The implantable cardiac monitor in heart failure patient: a possible new indication?

Implantable cardiac monitors (ICMs) have found increasing use in clinical practice over the years, proving, when used in high-risk populations, to facilitate the diagnosis of bradyarrhythmias and tachyarrhythmias requiring treatment. Experience with heart failure patients undergoing pacemaker (PMK) or implantable defibrillator (ICD) implantation, which allow for continuous electrocardiographic monitoring and transthoracic impedance assessment, has made it possible to identify predictors of heart failure flare-ups. In this context, the use of telemonitoring has been shown to ensure better management of patients with heart failure. These benefits cannot be assessed to date in patients with heart failure and left ventricular ejection fraction (LVEF) > 35% who have no indication for PMK or ICD implantation. This population has been shown to have a significant incidence of ventricular arrhythmias and bradyarrhythmias. In addition, a significant number of cerebrovascular events are observed in this population, largely attributable to the high incidence of atrial fibrillation (AF). In this population, the occurrence of AF has also been shown to have a negative impact on patients' prognosis; at the same time, a rhythm control strategy has been shown to be more beneficial in this area than a rate control strategy. Studies also suggest arrhythmias have a negative impact on the cognitive status and quality of life of heart failure patients. These reasons could justify the implantation of ICMs equipped with telemonitoring systems in heart failure patients. The information provided by the monitoring system, if properly managed, could bring benefits in terms of prognosis and quality of life along with a reduction in economic costs. We will try here, by answering a few questions, to assess whether there is an indication for ICM in heart failure, which patients should be candidates and how these patients should be managed.

Sodium-glucose co-transporter 2 inhibitors in heart failure: an updated evidence-based practical guidance for clinicians.

The sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to reduce risks of clinical events in patients with heart failure (HF), with early and sustained benefits regardless of ejection fraction, diabetic status, and care setting. As part and parcel of the modern foundational HF therapy, clinicians should be familiar with these drugs, in order to implement their use and limit the potential adverse effects. We present an up-to-date review of current evidence and a practical guide for the prescription of SGLT2 inhibitors in patients with HF, highlighting important elements for patient selection, treatment initiation, dosing, and problem solving.

Heart failure and telemedicine: where are we and where are we going? Opportunities and critical issues.

Heart failure (HF) is one of the main causes of morbidity in the world and is responsible for an enormous amount of health costs, mostly due to hospitalizations. The remote control techniques of vital signs and health status have the potential to help prevent factors leading to HF instability by stimulating early therapeutic interventions. The goal of telemedicine is to change the intervention strategy from a 'reactive' type, in which therapy is optimized in response to the worsening of symptoms, to a 'pro-active' type, in which therapeutic changes are undertaken based on changes in the monitored parameters during the sub-clinical phase. This article is aimed at exploring the major results obtained by telemedicine application in HF patients with and without cardiac electronic devices or in those with haemodynamic sensors and to analyse the critical issues and the opportunities of its use.

Significant increase of flow kinetic energy in "nonresponders" patients to cardiac resynchronization therapy.

BACKGROUNDS: It's still unclear if different patterns of intraventricular flow dynamics may be detected in patients nonresponders to cardiac resynchronization therapy (CRT) as compared to responders ones. Aim of this study was to evaluate the characteristics of left ventricular (LV) flow dynamics 6-months after CRT to identify Echo-particle imaging velocity (PIV) patterns were more frequently detected in nonresponders patients. METHODS: Thirty-two patients with dilated cardiomyopathy, undergoing CRT, were enrolled in this study. All patients underwent 2D and 3D echo and fluid dynamics assessment 6 months after CRT, during active CRT (CRT-ON) and during a temporarily discontinued state (CRT-OFF). LV volumes systolic and diastolic volumes (LVESV and LVEDV), ejection fraction (LVEF), global longitudinal strain (GLS), systolic dyssynchrony index (SDI), and several geometrical and functional Echo-PIV-derived parameters were calculated. Patients were divided in two groups: "responders" to CRT (decrease in LVESV>15% 6 months after CRT) and "nonresponders." RESULTS: During CRT-OFF, LVEF, GLS were lower, while SDI and LVESV were higher in nonresponders group (P=.030, P=.051, P=.035, and P=.025, respectively). Energy dissipation, vortex area, and vorticity fluctuation were higher in "nonresponders" patients during CRT-OFF (P=.038, P=.054, and P=.035, respectively). During CRT-ON, energy dissipation, vortex area, and vorticity fluctuation further increase in nonresponders patients (P=.020, P=.038, and P=.030, respectively) with a concomitant worsening of SDI (P=.045). CONCLUSION: Our data show a significant worsening in flow-derived parameters in CRT "nonresponders" patients as compared with responders. Further larger longitudinal studies are necessary to assess whether these more chaotic intraventricular flow-patterns may contribute to a persistent adverse remodeling observed in this subset of patients.

Value of two-dimensional longitudinal strains analysis to assess the impact of thrombus aspiration during primary percutaneous coronary intervention on left ventricular function: a speckle tracking imaging substudy of the EXPIRA trial.

BACKGROUND: Thrombectomy during primary percutaneous coronary intervention (Th-PCI) improves myocardial reperfusion in the absence of significant changes, in the acute phase, in traditional two-dimensional (2D) echo indexes of left ventricular (LV) function. The aim of this study was to evaluate the potential of 2D speckle tracking echocardiography (2DSTE) analysis in assessing the efficacy of thrombectomy as compared to standard 2D echo and cardiac magnetic resonance (CMR) data. METHODS: Two-dimensional speckle tracking echocardiography analysis was performed in 60 anterior ST-segment elevation myocardial infarction (STEMI) patients to assess global (GLS), segmental (SLS) and regional longitudinal strain (RLS). 2D echo and CMR were performed within 5 days after PCI. Patients were divided into 2 groups according to the different methods of reperfusion used: 28 pts Th-PCI and 32 pts standard PCI (S-PCI). RESULTS: Baseline clinical and angiographic characteristics, 2D echo, and DE-CMR data before and after PCI were similar in the 2 groups, except for microvascular obstruction (MVO), significantly lower (P = 0.001) in Th-PCI group. Conversely, GLS was significantly higher in Th-PCI group (P < 0.001), and in particular in the subset of patients without MVO (P = 0.012). RLS was also significantly higher in Th-PCI group (P = 0.001). GLS significantly correlates with infarct size, (R = 0.47; P = 0.03) and MVO (R = 0.69, P = 0.001). Finally, SLS was significantly lower in the DE segments (P < 0.001). CONCLUSIONS: Patients treated with Th-PCI had a more preserved microvascular integrity resulting in a better myocardial longitudinal deformation. 2DSTE analysis adds significant information on the efficacy of thrombus aspiration as compared to standard echocardiography and it is closely related to the extent of microvascular damage.

A case of transient constrictive pericarditis after COVID-19.

Cardiovascular disorders have been associated with coronavirus disease 2019 (COVID-19). Here, we describe a case of transient constrictive pericarditis after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A few days following SARS-CoV-2 pneumonia, a 55-year-old man developed fever and chest pain exacerbated by movement and breathing, and acute pericarditis was diagnosed. After two weeks, he progressively developed fatigue, dyspnea, peripheral edema, ascites, and bilateral pleural effusion. The patient's clinical condition, as well as imaging findings, were consistent with a diagnosis of constrictive pericarditis. Therefore, medical therapy was optimized with a progressive clinical improvement. Follow-up echocardiography showed full recovery of pericardial constriction. Transient constrictive pericarditis, defined as a reversible pericardial constriction followed by resolution, can be spontaneous or treatment-related, and represents an uncommon complication of acute pericarditis. Although a broad spectrum of COVID-19-related cardiac diseases (including pericarditis) have already been reported, transient pericardial constriction after SARS-CoV-2 infection has not previously been described. Learning objective: Transient constrictive pericarditis is an uncommon complication of acute pericarditis that can occur sporadically after viral acute pericarditis. We hereby describe a case of coronavirus disease 2019-related transient pericardial constriction. This case confirms that pericardial constriction after viral acute pericarditis often resolves with medical therapy.

Atrial fibrillation and sport: need for monitoring.

Historically, regular exercise contributed to reduce the arrhythmic burden and improve cardiovascular outcomes in the general population. However, a heightened risk of atrial fibrillation (AF) seems to occur mainly amongst endurance athletes. The exact mechanisms are not fully elucidated, but dynamic interactions between electro-anatomical changes induced by exercise, the autonomic system, variable triggers, along individual genetic predisposition are the main contributors to AF development in athletes. The type and training load of sports are also crucial in determining the arrhythmogenic milieu predisposing to AF insurgence and perpetuation. Moreover, a sex difference seems to influence an increased risk of AF only in men undergoing strenuous exercise, whereas women appear protected even during more vigorous training. In the absence of solid evidence, the advent of modern technologies could help to monitor and deep investigate the peculiar aspects of AF in these athletes. This review aims to describe the pathophysiology, diagnosis, and management of AF in athletes, shedding light on possible future strategies to face AF in this population.

Sodium-glucose co-transporter-2 inhibitors eligibility in patients with heart failure with reduced ejection fraction.

BACKGROUND: The sodium-glucose co-transporter-2 (SGLT2) inhibitors dapagliflozin and empagliflozin have been demonstrated to reduce adverse cardiovascular outcomes in patients with heart failure with reduced ejection fraction (HFrEF). Limited data are available characterizing the generalizability of SGLT2 inhibitors treatment in the clinical practice. The aim of the study was to evaluate the proportion of outpatients with HFrEF that would be eligible for SGLT2 inhibitors in a contemporary real-world population. METHODS: We retrospectively evaluated patients with chronic stable HFrEF followed-up at the HF outpatient clinic of our institution. Patients' eligibility was assessed according to the entry criteria of DAPA-HF (dapagliflozin) and EMPEROR-Reduced (empagliflozin) trials and to US Food and Drug Administration (FDA) label criteria (only dapagliflozin). RESULTS: A total of 441 HFrEF patients was enrolled. According to the major inclusion and exclusion criteria from DAPA-HF and EMPEROR-Reduced trials, 198 (45%) patients would be candidates for initiation of both dapagliflozin and empagliflozin, 61 (14%) would be eligible only to dapagliflozin and 23 (5%) only to empagliflozin, without significant differences between diabetic and non-diabetic patients (p = 0.23). Among patients not suitable for gliflozins treatment (159 patients; 36%), the major determinant of ineligibility was the failure to achieve the predefined NT-proBNP inclusion threshold. Excluding NTproBNP as per FDA label criteria, dapagliflozin eligibility increased to 86%. CONCLUSIONS: In our real-world analysis a large proportion of HFrEF patients would be candidates for initiation of SGLT2 inhibitors, supporting its broad generalizability in clinical practice. This would be expected to reduce morbidity and mortality in eligible patients.

Ivabradine versus bisoprolol in the treatment of inappropriate sinus tachycardia: a long-term follow-up study.

AIM: The aim of our study was to compare ivabradine versus bisoprolol in the short-term and long-term treatment of inappropriate sinus tachycardia. METHODS: From this prospective, parallel-group, open-label study, consecutive patients affected by inappropriate sinus tachycardia received ivabradine or bisoprolol and were evaluated with Holter ECG, ECG stress test, European Heart Rhythm Association score and Minnesota Living With Heart Failure Questionnaire at baseline, after 3 and 24 months. RESULTS: Overall, 40 patients were enrolled. Baseline parameters were comparable in the ivabradine and bisoprolol subgroups. Two patients had transient phosphenes with ivabradine and two others interrupted the drug after 3 months as they planned to become pregnant. Eight individuals treated with bisoprolol experienced hypotension and weakness, which caused drug discontinuation in five of them. Ivabradine was superior to bisoprolol in reducing Holter ECG mean heart rate (HR) and mean HR during daytime at short- and long-term follow-up. Moreover, ivabradine but not bisoprolol significantly reduced Holter ECG mean HR during night-time as well as maximal and minimal HR and significantly increased the time duration and maximal load reached at ECG stress test. The quality of life questionnaires significantly improved in both subgroups. CONCLUSION: This study suggests that ivabradine is better tolerated than bisoprolol and seems to be superior in controlling the heart rate and improving exercise capacity in a small population of individuals affected by inappropriate sinus tachycardia during a short-term and long-term follow-up.