Incremental Value of Renal Dysfunction Addition to the CHA2DS2-Vasc Score for Mortality Prediction in Patients with Acute Coronary Syndrome.

INTRODUCTION: This study analyzes the usefulness of the CHA2DS2-VASc score for mortality prediction in patients with acute coronary syndromes (ACSs) and evaluates if the addition of renal functional status could improve its predictive accuracy. METHODS: CHA2DS2-VASc score was calculated by using both the original scoring system and adding renal functional status using 3 alternative renal dysfunction definitions (CHA2DS2-VASc-R1: eGFR <60 mL/min/1.73 mq = 1 point; CHA2DS2-VASc-R2: eGFR <60 mL/min/1.73 mq = 2 points; and CHA2DS2-VASc-R3: eGFR <60 mL/min/1.73 mq = 1 point, <30 mL/min/1.73 mq = 2 points). Inhospital mortality (IHM) and post-discharge mortality (PDM) were recorded, and discrimination of the various risk models was evaluated. Finally, the net reclassification index (NRI) was calculated to compare the mortality risk classification of the modified risk models with that of the original score. RESULTS: Nine hundred and eight ACS patients (median age 68 years, 30% female, 51% ST-elevation) composed the study population. Of the 871 patients discharged, 865 (99%) completed a 12-month follow-up. The IHM rate was 4.1%. The CHA2DS2-VASc score demonstrated a good discriminative performance for IHM (C-statistic 0.75). Although all the eGFR-modified risk models showed higher C-statistics than the original model, a statistically significant difference was observed only for CHA2DS2-VASc-R3. The PDM rate was 4.5%. The CHA2DS2-VASc C-statistic for PDM was 0.75, and all the modified risk models showed significantly higher C-statistics values than the original model. The NRI analysis showed similar results. CONCLUSIONS: CHA2DS2-VASc score demonstrated a good predictive accuracy for IHM and PDM in ACS patients. The addition of renal dysfunction to the original score has the potential to improve identification of patients at the risk of death.

Ventricular ectopy following accessory pathway ablation in WPW syndrome.

INTRODUCTION: Many Authors already described automatic activity arising from accessory pathways, but the underlying mechanism has not been clarified yet. They may be due to embryogenetic features of myocardium or may be related to specific excitability during radiofrequency ablation. CASE: Our report shows that ventricular accelerated rhythm may transiently arise from the ventricular edge of a common myocardium made accessory pathway right after the ablation. No further action were required in our experience, since the phenomenon self extinguished in approximately hour. CONCLUSIONS: If this manifestation represents the effect of thermal injury or if it is a real intrinsic automaticity is not fully documented and may need further reporting and investigation.

Prognostic utility of quantitative offline 2D-echocardiography in hospitalized patients with COVID-19 disease.

PURPOSE: To assess the prognostic utility of quantitative 2D-echocardiography, including strain, in patients with COVID-19 disease. METHODS: COVID-19-infected patients admitted to the San Paolo University Hospital of Milan that underwent a clinically indicated echocardiographic examination were included in the study. To limit contamination, all measurements were performed offline. Quantitative measurements were obtained by an operator blinded to the clinical data. RESULTS: Among the 49 patients, nonsurvivors (33%) had worse respiratory parameters, index of multiorgan failure, and worse markers of lung involvement. Right ventricular (RV) dysfunction (as assessed by conventional and 2-dimensional speckle tracking) was a common finding and a powerful independent predictor of mortality. At the ROC curve analyses, RV free wall longitudinal strain (LS) showed an AUC 0.77 ± 0.08 in predicting death, P = .008, and global RV LS (RV-GLS) showed an AUC 0.79 ± 0.04, P = .004. This association remained significant after correction for age (OR = 1.16, 95%CI 1.01-1.34, P = .029 for RV free wall LS and OR = 1.20, 95%CI 1.01-1.42, P = .033 for RV-GLS), for oxygen partial pressure at arterial gas analysis/fraction of inspired oxygen (OR = 1.28, 95%CI 1.04-1.57, P = .021 for RV free wall-LS and OR = 1.30, 95%CI 1.04-1.62, P = .020 for RV-GLS) and for the severity of pulmonary involvement measured by a computed tomography lung score (OR = 1.27, 95%CI 1.02-1.19, P = .034 for RV free wall LS and OR = 1.30, 95%CI 1.04-1.63, P = .022 for RV-GLS). CONCLUSIONS: In patients hospitalized with COVID-19, offline quantitative 2D-echocardiographic assessment of cardiac function is feasible. Parameters of RV function are frequently abnormal and have an independent prognostic value over markers of lung involvement.

Role of cardiac and lung ultrasound in the COVID-19 era.

INTRODUCTION: The primary diagnostic method of Coronavirus disease 2019 is reverse transcription polymerase chain reaction of the nucleic acid of severe acute respiratory syndrome coronavirus 2 in nasopharyngeal swabs. There is growing evidence regarding the 2019 coronavirus disease imaging results on chest X-rays and computed tomography but the accessibility to standard diagnostic methods may be limited during the pandemic. EVIDENCE ACQUISITION: Databases used for the search were MEDLINE (PubMed), Scopus Search, and Cochrane Library. The research took into consideration studies published in English until March 2022 and was conducted using the following research query: ((((sars cov [MeSH Terms])) OR (COVID-19)) OR (Sars-Cov2)) OR (Coronavirus)) AND (((((2d echocardiography [MeSH Terms]) OR (doppler ultrasound imaging [MeSH Terms]))) OR (echography [MeSH Terms])) OR (LUS)) OR ("LUNG ULTRASOUND")). EVIDENCE SYNTHESIS: Pulmonary and cardiac ultrasound are cost-effective, widely available, and provide information that can influence management. CONCLUSIONS: Point-of-care ultrasonography is a method that can provide relevant clinical and therapeutic information in patients with COVID-19 where other diagnostic methods may not be easily accessible.

Long-Term Effects of Sacubitril-Valsartan on Cardiac Remodeling: A Parallel Echocardiographic Study of Left and Right Heart Adaptive Response.

Sacubitril/Valsartan (S/V) carries potential anti-remodeling properties, however long-term effects and biventricular adaptive response are poorly described. 76 HFrEF patients who underwent progressive uptitration of S/V, completed the annual scheduled follow-up. After a median follow-up of 11 (8-13) months, left ventricular (LV) reverse remodeling (RR) is defined as (1) absolute increase in LV ejection fraction (EF) ≥ 10% or LVEF ≥ 50% at follow-up and (2) decrease in indexed LV end-diastolic diameter (LVEDDi) of at least 10% or indexed LVEDDi ≤ 33 mm/m2, occurred in 27.6%. Non-ischemic etiology, shorter duration of HF, and absence of a history of AF were independently associated with LVRR (p < 0.05). TAPSE and TAPSE/PASP, a non-invasive index of right ventricular (RV) coupling to the pulmonary circulation, significantly improved at follow-up (0.45 vs. 0.56, p = 0.02). 41% of patients with baseline RV dysfunction obtained favorable RV remodeling despite only a moderate correlation between RV and LV function was observed (r = 0.478, p = 0.002). Our data point to a potential long-term reverse global remodeling effect by S/V, especially in patients who start S/V at an early stage of the disease, and focus our attention on a possible direct effect of the drug in synergistic hemodynamics between RV and pulmonary circulation.

Risk of cardiovascular complications during non-cardiac surgery and preoperative cardiac evaluation.

The preoperative evaluation of candidates to non-cardiac surgery requires a knowledge of factors related both to the type of surgery and to the risk of each patient, in order to predict the potential cardiovascular complications. Over the past several decades, the field of preoperative cardiac evaluation before non-cardiac surgery has evolved substantially on the basis of the current guidelines of international medical societies. The aim of this paper is to summarize available evidence on the risk of non-cardiac surgery, focusing on appropriate cardiovascular assessment prior to surgery.

Influence of Different COVID-19 Pandemic Phases on STEMI: Experience From an Italian Hub Centre.

INTRODUCTION: During Coronavirus disease 2019 (COVID-19) pandemic a reduction in ST-elevation acute myocardial infarction with an increase in in-hospital mortality has been observed. In our region the pandemic temporal trend was sinusoidal with peaks and valleys. A first outbreak was in March 2020, a reduction in May 2020 and a second outbreak in November 2020. MATHERIALS & METHODS: Our hospital was reorganized as one of the 13 Macro-Hubs identified in Lombardy and we retrospectively analysed consecutive STEMI patients hospitalized in the three different phases of COVID-19 pandemic. RESULTS: We did not register any difference in the number of STEMI hospitalized in the three phases. At multivariate analysis for the entire population COVID-19 infection was the strongest independent predictor of in-hospital mortality. Focusing on COVID-19 patients they experienced a 5-time increased incidence of in-hospital mortality (COVID-19pos vs COVID-19neg, 47.1% vs 8.6%; p < 0.0001) mainly driven by a higher incidence of respiratory complications (COVID-19pos vs COVID-19neg, 41.2% vs 6.2%; p < 0.0001) with a similar incidence of cardiac death. DISCUSSION: Among STEMI admitted during different phases of pandemic, this study found an increased mortality in patients affected by COVID-19; the co-presence of COVID-19 infection leads to an increase of mortality mostly related to respiratory complications. Interestingly the different incidence in the general population of COVID-19 did not influence the incidence of STEMI. CONCLUSION: In conclusion our data suggest the crucial need for an early and precise diagnosis of COVID-19 infection in STEMI to establish a correct management of these very high-risk patients.

Cardiac Implantable Electronic Devices Infection Assessment, Diagnosis and Management: A Review of the Literature.

The use of increasingly complex cardiac implantable electronic devices (CIEDs) has increased exponentially in recent years. One of the most serious complications in terms of mortality, morbidity and financial burden is represented by infections involving these devices. They may affect only the generator pocket or be generalised with lead-related endocarditis. Modifiable and non-modifiable risk factors have been identified and they can be associated with patient or procedure characteristics or with the type of CIED. Pocket and systemic infections require a precise evaluation and a specialised treatment which in most cases involves the removal of all the components of the device and a personalised antimicrobial therapy. CIED retention is usually limited to cases where infection is unlikely or is limited to the skin incision site. Optimal re-implantation timing depends on the type of infection and on the results of microbiological tests. Preventive strategies, in the end, include antibiotic prophylaxis before CIED implantation, the possibility to use antibacterial envelopes and the prevention of hematomas. The aim of this review is to investigate the pathogenesis, stratification, diagnostic tools and management of CIED infections.

Impact of Right Ventricular-Pulmonary Circulation Coupling on Mortality in SARS-CoV-2 Infection.

Background The COVID-19-related pulmonary effects may negatively impact pulmonary hemodynamics and right ventricular function. We examined the prognostic relevance of right ventricular function and right ventricular-to-pulmonary circulation coupling assessed by bedside echocardiography in patients hospitalized with COVID-19 pneumonia and a large spectrum of disease independently of indices of pneumonia severity and left ventricular function. Methods and Results Consecutive COVID-19 subjects who underwent full cardiac echocardiographic evaluation along with gas analyses and computed tomography scans were included in the study. Measurements were performed offline, and quantitative analyses were obtained by an operator blinded to the clinical data. We analyzed 133 patients (mean age 69±12 years, 57% men). During a mean hospital stay of 26±16 days, 35 patients (26%) died. The mean tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio was 0.48±0.18 mm/Hg in nonsurvivors and 0.72±0.32 mm/Hg in survivors (P=0.002). For each 0.1 mm/mm Hg increase in TAPSE/PASP, there was a 27% lower risk of in-hospital death (hazard ratio [HR], 0.73 [95% CI, 0.59-0.89]; P=0.003). At multivariable analysis, TAPSE/PASP ratio remained a predictor of in-hospital death after adjustments for age, oxygen partial pressure at arterial gas analysis/fraction of inspired oxygen, left ventricular ejection fraction, and computed tomography lung score. Receiver operating characteristic analysis was used to identify the cutoff value of the TAPSE/PASP ratio, which best specified high-risk from lower-risk patients. The best cutoff for predicting in-hospital mortality was TAPSE/PASP <0.57 mm/mm Hg (75% sensitivity and 70% specificity) and was associated with a >4-fold increased risk of in-hospital death (HR, 4.8 [95% CI, 1.7-13.1]; P=0.007). Conclusions In patients hospitalized with COVID-19 pneumonia, the assessment of right ventricular to pulmonary circulation coupling appears central to disease evolution and prediction of events. TAPSE/PASP ratio plays a mainstay role as prognostic determinant beyond markers of lung injury.

Clinical Management of New-Onset Atrial Fibrillation in COVID-19 Patients Referred to a Tertiary Cardiac Arrhythmia Center after Hospital Discharge.

BACKGROUND: Available reports on the post-discharge management of atrial fibrillation (AF) in COVID-19 patients are scarce. The aim of this case series was to describe the clinical outcomes of new-onset AF in COVID-19 patients referred to a tertiary cardiac arrhythmia center after hospital discharge. METHODS: All consecutive patients referred to our center for an ambulatory evaluation from 18 May 2020 to 15 March 2022 were retrospectively screened. Patients were included in the current analysis if new-onset AF was diagnosed during hospitalization for COVID-19 and then referred to our clinic. RESULTS: Among 946 patients, 23 (2.4%) were evaluated for new-onset AF during COVID-19. The mean age of the study cohort was 71.5 ± 8.1 years; 87.0% were male. Median time from COVID-19 discharge and the first ambulatory evaluation was 53 (41.5-127) days; median follow-up time was 175 (83-336) days. At the in-office evaluation, 14 (60.9%) patients were in sinus rhythm, and nine patients were in AF. In 13.0% of cases, oral anticoagulation was stopped according to CHADS-VASc. Eight patients in AF were scheduled for electrical cardioversion; one patient was rate-controlled. Four patients were treated with catheter ablation (CA) during follow-up. Two post-cardioversion AF recurrences were detected during follow-up, while no recurrences were diagnosed among patients who underwent CA. CONCLUSION: Our data suggest that AF may not be considered as a simple bystander of the in-hospital COVID-19 course. Management of new-onset AF in post-COVID-19 patients referred to our clinic did not significantly differ from our usual practice, both in terms of long-term oral anticoagulation and in terms of rhythm control strategy.

Diagnosis and Management of Aortic Valve Stenosis: The Role of Non-Invasive Imaging.

Aortic stenosis is the most common heart valve disease necessitating surgical or percutaneous intervention. Imaging has a central role for the initial diagnostic work-up, the follow-up and the selection of the optimal timing and type of intervention. Referral for aortic valve replacement is currently driven by the severity and by the presence of aortic stenosis-related symptoms or signs of left ventricular systolic dysfunction. This review aims to provide an update of the imaging techniques and seeks to highlight a practical approach to help clinical decision making.

Echocardiographic Advances in Dilated Cardiomyopathy.

Although the overall survival of patients with dilated cardiomyopathy (DCM) has improved significantly in the last decades, a non-negligible proportion of DCM patients still shows an unfavorable prognosis. DCM patients not only need imaging techniques that are effective in diagnosis, but also suitable for long-term follow-up with frequent re-evaluations. The exponential growth of echocardiography's technology and performance in recent years has resulted in improved diagnostic accuracy, stratification, management and follow-up of patients with DCM. This review summarizes some new developments in echocardiography and their promising applications in DCM. Although nowadays cardiac magnetic resonance (CMR) remains the gold standard technique in DCM, the echocardiographic advances and novelties proposed in the manuscript, if properly integrated into clinical practice, could bring echocardiography closer to CMR in terms of accuracy and may certify ultrasound as the technique of choice in the follow-up of DCM patients. The application in DCM patients of novel echocardiographic techniques represents an interesting emergent research area for scholars in the near future.

Sex-Specific Cut-Offs for High-Sensitivity Cardiac Troponin: Is Less More?

Management of patients presenting to the Emergency Department with chest pain is continuously evolving. In the setting of acute coronary syndrome, the availability of high-sensitivity cardiac troponin assays (hs-cTn) has allowed for the development of algorithms aimed at rapidly assessing the risk of an ongoing myocardial infarction. However, concerns were raised about the massive application of such a simplified approach to heterogeneous real-world populations. As a result, there is a potential risk of underdiagnosis in several clusters of patients, including women, for whom a lower threshold for hs-cTn was suggested to be more appropriate. Implementation in clinical practice of sex-tailored cut-off values for hs-cTn represents a hot topic due to the need to reduce inequality and improve diagnostic performance in females. The aim of this review is to summarize current evidence on sex-specific cut-off values of hs-cTn and their application and usefulness in clinical practice. We also offer an extensive overview of thresholds reported in literature and of the mechanisms underlying such differences among sexes, suggesting possible explanations about debated issues.

Treatment and Response to Statins: Gender-related Differences.

Response to drug administration is a primary determinant for treatment success. Sex and gender disparities play a role in determining the efficacy and safety of the most commonly used medications suggesting the need for a sex-tailored approach in prescription. Statins are a cost-effective strategy for cardiovascular disease (CVD) prevention. While statins are similarly effective in secondary CVD prevention, some concerns raised by conflicting data reported in primary CVD prevention clinical trials. The small representation of women in clinical trials and the fewer rates of events due to the lower female baseline CVD risk may have conditioned contradictory meta-analysis findings. Specifically, benefits outweigh disadvantages of statin therapy in women with a high CVD risk, while several doubts exist for the primary prevention of women at low-intermediate CVD risk. Furthermore, disparities between women and men in medication adherence may influence statin efficacy in CVD prevention. The sex-dependent impact of adverse side effects is one of the reasons advocated for explaining the gender gap, but it is not evidence-proved. The present review summarizes the sex and gender differences in the use of statins, pointing out new perspectives and opening issues in sex-tailored CVD prevention strategy.

Impaired flow-mediated dilation in hospitalized patients with community-acquired pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is complicated by cardiovascular events as myocardial infarction and stroke but the underlying mechanism is still unclear. We hypothesized that endothelial dysfunction may be implicated and that endotoxemia may have a role. METHODS: Fifty patients with CAP and 50 controls were enrolled. At admission and at discharge, flow-mediated dilation (FMD), serum levels of endotoxins and oxidative stress, as assessed by serum levels of nitrite/nitrate (NOx) and isoprostanes, were studied. RESULTS: At admission, a significant difference between patients with CAP and controls was observed for FMD (2.1±0.3 vs 4.0±0.3%, p<0.001), serum endotoxins (157.8±7.6 vs 33.1±4.8pg/ml), serum isoprostanes (341±14 vs 286±10 pM, p=0.009) and NOx (24.3±1.1 vs 29.7±2.2µM). Simple linear correlation analysis showed that serum endotoxins significantly correlated with Pneumonia Severity Index score (Rs=0.386, p=0.006). Compared to baseline, at discharge CAP patients showed a significant increase of FMD and NOx (from 2.1±0.3 to 4.6±0.4%, p<0.001 and from 24.3±1.1 to 31.1±1.5µM, p<0.001, respectively) and a significant decrease of serum endotoxins and isoprostanes (from 157.8±7.6 to 55.5±2.3pg/ml, p<0.001, and from 341±14 to 312±14 pM, p<0.001, respectively). Conversely, no changes for FMD, NOx, serum endotoxins and isoprostanes were observed in controls between baseline and discharge. Changes of FMD significantly correlated with changes of serum endotoxins (Rs=-0.315; p=0.001). CONCLUSIONS: The study provides the first evidence that CAP is characterized by impaired FMD with a mechanism potentially involving endotoxin production and oxidative stress.