Type 2 Diabetes Mellitus: GLP1 Receptor Agonists and SGLT2 Inhibitors in Patients Referred to Ambulatory Consultant Cardiology Clinics.

BACKGROUND: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA) are new antidiabetic drugs that are recommended by current guidelines as a class I novel glucose-lowering treatment that improves cardiovascular outcome in type 2 diabetes mellitus (T2DM), particularly in patients with cardiovascular disease. OBJECTIVES: To evaluate adherence to the current guidelines for treatment with SGLT2i and GLP1-RA drugs in patients referred to ambulatory consultant cardiology clinics with pre-existing T2DM. METHODS: We studied consecutive new patients with a pre-existing diagnosis of T2DM who were referred to the Clalit Health Services ambulatory consultant cardiology clinic over a 6-month period. The recorded information included demographics, co-morbidities, and prescribed drugs at patient admission. RESULTS: During the study period, 1782 patients visited our outpatient cardiology clinic. At screening, T2DM was present in 428 patients (24%); 77 (18%) were being treated with SGLT2i, and 39 (9.1%) with GLP1-RA. Patients receiving SGLT2i and GLP1-RA were younger and had more coronary artery disease, lower mean left ventricular ejection fraction, and higher mean estimated glomerular filtration rates than those who were not receiving these drugs. HbA1C was > 7 in 205 (47.9%) patients and > 7.5 in 136 patients (31.8%). Body mass index was > 30 kg/m2 in 231 (54%) patients. CONCLUSIONS: GLP1-RA and SGLT2i drugs were found to be administered more frequently than previously reported, but they are not yet satisfactorily prescribed.

Global longitudinal strain and long-term outcome in patients presenting to the emergency department with suspected acute coronary syndrome.

AIMS: We have previously shown that 2-dimentional strain is not a useful tool for ruling out acute coronary syndrome (ACS) in the emergency department (ED). The aim of the present study was to determine whether in patients with suspected ACS, global longitudinal strain (GLS), measured in the ED using 2-dimensional strain imaging, can predict long-term outcome. METHODS: Long-term (median 7.7 years [IQR 6.7-8.2]) major adverse cardiac events (MACE; cardiac death, ACS, revascularization, hospitalization for heart failure, or atrial fibrillation) and all-cause mortality data were available in 525/605 patients (87%) enrolled in the Two-Dimensional Strain for Diagnosing Chest Pain in the Emergency Room (2DSPER) study. The study prospectively enrolled patients presenting to the ED with chest pain and suspected ACS but without a diagnostic ECG or elevated troponin. GLS was computed using echocardiograms performed within 24 hours of chest pain. MACE of patients with worse GLS (>median GLS) were compared to patients with better GLS (≤ median GLS). RESULTS: Median GLS was -18.7%. MACE occurred in 47/261 (18%) of patients with worse GLS as compared with 45/264 (17%) with better GLS, adjusted HR 0.87 (95% CI 0.57-1.33, P = .57). There was no significant difference in all-cause mortality or individual endpoints between groups. GLS did not predict MACE even in patients with optimal 2-dimensional image quality (n = 164, adjusted HR=1.51, 95% CI 0.76-3.0). CONCLUSIONS: Global longitudinal strain did not predict long-term outcome in patients presenting to the ED with chest pain and suspected ACS, supporting our findings in the 2DSPER study.

Right-Sided Endocarditis involving Eustachian Valve Following the Use of a Central Venous Line.

BACKGROUND Right-sided endocarditis is a well-known condition that occurs predominantly in intravenous drug users and patients with cardiovascular implantable electronic devices, central venous lines, and congenital heart disease. Most cases involve the tricuspid valve apparatus. Eustachian valve endocarditis (EVE) is a very rare and underdiagnosed condition with only a few previously reported cases. CASE REPORT We present a rare case of 2-sided infective thromboembolism from Staphylococcus aureus endocarditis involving both the eustachian and mitral valves in a 27-year-old man with mitochondrial neurogastrointestinal encephalopathy disease, which is a rare mitochondrial disease. CONCLUSIONS Endocarditis involving the eustachian valve is rare and presents a significant dilemma in diagnosis and treatment. Late diagnosis can lead to missed thromboembolic events and can have a significant impact on treatment and prognosis. In cases with high suspicion, early use of transesophageal echocardiography and chest CT can greatly advance diagnosis. The international guidelines do not specifically address patients with EVE; therefore, we recommend that the endocarditis team should be involved in any case of EVE to customize a treatment strategy.

Screening of Abdominal Aortic Aneurysm Using Portable Transthoracic Echocardiography among Patients with Acute Coronary Syndrome.

BACKGROUND: Abdominal aortic aneurysm (AAA) and acute coronary syndrome (ACS) share common risk factors. OBJECTIVES: To assess the abdominal aortic diameter (AAD) among patients with ACS using transthoracic echocardiography (TTE). METHODS: Patients with ACS admitted to our intensive cardiac care unit from December 2013 to June 2014 were screened prospectively for AAA via AAD measurement in the subcostal TTE view. AAA was defined as an aneurysm with a transverse diameter of ≥30 mm. RESULTS: Sixty seven patients were included. The male-to-female sex ratio was 7 : 1. The vast majority of patients were admitted due to STEMI (73%), and the rest were equally divided as NSTEMI and unstable angina. The mean patient age was 58.4 ± 10.4 years. AAD measurements were feasible in 57 patients (85%); among them, AAA was diagnosed in six patients (10.5%). The average additional time required to measure the abdominal aorta was 4 ± 1 min. All patients with AAA were men and had a higher prevalence of smoking (83.3% vs. 60.6%, p < 0.003) and a lower incidence of diabetes mellitus than those without aneurysm. The prevalence of AAA tended to be related to age (12.5% in those older than 60 years and 18.7% in those older than 65 years). CONCLUSIONS: The overall prevalence of AAA is significantly high among patients with ACS and increases with age. AAA screening as a part of routine cardiac TTE can be easily, rapidly, and feasibly performed and yield accurate findings. AAD measurement in the subcostal view should be implemented as a part of routine TTE in patients with ACS.

Impact of Chronic Statins Use on the Development of Esophagitis in Patients with Gastroesophageal Reflux Disease.

Background and Aims: We aimed to assess whether chronic statins used (> 6 months) were protective of the development of esophagitis in patients with gastroesophageal reflux disease. In the presence of esophagitis, complications such as strictures, Barrett's esophagus, and adenocarcinoma were the most common. Statins, lipid lowering drugs with a pleiotropic effect, are recently implicated in various pathologies. Nevertheless, the possible impact of statins in esophagitis development has never been assessed. Methods: We performed a retrospective, cross-sectional, single center study that included 4148 gastroesophageal reflux disease patients from 2014 and 2018 at EMMS Nazareth Hospital. We divided the patients into 5 groups. The groups were split into positive control group, which was the nonesophagitis group, and the other 4 groups were A-D (as per Los Angeles classification). Results: Overall, out of the 4148 patients included, 48% were males and 2840 patients were in the control group. In groups A, B, C, and D there were 818, 402, 72, and 16 patients, respectively. Logistic regression analysis revealed that chronic statins usage is protective by preventing development esophagitis (OR 0.463 [95%CI 0.370-0.579], p < 0.0001). NSAIDS use, Hiatus hernia, and H. pylori were promoting factors (OR, 1.362, 1.779, and 1.811; 95% CI, 1.183-1.569, 1.551-2.040, and 1.428-2.298; P<0.0001, P<0.0001, and P<0.0001, respectively). Conclusion: Using chronic statins was protective to the development of esophagitis among GERD patients. Our findings of potential clinical application mandate further randomized controlled trials to better assess the impact of statins on esophagitis.

Two-slope ascending arm of the early trans-mitral flow velocity Doppler wave in patients with heart failure and preserved ejection fraction.

Trans-mitral flow velocity (TMFV) examination is a standard echocardiographic measure for assessing diastolic function of the heart. Typically, the Doppler signal representing the early rapid filling phase of the left ventricle (LV), termed: E wave, is triangular. The ascending arm of the E wave (EWAA) represents blood accelerating into the LV from the left atrium (LA), whereas the descending arm reflects blood decelerating as the LV fills and resists further filling. The slope of EWAA is linear, starting at TMFV of zero cm/s (prior to mitral valve opening) and building to peak E wave value. The physical meaning of a single slope is that blood acceleration is constant with time. Little data exist regarding the significance of the shape of EWAA. It is hypothesized that in heart failure with preserved ejection fraction (HFPEF) the EWAA displays 2 slopes. A first steeper slope followed by a second less steep slope reaching peak E wave. The different slopes represent a change in the composition of driving forces propelling blood from LA to LV. It is hypothesized that the first steeper slope of EWAA represents a set of driving force including a force termed: diastolic suction, whereas in the second slope diastolic suction has already dissipated. This 2-slope phenomenon is not expected in healthy subjects because the assumed underlying mechanism is not operative.

[Requests for preoperative cardiology consultation for patients undergoing non cardiac surgery].

AIMS: The number of surgical procedures performed in patients with significant ischemic heart disease is growing. The need for preoperative cardiology consultation in patients undergoing non-cardiac surgery has been the subject of continuous debate. We evaLuated if the requests for preoperative cardiology consultation in patients undergoing non-cardiac surgery were consistent with the 2009 ACC/AHA Guidelines. METHODS AND RESULTS: Patients referred for cardiology consultation before non-cardiac surgery were eligible for the study. Data were collected on age, gender, reasons for consultation, type of surgery, Lee's Cardiac Risk Stratification Class, therapy changes, patients work capacity, and perioperative patients' outcome. Our study population consisted of one hundred and seventy patients; 89 were men (52.3%) and 81 women (47.6%), with a mean age of 74.2±years; 88 patients (51.8%) had a work capacity ≥4 metabolic equivalents [METs). Active cardiac conditions were present in 12 patients (7.1%). The reported clinical risk factors were: 75 patients (44.1%) had diabetes mellitus, 21 patients (12.3%) had prior or compensated heart failure, 79 patients (46.5%) had ischemic heart disease, 29 patients (17.1%) had stroke, and 30 patients (17.7%) had renal insufficiency. Fourteen patients (8.2%) had an implanted pacemaker. There were also 3 perioperative deaths (1.8%). The indication of the requests for preoperative cardiac consultation according to the 2009 ACC/AHA Guidelines was only found in 45 patients (26.5%). CONCLUSIONS: Only in a minority of patients undergoing non-cardiac surgery, the preoperative cardiology consultation requests followed the ACC/AHA Guidelines. Preoperative cardiology consultations in the daily clinical practice are overused.

Effect of clopidogrel plus aspirin on ST segments in patients with ST-elevation acute myocardial infarction.

Spontaneous ST-segment resolution (STR) after acute ST-elevation myocardial infarction is associated with favorable outcomes. Effect on STR of newer, more powerful antiplatelet and antithrombotic agents is unclear. The aim of this study was to identify independent clinical and angiographic predictors of STR in patients with ST-elevation acute myocardial infarction before percutaneous coronary intervention. We studied 206 patients admitted with ST-elevation acute myocardial infarction, of whom 37 (18%) had STR. There were 12 deaths (5.8%) that occurred in the group without spontaneous STR. Patients with spontaneous STR were younger (55 vs 61 years old, p = 0.02), had shorter duration of symptoms (117 vs 212 minutes, p <0.0001), had preserved ejection fraction (55% vs 40%, p <0.0001), had shorter hospital stays, and had lower in-hospital arrhythmias or death. Independent predictors of STR, identified by stepwise logistic regression analysis, were early clopidogrel administration (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.00 to 4.40, p = 0.045), single-vessel disease (OR 2.85, 95% CI 1.22 to 6.70, p = 0.02), chest pain duration (OR 0.98, 95% CI 0.98 to 0.99, p <0.0001), collaterals (OR 4.3, 95% CI 1.7 to 10.8, p = 0.002), circumflex as a culprit vessel (OR 4.74, 95% CI 1.5 to 14.95, p = 0.008), and coronary thrombus noted on angiography (OR 5.76, 95% CI 1.63 to 20.4, p = 0.006). In conclusion, early clopidogrel administration is associated with, and likely causal for, STR. Patients with thrombus, collateral flow, and circumflex culprit vessel are more likely to have STR. In addition, our study confirms previous findings that patients with STR have preserved left ventricular function and better hospital outcomes compared with those without STR.

'Frozen' posterior mitral leaflet in rheumatic mitral stenosis: incidence and impact on outcome of balloon mitral commissurotomy.

BACKGROUND AND AIM OF THE STUDY: The incidence and clinical significance of immobile and 'frozen' posterior mitral leaflet (FPML) were evaluated in the pathophysiology and immediate outcome of patients with severe pliable mitral stenosis (MS) undergoing percutaneous balloon mitral commissurotomy (PBMC). METHODS: During the past four years, 30 'ideal' patients (mean age 46 +/- 8 years) with Wilkins' score <8, bilateral commissural fusion and absence of commissural calcification underwent peri-procedural echocardiographic analysis. Anterior mitral leaflet (AML) mobility index (MI), chordae tendineae (CT) length, and mitral valve area (MVA) were evaluated. RESULTS: Pre-procedure FPML was noted in 28 patients (93%). All patients achieved MVA > or = 1.5 cm2. Post-procedure MVA in patients with bilateral commissural splitting was 1.9 +/- 0.2 cm2 versus 1.6 +/- 0.1 cm2 in patients with unilateral commissural splitting (p < 0.05). CT lengths directed to the AML and PML were 15 +/- 2 mm and 8 +/- 2 mm, respectively (p < 0.05). MI of the AML before and immediately after PBMC was 0.4 and 0.6, respectively (p < 0.05). None of the patients with FPML showed improved mobility following successful PBMC. CONCLUSION: FPML may be found in most patients with pliable MS. It is mainly a result of short, rigid and fused CT directed to the PML. A 'single-wing door' or a unicuspid valve may be used as a model for rheumatic pliable MS. It is suggested that pre-procedure leaflet morphology and functional assessment should focus on the AML.

Feasibility, safety, and morphologic predictors of outcome of repeat percutaneous balloon mitral commissurotomy.

Early and mid-term results of repeat percutaneous balloon mitral commissurotomy (PBMC) were analyzed in 35 patients with symptomatic valvular restenosis: 12 patients (34%) after first successful PBMC and 23 patients (66%) after successful surgical closed mitral commissurotomy. Twenty-one patients had bilateral fused commissures, and 14 patients had unilateral or bilateral split commissures. Mitral valve area gain was significantly greater in the group with fused commissures compared with the group with split commissures (0.6 +/- 0.2 vs 0.3 +/- 0.2 cm(2), respectively, p = 0.04).

Diagnostic and therapeutic percutaneous cardiac interventions without on-site surgical backup--review of 11 years experience.

BACKGROUND: Current clinical guidelines restrict catheterization laboratory activity without on-site surgical backup. Recent improvements in technical equipment and pharmacologic adjunctive therapy increase the safety margins of diagnostic and therapeutic cardiac catheterization. OBJECTIVE: To analyze the reasons for urgent cardiac surgery and mortality in the different phases of our laboratory's activity in the last 11 years, and examine the impact of the new interventional and therapeutic modalities on the current need for on-site cardiac surgical backup. METHODS: We retrospectively reviewed the mortality and need for urgent cardiac surgery (up to 12 hours post-catheterization) through five phases of our laboratory's activity: a) diagnostic (years 1989-2000), b) valvuloplasties and other non-coronary interventions (1990-2000), c) percutaneous-only balloon angioplasty (1992-1994), d) coronary stenting (1994-2000), and e) use of IIb/IIIa antagonists and thienopiridine drugs (1996-2000). RESULTS: Forty-eight patients (0.45%) required urgent cardiac surgery during phase 1, of whom 40 (83%) had acute coronary syndromes with left main coronary artery stenosis or the equivalent, and 8 (17%) had mechanical complications of acute myocardial infarction. Two patients died (0.02%) during diagnostic procedures. In phase 2, eight patients (2.9%) were referred for urgent cardiac surgery due to either cardiac tamponade or severe mitral regurgitation, and two patients (0.7%) died. The combined need for urgent surgery and mortality was significantly lower in phase 4 plus 5 as compared to phase 3 (3% vs. 0.85%, P = 0.006). CONCLUSION: In the current era using coronary stents and potent antithrombotic drugs, after gaining experience and crossing the learning curve limits, complex cardiac therapeutic interventions can safely be performed without on-site surgical backup.