Improvement of Global Longitudinal Strain and Myocardial Work in Type 2 Diabetes Patients on Sodium-Glucose Cotransporter 2 Inhibitors Therapy.

ABSTRACT: Sodium-glucose cotransporter 2 inhibitors (SGLT2-i) are a novel class of oral hypoglycemic agents currently used among patients with type 2 diabetes mellitus (T2DM). The effects of SGLT2-i inhibitors on cardiac structure and function are not fully understood. The aim of this study is to evaluate the echocardiographic changing among patients with well-controlled T2DM treated with SGLT2-i in real-world setting. Thirty-five well-controlled T2DM patients (65 ± 9 years, 43.7% male) with preserved left ventricular ejection fraction (LVEF) and 35 age and sex-matched controls were included. T2DM patients underwent clinical and laboratory evaluation; 12-lead surface electrocardiogram; 2-dimensional color Doppler echocardiography at enrolment, before SGLT2-i administration, and at 6 months follow-up after an uninterrupted 10 mg once daily of empagliflozin (n: 21) or dapagliflozin (n: 14). Standard echocardiographic measurements, LV global longitudinal strain (LV-GLS), global wasted work, and global work efficiency were calculated. T2DM patients showed higher E\E' ratio (8.3 ± 2.5 vs. 6.3 ± 0.9; P < 0.0001 ) and lower LV-GLS (15.8 ± 8.1 vs. 22.1 ± 1.4%; P < 0.0001 ) and global myocardial work efficiency (91 ± 4 vs. 94 ± 3%; P: 0.0007 ) compared with age and sex-matched controls. At 6-month follow-up, T2DM patients showed a significant increase in LVEF (58.9 ± 3.2 vs. 62 ± 3.2; P < 0.0001 ), LV-GLS (16.2 ± 2.8 vs. 18.7 ± 2.4%; P = 0.003 ), and global work efficiency (90.3 ± 3.5 vs. 93.3 ± 3.2%; P = 0.0004 ) values; conversely, global wasted work values (161.2 ± 33.6 vs. 112.72 ± 37.3 mm Hg%; P < 0.0001 ) significantly decreased. Well-controlled T2DM patients with preserved LVEF who are treated with a SGLT2-i on top of the guidelines direct medical therapy showed a favorable cardiac remodeling, characterized by the improvement of LV-GLS and myocardial work efficiency.

Non Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation Patients Scheduled for Electrical Cardioversion: A Real-Life Propensity Score Matched Study.

AIM: The aim of the present study was to assess the safety and effectiveness of non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients undergoing electrical cardioversion (EC). METHODS: A propensity score-matched analysis was performed in order to identify two homogeneous groups including AF patients on NOACs and VKAs treatment scheduled for EC. The primary safety endpoint was major bleeding. The composite of stroke, transient ischemic attack (TIA) and systemic embolism (SE) was the primary effectiveness endpoint. The discontinuation rate of anticoagulant therapy was assessed. RESULTS: A total of 495 AF patients on NOACs therapy and scheduled for EC were compared to 495 VKAs recipients. No statistically significant differences in the incidence of both major bleeding (1.01% versus 1.4%; P= 0.5) and thromboembolic events (0.6% versus 0.8%; P= 0.7) were observed during a mean follow-up of 15 ± 3 months. The discontinuation rate of NOACs was significantly lower compared to VKAs (1.6% versus 3.6%, P=0.04). CONCLUSION: We showed a safe and effective clinical profile of NOACs among AF patients scheduled for electrical cardioversion in real-life setting. Patients on NOACs therapy showed a lower discontinuation rate compared to those on VKAs.

Macrophage migration inhibitory factor (MIF) is associated with degree of collateralization in patients with totally occluded coronary arteries.

BACKGROUND: Collaterals in patients with coronary artery disease (CAD) limit myocardial infarction and improve survival. Macrophage migration inhibitory factor (MIF) might play a role in collateral development. We aimed this study to evaluate the association of Macrophage migration Inhibitory Factor (MIF) with the extent of collateralization in patients with coronary occlusion. METHODS AND RESULTS: We consecutively enrolled: a) 40 patients undergoing PCI of a chronic coronary total occlusion (CTO); b) 26 patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI (pPCI) of the infarct-related artery (IRA); c) 12 control patients undergoing angiography without significant coronary artery disease (CTRL). CTO patients were grouped in high (HCG) or low collateralization group (LCG). STEMI patients were grouped in COLL+ or COLL- group depending on the presence of collaterals to the IRA. Blood sampling was performed from the arterial sheath (SYSTEMIC), and distal to the occlusion (LOCAL). SYSTEMIC and LOCAL levels were significantly different between the 3 groups. A progressive increase in MIF ratio (defined as: % (LOCAL-SYSTEMIC)/SYSTEMIC) was observed (CTRL: -0.5[-23;28] vs. CTO: 4[-19;32] vs. STEMI: 55[37;87], p < 0.01). In CTO, MIF ratio was significantly higher in HCG vs. LCG (68 [45;120] vs. 46 [29;66], p = 0.02). In STEMI, MIF ratio was not different between COLL+ and COLL- patients; however, in COLL+, LOCAL was significantly higher as compared with SYSTEMIC (83 ng/ml [63;100] vs. 67 ng/ml [40;79], p = 0.04). CONCLUSIONS: Local MIF is significantly associated with the extent of collateralization in both acute and chronic total coronary occlusions.

Comparison of the Effect of Dual-Axis Rotational Coronary Angiography Versus Conventional Coronary Angiography on Frequency of Acute Kidney Injury, X-Ray Exposure Time, and Quantity of Contrast Medium Injected.

Dual-axis rotational coronary angiography (DARCA) has already been shown to reduce both the amount of contrast medium and radiation exposure compared with conventional coronary angiography (CCA). However, a clinical benefit of such imaging modality has never been demonstrated. The aim of this study was to evaluate the efficacy of DARCA to prevent acute kidney injury (AKI) compared with CCA. Consecutive patients who underwent coronary angiography were enrolled to DARCA (n = 80) or CCA (n = 80). Patients presenting with ST-segment elevation myocardial infarction or previously underwent coronary artery bypass graft were excluded. The 2 groups were homogeneous in terms of both clinical and procedural characteristics. Total x-ray time and total amount of contrast medium were significantly lower in the DARCA group compared with the CCA group (x-ray time 3.2 minutes [1.8 to 7.0] vs 5.1 minutes [2.6 to 9.9], p = 0.002; contrast medium amount 40 ml [31 to 116] vs 80 ml [50 to 150], p <0.001). AKI more often occurred in the CCA group compared with the DARCA group (16 [20%] vs 4 [5%], p = 0.007). Moreover, in patients presenting with acute coronary syndrome (ACS) or who underwent percutaneous coronary intervention (PCI), AKI more often occurred in the CCA group compared with the DARCA group (ACS patients, 6 [29%] vs 2 [6%], p = 0.04, and PCI patients, 11 [33%] vs 0 [0%], p <0.001). In addition, in patients with high pretest probability of coronary artery disease, AKI more often occurred in the CCA group compared with the DARCA group (11 [55%] vs 2 [6%], p <0.001). In conclusion, DARCA significantly reduces both x-ray exposure and amount of contrast medium usage, thereby reducing the occurrence of AKI compared with CCA.

FFR prediction model based on conventional quantitative coronary angiography and the amount of myocardium subtended by an intermediate coronary artery stenosis.

BACKGROUND: Coronary angiography has poor predictive value for functionally significant coronary artery stenosis. The Fractional Flow Reserve (FFR) currently represents the gold standard to define the ischemic potential of epicardial stenosis and, recently, the instantaneous wave-free ratio (iFR), has also been introduced as alternative to the FFR, but it still remains an invasive procedure. We aimed this study in order to evaluate the accuracy of the "Angiography-DeriveD hEmoDynamic index" (ADDED index) to predict the FFR as compared with the iFR. METHODS AND RESULTS: Consecutive patients with at least one equivocal stenosis in one major coronary artery were enrolled. Both the FFR and iFR were measured. The amount of jeopardized myocardium was evaluated using the Duke Jeopardy Score (DJS). Two-dimensional quantitative coronary angiography (QCA) was used to assess the angiographic features of the coronary stenosis and both the reference vessel diameter (RVD) and minimal lumen diameter (MLD) were calculated. The ADDED index was defined as the ratio between DJS and MLD. We evaluated 100 intermediate coronary artery stenoses in 83 patients. Both FFR and iFR inversely correlated with the ADDED index (respectively, r2=0.59, p<0.001 and r2=0.61, p<0.001). This latter also showed high accuracy in predicting the FFR value (ROC analysis: 0.94[0.90-0.99], p<0.001) as well as the iFR (0.91[0.86-0.97], p<0.001, difference: 0.03 SD 0.04, p=0.52). CONCLUSIONS: The ADDED index, taking into account both the MLD and DJS, showed high accuracy to predict FFR and it might be used to detect functionally significant coronary artery stenosis.

Long-term clinical outcome after fractional flow reserve- versus angio-guided percutaneous coronary intervention in patients with intermediate stenosis of coronary artery bypass grafts.

BACKGROUND: Fractional flow reserve (FFR)-guided percutaneous revascularization (percutaneous coronary intervention [PCI]) of intermediate stenosis in native coronary artery is safe and associated with better clinical outcomes as compared with an angiography-guided PCI. It is unknown whether this applies to coronary artery bypass grafts (CABGs). METHODS: We included 223 patients with CABG and with stable or unstable angina and an intermediate stenosis involving an arterial or a venous graft. Patients were divided into 2 groups: FFR guided (n = 65, PCI performed in case of FFR ≤0.80) and angio guided (n = 158, PCI performed based on angiographic evaluation). Primary end point was major adverse cardiac and cerebrovascular event, defined as death, myocardial infarction, target vessel failure, and cerebrovascular accident (CVA). RESULTS: The 2 groups were similar in terms of demographic and clinical characteristics. Percutaneous coronary intervention was performed in 23 patients (35%) of the FFR-guided group and 90 patients (57%) of the angio-guided group (P < .01). In the FFR-guided group, PCI was more often performed in arterial grafts as compared with the angio-guided group (16 [70%] vs 12 [13%], respectively; P < .01). Follow-up was obtained in 96% of patients at a median of 3.8 years (1.6-4.0 years). At multivariate analysis, major adverse cardiac and cerebrovascular event rate was significantly lower in the FFR-guided group as compared with the angio-guided group (18 [28%] vs 77 [51%], hazard ratio 0.33 [0.11-0.96], P = .043]. Procedure costs were overall reduced in the FFR-guided group (€2240 ± €652 vs €2416 ± €522, P = .03). CONCLUSIONS: An FFR-guided PCI of intermediate stenosis in bypass grafts is safe and results in better clinical outcomes as compared with an angio-guided PCI. This clinical benefit is achieved with a significant overall reduction in procedural costs.

Assessing the exposure of pregnant women to drinking water disinfection byproducts.

BACKGROUND: To evaluate associations between exposure to disinfection byproducts in drinking water and adverse birth outcomes, personal exposure to disinfection byproducts must take into consideration multiple routes of exposure. METHODS: We assessed the reproducibility and validity of a questionnaire measuring water consumption, showering and bathing habits, use of chlorine-based products, and swimming pool attendance in 237 pregnant Italian women enrolled between June and December 1999. The questionnaire was completed during the last trimester of pregnancy (preQ) and again a few days after delivery (postQ). Data from postQ were compared with a 7-day diary completed during the last trimester. RESULTS: According to postQ, total water intake was 2.6 liters per day, whereas tap water intake was 0.6 liters per day. Intraclass correlation coefficients of postQ compared with preQ were 0.85 for tap water daily intake and 0.77 for duration of showering and bathing. Pearson's correlation coefficients were 0.84 for tap water daily intake, 0.81 for frequency of showering, and 0.94 for bathing. The kappa statistics were 0.76 (95% confidence limits = 0.68, 0.85) for use of domestic chlorine-based products and 0.82 (0.70, 0.94) for indoor swimming. Pearson's coefficients for postQ compared with the diary were 0.78 for tap water daily intake, 0.62 for frequency of showering, and 0.64 for bathing. Compared with the diary, the sensitivity and specificity of postQ in assessing indoor swimming were 75% and 90%, respectively. CONCLUSIONS: The questionnaire appears to be a valid and reliable method for assessing exposure to disinfection byproducts in the last trimester of pregnancy.