Diagnosis and management of silent coronary ischemia in patients undergoing carotid endarterectomy.

BACKGROUND: Coronary artery disease is the primary cause of death in patients with carotid artery disease and silent ischemia is a marker for adverse coronary events. A new noninvasive cardiac diagnostic test, coronary computed tomography-derived fractional flow reserve (FFRCT) can reliably identify ischemia-producing coronary stenosis in patients with coronary artery disease and help to select patients for coronary revascularization. The purpose of this study is to determine the prevalence of silent coronary ischemia in patients undergoing carotid endarterectomy (CEA) and to evaluate the usefulness of FFRCT in selecting patients for coronary revascularization to decrease cardiac events and improve survival. METHODS: Patients with no cardiac history or symptoms admitted for elective CEA were enrolled in a prospective, open-label, institutional review board-approved study and underwent preoperative coronary computed tomography angiography (CTA) and FFRCT with results available to physicians for patient management. Lesion-specific coronary ischemia was defined as FFRCT of 0.80 or less distal to a focal coronary stenosis with an FFRCT of 0.75 or less, indicating severe ischemia. Primary end point was incidence of major adverse cardiovascular events (MACE; defined as cardiovascular death, myocardial infarction, or stroke) at 30 days and 1 year. RESULTS: Coronary CTA and FFRCT was performed in 90 CEA patients (age 67 ± 8 years; male 66%). Lesion-specific coronary ischemia was found in 51 patients (57%) with a mean FFRCT of 0.71 ± 0.14. Severe coronary ischemia was present in 39 patients (43%), 26 patients had multivessel ischemia, and 5 had left main disease. CEA was performed as scheduled in all patients with no postoperative deaths or myocardial infarctions. There were no MACE events at 30 days. After recovery from surgery, 36 patients with significant lesion-specific ischemia underwent coronary angiography with coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting) in 30 patients (33%). Survival at 1 year was 100% and freedom from MACE was 98%. CONCLUSIONS: Patients undergoing CEA have a high prevalence of unsuspected (silent) coronary ischemia, which may place them at risk for coronary events. Preoperative diagnosis of silent ischemia using CTA and FFRCT can identify high-risk patients and help to guide patient management. Selective postoperative coronary revascularization of patients with significant ischemia may decrease the risk of cardiac events and improve survival, but longer follow-up is needed and prospective, controlled trials are indicated.

Medical history of coronary artery disease and time to electrocardiogram in the emergency department: a real-life, single-center, retrospective analysis.

BACKGROUND: Timely acquisition of 12-lead Electrocardiogram (ECG) in the emergency department (ED) is crucial and recommended by current guidelines. OBJECTIVES: To evaluate the association of medical history of coronary artery disease (hCAD) on door-to-ECG time in the ED. METHODS: In this single center, retrospective cohort study, patients admitted to ED for cardiac evaluation were grouped according to hCAD and no hCAD. The primary outcome was door-to-ECG time. A multivariate analysis adjusted for the cofounders sex, age, type of referral and shift was performed to evaluate the association of hCAD with door-to-ECG time. RESULTS: 1101 patients were included in this analysis. 362 patients (33%) had hCAD. Patients with hCAD had shorter door-to-ECG time (20 min. [Inter Quartile Range [IQR] 13-30] vs. 22 min. [IQR 14-37]; p < 0.001) when compared to patients with no hCAD. In a multivariable regression analysis hCAD was significantly associated with a shorter door-to-ECG time (- 3 min [p = 0.007; 95% confidence Interval [CI] - 5.16 to - 0.84 min]). CONCLUSION: In this single center registry, hCAD was associated with shorter door-to-ECG time. In patients presenting in ED for cardiac evaluation, timely ECG diagnostic should be facilitated irrespective of hCAD.

Assessment of cardiac function and electrocardiographic findings in patients with Wilson's disease.

BACKGROUND: This study evaluated cardiac function using tissue Doppler echocardiography and assessed electrocardiographic findings in children diagnosed with Wilson's disease. METHOD: Asymptomatic patients with a diagnosis of Wilson's disease (n = 43) were compared to healthy controls (n = 37) that were age and gender matched. RESULTS: The standard electrocardiographic and conventional echocardiographic examinations were similar in both groups. The left ventricular ejection fraction, shortening fraction, and diastolic function were not significantly different between the two groups. The Tei index for mitral lateral, mitral septal, tricuspid lateral, tricuspid septal, and inter-ventricular septum on tissue Doppler echocardiography was higher in the patient group, yet it did not reach statistical significance. Mitral lateral and septal systolic annular velocity values were significantly lower in the patient group when compared to the control group (p = 0.02 and 0.04, respectively). Also, mitral lateral and septal isovolumetric contraction time values were higher in the patient group (p = 0.04). Although the left ventricular values were not significantly different, relative left ventricular wall thickness was higher in the patient group when compared to the control group, and concentric remodelling in the left ventricle was found in 7 (16%) of 42 patients. QT interval (p = 0.02) and P-wave dispersion values (p = 0.04) were significantly higher in the patient group compared to the control group, and these tend to predict arrhythmias. CONCLUSION: Our study based on the tissue Doppler echocardiography assessment indicated a subclinical systolic, rather than diastolic, dysfunction in the myocardium with increased QT interval and P-wave dispersion, despite the young age of the patients and short disease duration.

Establishment of methodology for non-invasive electrocardiographic measurements in turtles and tortoises.

The lack of knowledge on how to perform species-specific electrocardiographic (ECG) measurements in chelonians makes ECG evaluations difficult. The aim of this study was to establish non-invasive methods for ECG sample collection in different species of non-anaesthetised chelonians, focusing on adhesive and clamp electrodes. A total of 72 turtles and tortoises from 20 species and various sizes were used for the study. Body weight ranged from 32 g to 65 kg. From the aspect of specimen fixation, dorsal recumbency proved to be the most useful. Both adhesive and clamp electrodes yielded results when applied to the plastron and skin folds. Pre-emptive results suggest an indirect correlation with plastron thickness, the presence of a hinge, habitat and measurable ECG wave amplitude. ECG wave recordings are more likely in aquatic chelonians and species with a hinge. With size the plastron also thickens, making wave detection impossible. ECG waves were detected in 41 of the 72 specimens, complete PQRST complexes in 19 animals, with the rest showing absent P waves in all leads. ECG amplitudes were below 1 mV, with an average of 0.15 mV R wave amplitude.

A new protocol for a single-stage combined cardiopulmonary and echocardiography exercise test: a pilot study.

Aims: The value of cardiopulmonary exercise testing (CPET) and exercise stress echocardiography (ESE) in managing cardiac disease is well known, but no standard CPET-ESE protocol is currently recommended. This pilot study aims to compare feasibility and cardiac function responses between a new high-intensity single-stage combined test (CPET-hiESE) and a standard maximal ESE (smESE). Methods and results: After screening and maximal CPET, all volunteers (n = 21) underwent three ESE modalities: (i) based on the gas exchange threshold (hiESE-GET, 40% of peak-GET, 6 min), (ii) based on heart rate (HR) (hiESE-HR, 80% of peak HR, 6 min), and (iii) smESE (85% of predicted peak HR for age, 3 min). Speckle tracking echocardiography (STE) and tissue Doppler imaging (TDI) were measured at each step. There was superior image quality and data completeness for the right ventricle strain for both hiESE modalities compared with smESE (71.4 and 76.2 vs. 42.9%, P = 0.07). Left ventricular STE data completeness was similar for all three conditions. Despite systematically higher HR, work rate and levels of exertion in the smESE compared with hiESE, STE and TDI parameters were not systematically different. Concordance correlation coefficients ranged from 0.56 to 0.88, lowest for strain rate parameters and mean difference from -0.34 to 1.53, highest for TDI measurements. Conclusion: The novel CPET-hiESE protocol allowed for better data completeness, at lower levels of exertion compared with smESE, without systematically different cardiac reserve measurements in healthy participants. This single-stage protocol can be individualized to clinical populations, which would provide practical advantages to standard testing.

Early Cardiac Evaluation, Abnormal Test Results, and Associations with Outcomes in Patients with Acute Brain Injury Admitted to a Neurocritical Care Unit.

Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF < 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p < 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th-50th quartile (aOR 1.65 [1.10-2.47]), troponin 50th-75th quartile (aOR 1.79 [1.22-2.63]), troponin >75th quartile (aOR 2.18 [1.49-3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28-6.40]), BNP >75th quartile (aOR 4.54 [2.09-9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF < 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th-75th quartile (aOR 1.77 [1.14-2.73]), troponin >75th quartile (aOR 1.81 [1.18-2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort.

A Rare Case of Severe Mitral Stenosis Presenting As Cardiogenic Shock.

We report a case of severe mitral stenosis (MS) in a 58-year-old female from Guyana. Though rheumatic MS continues to be less prevalent in third-world countries, it poses a significant threat as far as morbidity and mortality are concerned. The modern definition of "Third World" is used to classify countries that are poor or developing. Countries that are part of the "third world" are generally characterized by (1) high rates of poverty, (2) economic and/or political instability, and (3) high mortality. The standard method of diagnosing MS in patients has been established as transthoracic echocardiograms (TTE), along with pertinent historical and physical exam findings. Specifically, with TTE, criteria include a mitral valve area ≤1.5 cm2, severe left atrial enlargement, and elevated pulmonary artery systolic pressure >50 millimeters of mercury (mmHg). Once diagnosed with severe MS, treatment options for patients range from non-surgical percutaneous mitral balloon valvuloplasty to surgical mitral valve commissurotomy. In our case, she was a 58-year-old female with a past medical history of seizures of unknown etiology, not on any home medication regimen, presenting to the emergency department with shortness of breath, malaise, weight loss, and bilateral lower leg edema. Vitals were significant for tachycardia at 153 bpm, tachypnea at 24 breaths per minute, and saturating at 96% on room air. On the physical exam, there was an irregularly irregular rhythm, bilateral crackles at the bases, right upper quadrant tenderness to palpation, bilateral pitting edema, and no calf tenderness. Lab findings were significant for elevated brain natriuretic peptide, but three electrocardiograms were performed in the emergency department, all confirming the new onset of atrial fibrillation. A CT angiogram of the chest was performed, which ruled out pulmonary embolus but additionally found marked reflux of contrast noted within the inferior vena cava and hepatic veins, along with right atrial dilation reflective of right heart strain; additionally, mitral valve calcifications were noted. The cardiologist on duty confirmed the diagnosis using point-of-care ultrasound (POCUS) followed by TTE; the patient was rapidly transferred to a hospital with appropriate services for surgical management within the same day of arrival at the emergency department. This case highlights the importance of bedside POCUS as an additional diagnostic tool for cardiologists, along with pertinent history, physical examination findings, and laboratory findings. Proper utilization of POCUS can allow for the immediate diagnosis of severe pathologies and prevent the delay of appropriate treatment, as seen in our case. Wider adoption of POCUS practices as a part of the general initial evaluation of patients has not yet been recommended by the American Heart Association but can offer clinical benefit in morbidity/mortality with expedited progression to appropriate treatment.

Challenges and Successes in Introducing Coronary CT Angiography in an Emergency Medicine-Run Observation Unit.

This study was designed to analyze the departmental changes in transitioning the Emergency Department (ED)-run Observation Medicine Unit's routine noninvasive cardiac evaluation from the traditional standard-of-care procedures to coronary computed tomography angiography (CCTA).  While the routine use of CCTA for the evaluation of chest pain has been deemed feasible and safe, provider confidence appears apprehensive, and ordering patterns appear reluctant to change.  We conducted a retrospective analysis of data from two risk-matched cohorts of ED patients who presented with symptoms suggestive of acute coronary syndrome (ACS) but without ischemic electrocardiogram (ECG) changes or positive troponin. Endpoints included length of stay, major adverse cardiovascular event (MACE) rates at 28 days, recidivism rate, and downstream findings on coronary catheterization.  The adoption of CCTA led to a significant reduction in the length of stay for patients in the ED-run Observation Medicine Unit. Provider and nursing education initiatives were crucial in overcoming initial resistance and improving the implementation of CCTA. Post-education, there was a marked increase in the volume of CCTA performed and a decrease in the length of stay, enhancing overall departmental throughput.  The results suggest that CCTA offers a reliable and efficient diagnostic alternative to traditional noninvasive tests, with high diagnostic accuracy contributing to faster decision-making and reduced need for invasive procedures. Continuous education for providers and nursing staff was essential to ensure adherence to the new protocol and improve clinical outcomes.  Transitioning to CCTA for routine noninvasive cardiac evaluation in the ED-run Observation Medicine Unit demonstrated significant efficiency and diagnostic accuracy benefits. Successful implementation requires targeted educational efforts to ensure competency and confidence among healthcare providers. The findings support the integration of CCTA into standard clinical practice for the evaluation of chest pain in the emergency setting, with future research needed to validate these results in broader patient populations and assess long-term outcomes.

Normal echocardiographic and radiographic reference values for crab-eating fox (Cerdocyon thous) anesthetized with ketamine and midazolam.

The cardiac evaluation of wild animals is still a wide and largely unknown field for several species. Therefore, through complimentary examinations such as radiography, echocardiography and serum troponin levels, this study aimed at describing the values observed in 12 crab-eating foxes (Cerdocyon thous) anesthetized with a combination of intramuscular ketamine and midazolam. Thus, through complementary exams such as radiography, echocardiography and serum troponin levels, the aim of this study was to describe the cardiac values in 12 wild foxes (C. thous) anesthetized with an intramuscular injection of ketamine and midazolam. After anaesthetization, the radiographic, echocardiographic and immunoenzymatic reference values for the 12 males in the sample group were determined. Compared with those in domestic canids, there was a decrease in the sizes of the septum, wall and left ventricular cavity as well as decreases in the transmitral blood flow velocity indices, correlated with preserved serum cardiac troponin (cTnI) levels. Thus, M-mode echocardiography proved to be safer, with results that were comparative to those for other species of wild canids with indexed values. In addition, when evaluating the systolic function and segmentary contractions, the anesthetic combination did not have any effects on the results of complementary examinations performed in crab-eating foxes (C. thous) included in this study.

The prognostic value of pre-operative coronary evaluation in kidney transplanted patients.

Aims: Non-invasive coronary assessment using single-photon emission computerized tomography (SPECT) testing for potential cardiac ischemia is an essential part of the evaluation of kidney transplant candidates. We aimed to examine the prognostic value of preoperative SPECT test results in kidney transplanted patients. Methods and results: We retrospectively analyzed the pre-surgical nuclear SPECT test results in a registry of kidney transplanted patients. Follow-up at 1 month and 1 year recorded major adverse cardiac events (MACE) including non-fatal myocardial infarction, all-cause mortality and hospitalization due to cardiovascular disease following the renal transplantation. Of 577 patients available for analysis, 408 (70.9%) patients underwent nuclear SPECT test pre-transplant and 83 (20.3%) had abnormal results with either evidence of ischemia or infarct. A significantly higher incidence of post-operative MACE at 1 month was evident among patients with abnormal SPECT test compared to patients with no evidence of ischemia (10.8 vs. 4.3% respectively; P = 0.019). Differences were mostly derived from significantly increased rates of myocardial infarction events (8.4 vs. 1.8%; P = 0.002). Yet, MACE rate was not statistically different at 1 year (20.5 vs. 13.1%; P = 0.88). Importantly, the prognostic impact of an abnormal SPECT was significantly attenuated for all outcomes following multivariable adjusting for conventional cardiovascular risk factors and coronary revascularization. Conclusion: Pre-surgical cardiac risk assessment of kidney transplant candidates with nuclear SPECT test was found to be predictive of post-operative MACE, yet apparently, its prognostic value was significantly attenuated when adjusted for cardiac risk factors.

The role of pre-participation cardiac evaluation in the management of an athlete with premature ventricular contraction-induced cardiomyopathy: a case report.

Background: Premature ventricular contractions (PVCs) are commonly observed during pre-participation cardiac screening in elite athletes. There is an ongoing debate about the clinical significance of PVCs in athletes and whether burden, morphology, or both should be used to differentiate benign PVCs from PVCs suggestive of cardiac disease. Case summary: A 28-year-old male athlete was evaluated as part of the pre-participation screening programme. He was asymptomatic, without specific cardiac signs and symptoms. A 12-lead electrocardiogram showed bigeminy PVCs with infundibular morphology and left ventricular outflow tract origin. Left ventricular dilatation and systolic dysfunction without valvular lesions was detected on echocardiography. Cardiac magnetic resonance imaging showed biventricular dilatation and dysfunction without evidence of myocardial fibrosis or fatty infiltration. A 48 h Holter monitoring showed 75191 PVCs (35% of total beats). Radiofrequency ablation was performed, and post-ablation assessments showed no PVCs with normalized ventricular function and dimension. Discussion: This case demonstrated that a high PVC burden of common morphology does not also represent a benign finding and requires a comprehensive evaluation to rule out any pathological condition. Furthermore, the present case highlights the critical role of pre-participation cardiac evaluation in identifying cardiac disease in asymptomatic athletes.

Clinical Risk Factors for Aortic Root Dilation in Patients with 22q11.2 Deletion Syndrome: A Longitudinal Single-Center Study.

BACKGROUND: Aortic root dilation (ARD) has been described in 22q11.2DS, even without congenital heart disease (CHD). However, the clinical implications and longitudinal course are unclear. In this study, we evaluated aortic root (AR) dimensions in 22q112.DS adolescents/adults without major intracardiac CHDs, analyzed the progression over time and investigated correlations with extracardiac comorbidities. METHODS: AR dimensions were evaluated in 74 patients, measuring the sinus of Valsalva (VS) and proximal ascending aorta (AA), using Z-score to define mild, moderate and severe degrees. Changes in AR dimensions during longitudinal echocardiographic follow-up were investigated. Phenotypic characteristics have been collected. RESULTS: Twenty-four patients (32.4%) showed ARD in terms of VS Z-score (2.43; IQR 2.08-3.01), eight (33.3%) of a moderate/severe degree. Thirteen (54.2%) had concomitant AAD (Z-score 2.34; IQR 1.60-2.85). The risk of ARD was significantly directly related to skeletal/connective tissue disorders (OR 12.82, 95% CI 1.43-115.31; p = 0.023) and inversely related to BMI (OR 0.86, 95% CI 0.77-0.97; p = 0.011). A significant increase in AR diameter's absolute value (p = 0.001) over time has been detected. CONCLUSION: Isolated ARD is common in 22q11.2DS. Although some clinical risk factors have been identified, pathogenetic mechanisms and risk of complications are undefined. Regular cardiac evaluations should be part of the 22q11.2DS follow-up, and also in non-CHDs patients, to improve long-term outcome.

Living Donor Liver Transplantation in a Cohort of Recipients With Left Ventricular Systolic Dysfunction.

Background: Data on feasibility, management, and outcomes of liver transplantation (LT) in patients with pre-existing left ventricular systolic dysfunction (LVSD), severe coronary artery disease (CAD) or cirrhotic cardiomyopathy (CCM) is scarce. Methods: We reviewed outcomes of living donor liver transplantation (LDLT) in recipients with LVSD (ejection fraction [EF] < 50%) from our series of 1946 LDLT's performed between July 2010 and July 2018. Results: LVSD was detected in 12 male patients with a mean age, BMI and MELD of 52 ± 9 years, 25 ± 5 kg/m2, and 19 ± 4 respectively. Out of these, 6 patients had CAD (2 with previous coronary artery bypass graft, 1 following recent percutaneous transluminal coronary angioplasty, 2 post myocardial infarction, 1 noncritical CAD), and 6 had CCM. The EF ranged from 25% to 45%. Ethanol was the predominant underlying etiology for cirrhosis (50%). During LDLT, 2 patients developed ventricular ectopic rhythm and were managed successfully with intravenous lidocaine. Stress cardiomyopathy manifested in 3 patients post operatively with decreased EF, of which 2 improved, while 1 needed IABP support and succumbed to multiorgan failure on 8th postoperative day (POD). Another patient died on POD30 due to septic shock. Both these patients had higher MELD scores (actual MELD), extremes of BMI (17.3and 35.8 kg/m2) and were diabetic. There were no long-term cardiac deaths. The 1-year, and 5-year survival were 75%, and 66%, respectively. Conclusion: Among potential LT recipients with LVSD, those with stable CAD and good performance status, and well optimized CCM patients may be considered for LDLT after careful risk stratification in experienced centers.

Assessment of cardiac variables using a new electrocardiography lead system in horses.

AIM: The objective of this study was to assess a new lead system method to improve electrocardiographic measurement in horses. MATERIALS AND METHODS: Twenty-two horses with an average age of 8.8±0.8 years were enrolled in this study. Horses were divided into two groups, consisting of a control group (n=11) and athlete group (n=11). Electrocardiography (ECG) and echocardiography were performed to provide information on the structure and function of the heart. Two lead systems, base apex and modified precordial leads, were used for the electrocardiogram to assess the cardiac electrophysiological functions. RESULTS: PR interval, QT interval, and QRS-T angle presented significant differences between the control and athlete groups when the modified precordial lead system was used. However, significant variations in the mean electrical axis were found when the base apex lead system was used. The modified precordial lead system resulted in more significant differences in cardiac electrophysiological parameters than the base apex lead system. In the athlete group, echocardiography showed cardiac adaptations such as increases in the left atrial and left ventricular dimensions and stroke volume and a decrease in heart rate in response to exercise and training. The observed differences in cardiac morphology and function between groups suggested differences in health performance in the athlete group. CONCLUSION: These data provided the first evidence that the modified precordial lead system improved statistical variation in ECG recording and provided the most reliable method for health screening in horses.

Duchenne muscular dystrophy: an overview to the cardiologist.

INTRODUCTION: Duchenne muscular dystrophy (DMD) is the most common form of muscular dystrophy in children, affecting approximately one in 3,500-5,000 liveborn boys. The main signs and symptoms include gait disturbances beginning in early childhood, with later onset of respiratory and cardiac function disorders, both directly affecting the prognosis. AREAS COVERED: The recent improvement of mechanical ventilation increased the mean DMD survival age; however, there has been little progress in the treatment and prevention of cardiac complications, which currently predominantly impact survival. Cardiological evaluation with imaging methods, such as echocardiography and magnetic resonance imaging, can improve the understanding and detect changes in cardiac function early. EXPERT OPINION: Close monitoring by the cardiologists and early treatment, with adequate heart disease stratification, may be the key to prolong the lives of these patients until more promising therapies are available and can predict DMD prognosis and progression more accurately. The objective of this brief review is to update the cardiologists by highlighting the most relevant aspects of treatment and follow-up, in a practical and concise way.

Rise and fall of preoperative coronary revascularization.

INTRODUCTION: About 234 million major surgical procedures are performed each year worldwide, of which >60 million surgeries are performed in the United States. Though postoperative major adverse cardiac complications are relatively low, patients with postoperative myocardial infarction have higher in-hospital mortality. Thus, comprehensive cardiac evaluations, and in some cases, elective coronary revascularizations, are performed prior to surgery with an intent to minimize these complications. In 2009, approximately 4% of all elective percutaneous coronary interventions were performed in preparation for noncardiac surgery. AREAS COVERED: We discuss relevant articles from the last 50 years regarding elective preoperative coronary revascularization prior to noncardiac surgery. EXPERT OPINION: In the early years there was an interest in preemptive revascularization to reduce postoperative cardiac events; however, subsequent studies in patients with stable coronary artery disease have mostly shown that a strategy of routine prophylactic coronary revascularization prior to noncardiac surgery does not reduce postoperative cardiac complications.

Efficacy of pre-participation cardiac evaluation recommendations among athletes participating in World Athletics Championships.

BACKGROUND: Athletes competing in athletics (track and field) at international level may be participating with underlying undiagnosed life-threatening cardiovascular conditions. Our objective was to analyse variations in pre-participation cardiac evaluation prevalence among athletes participating in two International Association of Athletics Federations (IAAF) World Athletics Championships, with regard to the human developmental level and global region of their home countries, as well as athletes' age category, gender, event group and medical insurance type. DESIGN: Cross-sectional web-based survey. METHODS: A total of 1785 athletes competing in the IAAF World Under 18 Championships Nairobi 2017 and World Championships London 2017 were invited to complete a pre-participation health questionnaire investigating the experience of a pre-participation cardiac examination. RESULTS: A total of 704 (39%) of the athletes participated. Among these, 59% (60% of women; 58% of men) reported that they had been provided at least one type of pre-participation cardiac evaluation. Athletes from very high income countries, Europe and Asia, showed a higher prevalence of at least one pre-participation cardiac evaluation. CONCLUSIONS: The prevalence of pre-participation cardiac evaluation in low to middle income countries, and the African continent in particular, needs urgent attention. Furthermore, increases in evaluation prevalence should be accompanied by the development of cost-effective methods that can be adopted in all global regions.

Ability of artificial intelligence to diagnose coronary artery stenosis using hybrid images of coronary computed tomography angiography and myocardial perfusion SPECT.

BACKGROUND: Detecting culprit coronary arteries in patients with ischemia using only myocardial perfusion single-photon emission computed tomography (SPECT) can be challenging. This study aimed to improve the detection of culprit regions using an artificial neural network (ANN) to analyze hybrid images of coronary computed tomography angiography (CCTA) and myocardial perfusion SPECT. METHODS: This study enrolled 59 patients with stable coronary artery disease (CAD) who had been assessed by coronary angiography within 60 days of myocardial perfusion SPECT. Two nuclear medicine physicians interpreted the myocardial perfusion SPECT and hybrid images with four grades of confidence, then drew regions on polar maps to identify culprit coronary arteries. The gold standard was determined by the consensus of two other nuclear cardiology specialist based on coronary angiography findings and clinical information. The ability to detect culprit coronary arteries was compared among experienced nuclear cardiologists and the ANN. Receiver operating characteristics (ROC) curves were analyzed and areas under the ROC curves (AUC) were determined. RESULTS: Using hybrid images, observer A detected CAD in the right (RCA), left anterior descending (LAD), and left circumflex (LCX) coronary arteries with 83.6%, 89.3%, and 94.4% accuracy, respectively and observer B did so with 72.9%, 84.2%, and 89.3%, respectively. The ANN was 79.1%, 89.8%, and 89.3% accurate for each coronary artery. Diagnostic accuracy was comparable between the ANN and experienced nuclear medicine physicians. The AUC was significantly improved using hybrid images in the RCA region (observer A: from 0.715 to 0.835, p = 0.0031; observer B: from 0.771 to 0.843, p = 0.042). To detect culprit coronary arteries in perfusion defects of the inferior wall without using hybrid images was problematic because the perfused areas of the LCX and RCA varied among individuals. CONCLUSIONS: Hybrid images of CCTA and myocardial perfusion SPECT are useful for detecting culprit coronary arteries. Diagnoses using artificial intelligence are comparable to that by nuclear medicine physicians.

Assessment and Management of Hypotension in the Elderly Patient.

INTRODUCTION: Elderly patients often present to the emergency department (ED) with nonspecific signs of infection and excessive fluid loss, with limited research into their management. The purpose of this audit was to assess the initial management of hypotensive elderly patients in the ED: observations within 15 min, fluid challenge within 1 h, time to assessment by a physician, and initial management of septic shock. SUBJECTS AND METHODS: Online patient systems were reviewed to find 40 patients >65 years old who were hypotensive (systolic blood pressure <100 mmHg or diastolic blood pressure <60 mmHg) in the ED between 1st October 2015 and 16th November 2015. This data were used to perform a retrospective audit to assess their management. RESULTS: Forty hypotensive patients were identified with an average age of 79.6, with 55% being male. Eighty-three percent had their observations recorded within 15 min of presentation, 35% had their observations repeated within 1 h, and 35% were fluid challenged within 1 h. Nearly 60% patients were reviewed within 1 h by a physician. About 33% patients were in septic shock with 41% receiving IVF within 1 h, and all 40 patient receiving antibiotics. DISCUSSION: The majority of patients had their observations performed within 15 min; however, a smaller percentage was fluid challenged within 1 h with their observations rechecked. Despite a sepsis pathway, hypotensive patients were still not receiving fluids within the hour. CONCLUSION: Developing a fast-track protocol for hypotensive elderly patients in the ED could improve initial rehydration management and ensure observations are reported in a timely manner.

Cardiac Evaluation and Monitoring of Patients Undergoing Noncardiac Surgery.

Surgical management of disease has a tremendous impact on our health system. Millions of people worldwide undergo surgeries every year. Cardiovascular complications in the perioperative period are one of the most common events leading to increased morbidity and mortality. Although such events are very small in number, they are associated with a high mortality rate making it essential for physicians to understand the importance of perioperative cardiovascular risk assessment and evaluation. Its involves a detailed process of history taking, patient's medical profile, medications being used, functional status of the patient, and knowledge about the surgical procedure and its inherent risks. Different risk assessment tools and calculators have also been developed to aid in this process, each with their own advantages and limitations. After such a comprehensive evaluation, a physician will be able to provide a risk assessment or it may all lead to further testing if it is believed that a change in management after such testing will help to reduce perioperative morbidity and mortality. There is extensive literature on the significance of multiple perioperative testing modalities and how they can change management. The purpose of our review is to provide a concise but comprehensive analysis on all such aspects of perioperative cardiovascular risk assessment for noncardiac surgeries and provide a basic methodology toward such assessment and decision making.