-In patients with increased LV wall thickness, a combined ECG/ echocardiogram analysis provides accurate indexes to non-invasively identify AC. Total QRS score divided by LVMI or LV wall thickness offers the best diagnostic performance.