Parenteral Anticoagulation at First Medical Contact Improves Infarct Related Artery Patency in STEMI.

(1) Background: Acute ST-segment elevation myocardial infarction (STEMI) remains one of the main morbidity and mortality contributors worldwide. Its main treatment, primary percutaneous coronary intervention (pPCI), can only be performed with a high anticoagulation regimen, usually with heparin. There is still not enough evidence regarding the timing of heparin administration. (2) Methods: We conducted a multicenter observational study of 614 consecutive STEMI patients treated between 2017 and 2019. We split the population in two groups: one that received heparin at the first medical contact, as early as possible, and the second group that received heparin at the PCI capable center or in the cath lab. (3) Results: There was a significantly higher rate of infarct-related artery (IRA) patency at the time of the coronary angiogram in the pre-transfer heparin group than in the on-site heparin group, 44.7% vs. 37.3%, p = 0.042. Also, the early heparin group received shorter and wider stents. There was no difference in bleeding rates or in the in-hospital and two-year mortality rates. (4) Conclusions: Early administration of heparin leads to a higher rate of reperfusion in the IRA, before pPCI, with significant related benefits, such as better stent implantation parameters, without increased bleeding rates.

Co-registered optical coherence tomography and X-ray angiography for the prediction of fractional flow reserve.

Cardiovascular disease (CVD) stands as the leading global cause of mortality, and coronary artery disease (CAD) has the highest prevalence, contributing to 42% of these fatalities. Recognizing the constraints inherent in the anatomical assessment of CAD, Fractional Flow Reserve (FFR) has emerged as a pivotal functional diagnostic metric. Herein, we assess the potential of employing an ensemble approach with deep neural networks (DNN) to predict invasively measured Fractional Flow Reserve (FFR) using raw anatomical data extracted from both optical coherence tomography (OCT) and X-ray coronary angiography (XA). In this study, we used a challenging dataset, with 46% of the lesions falling within the FFR range of 0.75 to 0.85. Despite this complexity, our model achieved an accuracy of 84.3%, demonstrating a sensitivity of 87.5% and a specificity of 81.4%. Our results demonstrate that incorporating both OCT and XA signals, co-registered, as inputs for the DNN model leads to an important increase in overall accuracy.

Assessment of the functional severity of coronary lesions from optical coherence tomography based on ensembled learning.

BACKGROUND: Atherosclerosis is one of the most frequent cardiovascular diseases. The dilemma faced by physicians is whether to treat or postpone the revascularization of lesions that fall within the intermediate range given by an invasive fractional flow reserve (FFR) measurement. The paper presents a monocentric study for lesions significance assessment that can potentially cause ischemia on the large coronary arteries. METHODS: A new dataset is acquired, comprising the optical coherence tomography (OCT) images, clinical parameters, echocardiography and FFR measurements collected from 80 patients with 102 lesions, with stable multivessel coronary artery disease. Having the ground truth given by the invasive FFR measurement, the dataset is challenging because almost 40% of the lesions are in the gray zone, having an FFR value between 0.75 and 0.85. Twenty-six features are extracted from OCT images, clinical characteristics, and echocardiography and the most relevant are identified by examining the models' accuracy. An ensembled learning is performed for solving the binary classification problem of lesion significance considering the leave-one-out cross-validation approach. RESULTS: Ensemble models are designed from the multi-features voting from 5 features models by prediction aggregation with a maximum accuracy of 81.37% and a maximum area under the curve score (AUC) of 0.856. CONCLUSIONS: The proposed explainable supervised learning-based lesion classification is a new method that can be improved by training with a larger multicenter dataset for further designing a tool for guiding the decision making of the clinician for the cases outside the gray zone and for the other situation extra clinical information about the lesion is needed.

Impact of rs1805127 and rs55742440 Variants on Atrial Remodeling in Hypertrophic Cardiomyopathy Patients with Atrial Fibrillation: A Romanian Cohort Study.

Atrial fibrillation (AFib) is characterized by a complex genetic component. We aimed to investigate the association between variations in genes related to cardiac ion handling and AFib in a cohort of Romanian patients with hypertrophic cardiomyopathy (HCM). Forty-five unrelated probands with HCM were genotyped by targeted next-generation sequencing (NGS) for 24 genes associated with cardiac ion homeostasis. Subsequently, the study cohort was divided into two groups based on the presence (AFib+) or absence (AFiB-) of AFib detected during ECG monitoring. We identified two polymorphisms (rs1805127 located in KCNE1 and rs55742440 located in SCN1B) linked to AFib susceptibility. In AFib+, rs1805127 was associated with increased indexed left atrial (LA) maximal volume (LAVmax) (58.42 ± 21 mL/m2 vs. 32.54 ± 6.47 mL/m2, p < 0.001) and impaired LA strain reservoir (LASr) (13.3 ± 7.5% vs. 24.4 ± 6.8%, p < 0.05) compared to those without respective variants. The rs55742440 allele was less frequent in patients with AFib+ (12 out of 25, 48%) compared to those without arrhythmia (15 out of 20, 75%, p = 0.05). Also, AFib+ rs55742440 carriers had significantly lower LAVmax compared to those who were genotype negative. Among patients with HCM and AFib+, the rs1805127 variant was accompanied by pronounced LA remodeling, whereas rs55742440's presence was related to a milder LA enlargement.

Left Atrial Low-Voltage Areas Predict the Risk of Atrial Fibrillation Recurrence after Radiofrequency Ablation.

Atrial fibrillation (AF), the most frequently encountered arrhythmia worldwide, is associated with increased cardiovascular morbidity and mortality. Left atrial (LA) and antral region of the pulmonary veins (PVs) remodeling are risk factors for AF perpetuation. Among the methods of LA fibrosis quantification, bipolar voltage mapping during three-dimensional electro-anatomical mapping is less studied. The main aim of this study was to analyze the relationship between the degree of LA fibrosis quantified in low-voltage areas and the efficacy of AF radiofrequency catheter ablation. All consecutive patients with AF ablation were included, and the degree of LA fibrosis was measured based on the low-voltage areas in the LA and the antral region of PVs (<0.5 mV for patients in sinus rhythm and <0.25 mV for patients in AF at the time of the ablation procedure). The efficacy of AF ablation was determined by the rate of recurrence after a blanking period of three months. A total of 106 patients were included; from these, 38 (35.8%) had AF recurrence after RF ablation, while 68 (64.2%) were free of events. The area and percentage of LA fibrosis were significantly higher in the patients with AF recurrence (p = 0.018 and p = 0.019, respectively). However, no significant differences were found between the patients with and without AF recurrence in terms of the area and percentage of PVs fibrosis (p = 0.896 and p = 0.888, respectively). Moreover, LA fibrosis parameters proved to be excellent predictors for AF recurrence (areas under the curve of 0.834 and 0.832, respectively, p < 0.001) even after adjustment for LA indexed volume and CHA2DS2-VASc score. In conclusion, LA fibrosis measured on bipolar voltage maps increases the risk of AF recurrence after the RF catheter ablation procedure.

Molecular and cellular mechanisms of inflammation in atherosclerosis.

Atherosclerosis and its complications are a major cause of morbidity and mortality worldwide in spite of the improved medical and invasive treatment in terms of revascularization. Atherosclerosis is a dynamic, multi-step process in which inflammation is a ubiquitous component participating in the initiation, development, and entanglements of the atherosclerotic plaque. After activation, the immune system, either native or acquired, is part of the atherosclerotic dynamics enhancing the pro-atherogenic function of immune or non-immune cells, such as endothelial cells, smooth muscle cells, or platelets, through mediators such as cytokines or directly by cell-to-cell interaction. Cytokines are molecules secreted by the activated cells mentioned above that mediate the inflammatory component of atherosclerosis whose function is to stimulate the immune cells and the production of further cytokines. This review provides insights of the cell axis activation and specific mechanisms and pathways through which inflammation actuates atherosclerosis.

The Profile and All-Cause In-Hospital Mortality Dynamics of St-Segment Elevation Myocardial Infarction Patients during the Two Years of the COVID-19 Pandemic.

During the coronavirus pandemic 2019 (COVID-19), some studies showed differences in the profile of subjects presenting with acute coronary syndromes as well as in overall mortality due to the delay of presentation and other complications. The purpose of this study was to compare the profile and outcomes, with emphasis on all-cause in-hospital mortality, of ST-elevation myocardial infarction (STEMI) subjects presenting to the emergency department during the pandemic period compared with a control group from the previous year, 2019. The study enrolled 2011 STEMI cases, which were divided into two groups-pre-pandemic (2019-2020) and pandemic period (2020-2022). Hospital admissions for a STEMI diagnosis sharply decreased during the COVID-19 period by 30.26% during the first year and 25.4% in the second year. This trend was paralleled by a significant increase in all-cause in-hospital mortality: 11.5% in the pandemic period versus 8.1% in the previous year. There was a significant association between SARS-CoV-2 positivity and all-cause in-hospital mortality, but no correlation was found between COVID-19 diagnosis and the type of revascularization. However, the profile of subjects presenting with STEMI did not change over time during the pandemic; their demographic and comorbid characteristics remained similar.

In-stent restenosis in acute coronary syndrome-a classic and a machine learning approach.

Background: In acute coronary syndrome (ACS), a number of previous studies tried to identify the risk factors that are most likely to influence the rate of in-stent restenosis (ISR), but the contribution of these factors to ISR is not clearly defined. Thus, the need for a better way of identifying the independent predictors of ISR, which comes in the form of Machine Learning (ML). Objectives: The aim of this study is to evaluate the relationship between ISR and risk factors associated with ACS and to develop and validate a nomogram to predict the probability of ISR through the use of ML in patients undergoing percutaneous coronary intervention (PCI). Methods: Consecutive patients presenting with ACS who were successfully treated with PCI and who had an angiographic follow-up after at least 3 months were included in the study. ISR risk factors considered into the study were demographic, clinical and peri-procedural angiographic lesion risk factors. We explored four ML techniques (Random Forest (RF), support vector machines (SVM), simple linear logistic regression (LLR) and deep neural network (DNN)) to predict the risk of ISR. Overall, 21 features were selected as input variables for the ML algorithms, including continuous, categorical and binary variables. Results: The total cohort of subjects included 340 subjects, in which the incidence of ISR observed was 17.68% (n = 87). The most performant model in terms of ISR prediction out of the four explored was RF, with an area under the receiver operating characteristic (ROC) curve of 0.726. Across the predictors herein considered, only three predictors were statistically significant, precisely, the number of affected arteries (≥2), stent generation and diameter. Conclusion: ML models applied in patients after PCI can contribute to a better differentiation of the future risk of ISR.

Takotsubo Cardiomyopathy and ß-Blocker Poisoning: A Case Report.

ß-blocker poisoning is frequently observed because of its primary use for the treatment of cardiovascular diseases. The management of ß-blocker toxicity is dependent on the cardiovascular response and the severity of presentation. The present study describes the case of a patient with combined drug intoxication, ß-blocker, digoxin, benzodiazepines, acetaminophen and opiates in a suicidal attempt. A 63-year-old female was found somnolent and in a confused state at her residence following intentional poly-drug ingestion. Upon presentation, she was found to be hemodynamically unstable and was thus treated with vasopressors. The toxicological screening performed upon presentation was positive for polydrug ingestion. On day 3, the patient developed chest pain and ST-segment elevation in anterior leads, while transthoracic echocardiographic assessment disclosed a non-dilated left ventricle with moderate dysfunction and akinesia of the apex. Coronary angiogram revealed normal coronary arteries and, subsequently, the diagnosis of Takotsubo cardiomyopathy (TTC) was suspected. Supportive treatment was initiated with favorable evolution and left ventricular ejection fraction normalization. The management of hemodynamic instability with vasopressors should be judiciously administered in the treatment of ß-blocker poisoning, in view of the adverse effects on cardiac functions, including stress cardiomyopathy.

Artificial intelligence and cloud based platform for fully automated PCI guidance from coronary angiography-study protocol.

Ischemic heart disease represent a heavy burden for the medical systems irrespective of the methods used for diagnosis and treatment of such patients in the daily medical routine. The present paper depicts the protocol of a study whose main aim is to develop, implement and test an artificial intelligence algorithm and cloud based platform for fully automated PCI guidance using coronary angiography images. We propose the utilisation of multiple artificial intelligence based models to produce three-dimensional coronary anatomy reconstruction and assess function- post-PCI FFR computation- for developing an extensive report describing and motivating the optimal PCI strategy selection. All the relevant artificial intelligence model outputs (anatomical and functional assessment-pre- and post-PCI) are presented to the clinician via a cloud platform, who can then take the utmost treatment decision. The physician will be provided with multiple scenarios and treatment possibilities for the same case allowing a real-time evaluation of the most appropriate PCI strategy planning and follow-up. The artificial intelligence algorithms and cloud based PCI selection workflow will be verified and validated in a pilot clinical study including subjects prospectively to compare the artificial intelligence services and results against annotations and invasive measurements.

Increasing clinical impact and microbiological difficulties in diagnosing coagulase-negative staphylococci in infective endocarditis - a review starting from a series of cases.

Coagulase-negative staphylococci (CoNS) are an emergent aetiology of infective endocarditis (IE) on native valves in previously healthy individuals, its presence is associated with prosthetic valves or with other cardiac implants. The identification of CoNS in cultures was customarily seen as contamination, but more recent epidemiological studies have revealed an increasing number of causative and virulent new CoNS species. Starting from two clinical cases of community-acquired CoNS IE on native valves, the review debates the difficulties in identifying CoNS as the causal pathogens, comprising differentiation of contamination from infection in IE, alongside the challenges raised by antibiotic resistance. Even if the risk of CoNS IE is more increased in subjects with prosthetic materials or other foreign devices and immunodeficiencies, native valve infections with these staphylococci are increasing and should be considered important pathogens in IE. Despite the lack of sensitive and specific tools to correctly differentiate contamination from infection in CoNS endocarditis, a comprehensive evaluation with clinical and paraclinical data accurately succeeds in establishing the diagnosis. The genetic profile of CoNS predisposes to antibiotic multi-resistance, making the treatment of IE challenging; the rapid identification of antibiotic susceptibility is essential to prescribe the appropriate therapy and improve outcomes.

The Continuum of Invasive Techniques for the Assessment of Intermediate Coronary Lesions.

Ischemic heart disease is one of the most important causes of mortality and morbidity worldwide. Revascularization of coronary stenosis inducing ischemia, either by percutaneous or surgical intervention, significantly reduces major adverse cardiovascular events and improves quality of life. However, in cases of intermediate lesions, classified by a diameter stenosis between 50 and 90% by European guidelines and 40-70% in American counterparts with no clear evidence of ischemia, the indication of revascularization and impact is determined using various methods that altogether comprehensively evaluate the lesions. This review will discuss the various techniques to assess intermediate stenoses, highlighting indications and advantages, but also drawbacks. Fractional flow rate (FFR) and instantaneous wave-free ratio (iFR) are the gold standard for the functional evaluation of intermediate lesions, but there are clinical circumstances in which these pressure-wire-derived indices are not accurate. Complementary invasive investigations, mainly intravascular ultrasound and/or optical coherence tomography, offer parameters that can be correlated with FFR/iFR and additional insights into the morphology of the plaque guiding the eventual percutaneous intervention in terms of length and size of stents, thus improving the outcomes of the procedure. The development of artificial intelligence and machine learning with advanced algorithms of prediction will offer multiple scenarios for treatment, allowing real-time selection of the best strategy for revascularization.

Importance of Visual Estimation of Coronary Artery Stenoses and Use of Functional Evaluation for Appropriate Guidance of Coronary Revascularization-Multiple Operator Evaluation.

BACKGROUND: Visual estimation (VE) of coronary stenoses is the first step during invasive coronary angiography. The aim of this study was to evaluate the accuracy of VE together with invasive functional assessment (IFA) in defining the functional significance (FS) of coronary stenoses based on the opinion of multiple operators. METHODS: Fourteen independent operators visually evaluated 133 coronary lesions which had a previous FFR measurement, indicating the degree of stenosis (DS), FS and IFA intention. We determined the accuracy of FS prediction using several scenarios combining individual and group decision, considering IFA as deemed necessary by the operator or only in intermediate lesions. RESULTS: The accuracy of VE in predicting FS was largely variable between operators (average 66.1%); it improved significantly when IFA was used either as per operator's opinion (86.3%; p < 0.0001) or only in intermediate DS (82.9; p < 0.0001). There was no significant difference between using IFA per observer's opinion or only in intermediate DS lesions (p = 0.166). The poorest accuracy of VE for FS was obtained in intermediate DS lesions (59.1%). CONCLUSIONS: There are significant inter-observer differences in reporting the degree of DS, while the accuracy of VE prediction of FS is also largely dependent on the operator, and the worst performance is obtained in the evaluation of intermediate DS.

The Attitude of Patients from a Romanian Tertiary Cardiology Center Regarding Participation in Biomarker-Based Clinical Trials.

Background and Objectives: biomarker-based studies are the cornerstone of precision medicine, providing key data for tailored medical care. Enrollment of the planned number of patients is a critical determinant of a successful clinical trial. Moreover, for inclusive medical care, patients from different socio-demographic backgrounds must be recruited. Still, a significant number of trials fail to reach these prerequisites. Designing the informed consent forms based on the patients' feedback could optimize accrual. We aimed to explore the attitudes of patients from a Romanian tertiary cardiology center towards participation in biomarker-based clinical trials. Materials and Methods: three hundred forty inpatients were interviewed based on a semi-structured questionnaire which included four sections: demographics, personal medical history, attitudes and trust. Results: Roughly, 62.5% of the respondents were interested in enrolling, while altruistic reasons were the most frequently expressed. Clear exposure of the possible risks was most valued (37.78%), followed by the possibility of directly communicating with the research team (23.78%). The most frequently chosen answer by acutely ill patients was improvement of their health, whereas chronically ill individuals indicated the possibility of withdrawal without affecting the quality of medical care. Importantly, the participation rate could be improved if the invitation to enrollment were made by both the current physician and the study coordinator (p = 0.0001). The level of trust in researchers was high in more than 50% of the respondents, and was correlated with therapeutic compliance and with the desire to join a biomarker study. Conclusions: the information gained will facilitate a tailored approach to patient enrollment in future biomarker-based studies in our clinic.

Molecular Research in Cardiovascular Disease.

Cardiovascular diseases have attracted our full attention not only because they are the main cause of mortality and morbidity in many countries but also because the therapy for and cure of these maladies are among the major challenges of the medicine in the 21st century [...].

Inflammatory markers in acute myocardial infarction and the correlation with the severity of coronary heart disease.

INTRODUCTION: The inflammatory hypothesis of atherosclerosis is appealing in acute coronary syndromes, but the dynamics and precise role are not established. OBJECTIVES: The study investigates the levels of C reactive protein (CRP), interleukin 1ß (IL-1ß) and stromal-derived factor 1α (SDF-1α) at the time of acute myocardial infarction (AMI) and at 1 and 6 months afterwards, compared with a control group. RESULTS: In the acute phase of AMI, CRP and SDF-1α were significantly higher, while IL-1ß showed lower levels compared with controls. CRP positively correlated with coronary stenosis severity (rho = 0.3, p=.05) and negatively related with left ventricle ejection fraction (LVEF) at 1 month (rho= -0.43, p=.05). IL-1ß weakly correlated with the severity of coronary lesions (rho =0.29, p=.02) and strongly with LVEF (rho= -0.8, p=.05). SDF-1α, slightly correlated with LVEF at 1 month (rho = 0.22, p=.01) and with the severity of coronary atherosclerosis (rho= -0.41, p=.003). CONCLUSIONS: CRP, IL-1ß and SDF-1α have important dynamic in the first 6 months after AMI and CRP and SDF-1α levels correlated with the severity of coronary lesions and LVEF at 1 month after the acute ischaemic event.

Acute inferior myocardial infarction in a young man with testicular seminoma: A case report.

BACKGROUND: Atherosclerosis represents the main cause of myocardial infarction (MI); other causes such as coronary embolism, vasospasm, coronary-dissection or drug use are much rarely encountered, but should be considered in less common clinical scenarios. In young individuals without cardiovascular risk factors, the identification of the cause of MI can sometimes be found in the medical history and previous treatments undertaken. CASE SUMMARY: We present the case of a 34-year-old man presenting acute inferior ST-elevation MI without classic cardiac risk factors. Seven years ago, he suffered from orchidopexy for bilateral cryptorchidism, and was recently diagnosed with right testicular seminoma for which he had to undergo surgical resection and chemotherapy with bleomycin, etoposide and cisplatin. Shortly after the first chemotherapy treatment, namely on day five, he suffered an acute MI. Angiography revealed a mild stenotic lesion at the level of the right coronary artery with suprajacent thrombus and vasospasm, with no other significant lesions on the other coronary arteries. A conservative treatment was decided upon by the cardiac team, including dual antiplatelets therapy and anticoagulants with good further evolution. The patient continued the chemotherapy treatment according to the initial plan without other cardiovascular events. CONCLUSION: In young individuals with no cardiovascular risk factors undergoing aggressive chemotherapy, an acute MI can be caused by vascular toxicity of several anti-cancer drugs.

The Role of Left-Atrial Mechanics Assessed by Two-Dimensional Speckle-Tracking Echocardiography to Differentiate Hypertrophic Cardiomyopathy from Hypertensive Left-Ventricular Hypertrophy.

Hypertrophic cardiomyopathy (HCM) and arterial hypertension (HTN) are conditions with different pathophysiology, but both can result in left-ventricular hypertrophy (LVH). The role of left-atrial (LA) functional changes detected by two-dimensional speckle-tracking echocardiography (STE) in indicating LVH etiology is unknown. METHODS: We aimed to characterize LA mechanics using STE in LVH patients with HCM and HTN. LA 2D volumetric and STE parameters were analyzed in 86 LVH patients (43 HCM and 43 isolated HTN subjects) and 33 age- and sex-matched controls. RESULTS: The volumetric study showed that LA reservoir and conduit function were impaired in the HCM group compared to controls, while, in the HTN group, only LA conduit function was deteriorated. The HCM group had all three STE-derived LA functions impaired compared to controls. The HTN group, consistently with volumetric analysis, had solely LA conduit function reduced compared to controls. Ratios of LA booster-pump strain (S) and strain rate (SR) to interventricular septum (IVS) thickness were the most accurate parameters to discriminate between HCM and HTN. The subgroup harboring sarcomeric pathogenic (P)/likely pathogenic (LP) variants had reduced LA booster-pump S and SR compared with the genotype-negative subgroup. CONCLUSIONS: LA reservoir, conduit, and pump functions are decreased in HCM compared to HTN patients with similar LVH. We report the ratios between LA contraction S/SR and IVS thickness as novel parameters with high accuracy in discriminating LVH due to HCM. The presence of P/LP variants in sarcomeric or sarcomeric-associated genes could be associated with more severe LA dysfunction.