Cardiac assessment accuracy by students using palm-held ultrasound compared to physical examination by skilled cardiologists: a pilot study with a single medical student.

BACKGROUND: Despite the inherent limitations of the traditional cardiac physical examination (PE), it has not yet been replaced by a more accurate method. METHODS: We hypothesized that a single medical student, following a brief training (two academic hours) with the PHU, will better identify abnormal findings including significant valvular diseases, pericardial effusion and reduced LV function, as compared to PE performed by senior cardiologists and cardiology fellows. Transthoracic echocardiogram (TTE) served as a 'gold standard'. RESULTS: Seventy-seven patients underwent TTE, of them 64 had an abnormal finding. PE identified 34 patients with an abnormal finding compared to 52 identified by PHU (p < 0.05). Ejection fraction (EF) below 50% was found in 35 patients on TTE, compared to only 15 and 6 patients by PE and PHU, respectively (p < 0.05). There was no difference in valvular dysfunction diagnosis detected by PE and medical students using PHU. The overall accuracy of PHU compared to TTE was 87%, with a specificity of 94% and sensitivity of 64% (the low sensitivity was driven mainly by EF assessment), whereas the accuracy of PE was 91%, specificity 91% and sensitivity 38% (again driven by poor EF assessment). CONCLUSIONS: Cardiac evaluation using PHU by a single medical student was able to demonstrate similar accuracy as PE done by cardiac specialists or cardiology fellows. The study topic should be validated in future studies with more medical students with a very brief training of cardiac ultrasound.

The effects of a multi-day cross-country mountain bike race on myocardial function, stress, inflammation and cardiac biomarkers in amateur master athletes.

This study aimed to examine the effects of a multi-day mountain bike race on amateur master athlete cyclists (AMA). AMA (50±5 years) completed 2 stages of a mountain bike race. Six weeks before racing, echocardiography, blood and maximal cardiopulmonary exercise tests (CPET) were performed. One hour after completion of each race stage, echocardiography measurements were taken and blood was sampled for stress, inflammatory and cardiac biomarkers. Main outcomes of the CPET were maximal oxygen consumption (VO2max) 50.7±6.5 ml/kg/min; maximal power 328±45 Watt and ventilatory threshold of 86%VO2max. Participants completed 95.7km with an elevation of 1650m on the first day, and 92.5km with an elevation of 1410m on the second day, with completion times of 357±42 and 390 ±43 minutes, respectively. After racing, increases in Creatine Phosphokinase and C-reactive protein (3-6 fold) (p<0.001), Troponin I (4-fold) (p<0.001) and N-terminal pro-brain natriuretic peptide (NT-Pro BNP) (4-7-fold) (p<0.001) were noted, with a reduction in the myocardial global work index of 17-24% (p<0.001). No correlations were found between Troponin I or NT-Pro BNP and myocardial global work index. Highly aerobically fit AMA participating in demanding endurance events demonstrated elevated stress, inflammatory, muscle damage and cardiac biomarkers. However, these changes did not significantly correlate with altered cardiac function. In addition, consecutive days of demanding prolonged cycling exercise did not have cumulative effects on the measured myocardial parameters.

The Risk of Left Atrial Appendage Thrombus in Patients With Atrial Flutter Versus Atrial Fibrillation.

Objective: Patients with atrial fibrillation (AF) are at increased risk of thromboembolic events originating mainly from left atrial appendage thrombus (LAAT). Patients with atrial flutter (AFL) are treated with anticoagulation based on the same criteria as patients with AF. However, whether patients with AFL have similar thromboembolic risk as AF is unclear. In the current study we aimed to estimate the prevalence of LAAT in patients with AFL undergoing trans-esophageal echocardiography (TEE). Methods/results: We included 438 patients (404 with AF and 34 with AFL) scheduled for TEE to rule out LAAT before cardioversion (patients who reported no or inadequate anticoagulation before cardioversion). Demographic and echocardiographic data were compared between patients with and without LAAT. Despite a similar CHA2DS2-VASC score (3.8 ± 1.3 vs 3.4 ± 1.5 in the AF and AFL groups, respectively, P = .09), LAAT was documented in 12 (2.8%) in the AF group and in no patient in the AFL group (P < .0001). Conclusion: Based on our results and previous studies, it seems reasonable to re-evaluate the need for oral anticoagulation in specific populations with AFL such as those with solitary AFL (without a history of AF episodes) undergoing successful ablation and in those with low CHA2DS2-VASC score.

Outcomes of patients with acute coronary syndrome according to COVID-19 vaccination status.

BACKGROUND: COVID-19 vaccination has been associated with reduced risk of acute coronary syndrome (ACS); however, several studies have reported cardiovascular complications following vaccination. We aimed to investigate the effect of COVID-19 vaccination status on the treatment and outcome of ACS patients. METHODS: The study was based on the 2021 Acute Coronary Syndrome Israeli Survey. Patients were stratified into two groups according to COVID-19 vaccination status, vaccinated compared to unvaccinated. Patients who had received at least 2 vaccination doses up to 1 week prior to ACS hospitalization were considered vaccinated. The primary endpoint was 1-year all-cause mortality. RESULTS: A total of 1261 patients with ACS were included, of whom 990 (78.5%) were vaccinated. Vaccinated patients were older and less frequently smokers. There were no significant differences in coronary reperfusion rates and treatment with guideline-based medical therapy during hospital stay and at discharge. The primary endpoint of 1-year all-cause mortality occurred in 38 (3.8%) and 14 (5.2%) patients in the vaccinated and unvaccinated groups respectively (P = 0.42). 30-day MACE occurred in 94 (9.5%) in the vaccinated patients compared to 31 (11.5%) in the unvaccinated group (P = 0.39). These results remained similar following adjustment for confounders. CONCLUSION: There was no association between COVID-19 vaccination status and the outcomes of patients with ACS. Our findings provide support for the cardiovascular safety of COVID-19 mRNA vaccines in patients at high cardiovascular risk.

Temporal Trends in the Prevalence, Treatment and Outcomes of Patients with Acute Coronary Syndrome at High Bleeding Risk.

(1) Background: High bleeding risk is associated with adverse outcomes in ACS patients. We aimed to evaluate temporal trends in treatment and outcomes of ACS patients according to bleeding risk. (2) Methods: Included were ACS patients enrolled in ACSIS surveys. Patients were divided into three groups according to enrolment period: early (2002−2004), mid (2006−2010) and recent (2012−2018). Each group was further stratified into three subgroups according to CRUSADE bleeding risk score. The primary endpoints were 30-day MACE and 1-year all-cause mortality. (3) Results: Included were 13,058 ACS patients. High bleeding risk patients were less frequently treated with guideline-based medications and coronary revascularization. They also had higher rates of 30-day MACE and 1-year all-cause mortality regardless of the enrollment period. Among patients enrolled in early period, 30-day MACE rates were 10.8%, 17.5% and 24.3% (p < 0.001) and 1-year all-cause mortality rates were 2%, 7.7% and 23.6% (p < 0.001) in the low, moderate and high bleeding risk groups, respectively. Among patients enrolled in mid period, 30-day MACE rates were 7.7%, 13.4% and 23.5% (p < 0.001) and 1-year all-cause mortality rates were 1.5%, 7.2% and 22.1% (p < 0.001) in low, moderate and high bleeding risk groups, respectively. For patients enrolled in recent period, 30-day MACE rates were 5.7%, 8.6% and 16.2%, (p < 0.001) and 1-year all-cause mortality rates were 2.1%, 6% and 22.4%, (p < 0.001) in low, moderate and high bleeding risk groups, respectively. These differences remained significant following a multivariate analysis. (4) Conclusions: The percentage of patients at high bleeding risk has decreased over the last years. Despite recent improvements in the treatment of ACS patients, high bleeding risk remains a strong predictor of adverse outcomes.

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.

The value of three-dimensional echocardiography in the diagnosis and management of ruptured sinus of Valsalva aneurysm: a case report.

BACKGROUND: A sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly. Most SVA's rupture into right heart chambers and can be classified using the modified Sakakibara classification according to the site of rupture. Transoesophageal echocardiography (TOE) is a useful diagnostic tool and aides in treatment planning in patients with congenital anomalies in emergency situations. Three-dimensional TOE (3D-TOE) provides additional value over standard TOE. CASE SUMMARY: A 38-year-old man with a reported history of ventricular septal defect (VSD) presented to the emergency department complaining of chest pain and epigastric pain lasting several days. Physical examination revealed a continuous heart murmur and signs of acute heart failure. A 3D-TOE revealed an SVA rupture into the right ventricle (Type IIIv) but no evidence of a VSD. Urgent aortic valve replacement with correction of the ruptured SVA was performed. Neither a VSD nor signs of endocarditis were found during surgical exploration. The patient was discharged on post-operative Day 5 in good condition. DISCUSSION: A sinus of Valsalva aneurysm is a rare cardiac condition. Ventricular septal defect, bicuspid aortic valve, or aortic valve regurgitation may coexist with SVA. Xin-Jin et al. classified a ruptured SVA into five types according to the site of rupture. Transoesophageal echocardiography is an important tool for diagnosis, anatomical description, and typing of the ruptured SVA. Sinus of Valsalva aneurysm may be misdiagnosed as a VSD, as was the case in our patient, and 3D-TOE can be instrumental for providing both correct diagnosis and critical surgical planning.

Pericarditis and pericardial effusion in acute ST-elevation myocardial infarction in the thrombolytic era.

BACKGROUND: Myocardial infarction-associated pericarditis is a common cause of chest pain following MI, its frequency depending on how it is defined. OBJECTIVES: To investigate the incidence of acute pericarditis and pericardial effusion in the acute phase of ST-elevation MI treated with thrombolytic therapy. METHODS: The study group comprised 159 consecutive patients fulfilling the criteria for acute MI who were admitted to our department during 18 months. Infarct-associated pericarditis was defined as the finding of a pericardial friction rub, a typical pleuropericardial pain, or both. All patients underwent physical examination of the cardiovascular system four times daily for 7 days, as well as daily electrocardiogram and echo Doppler examinations. RESULTS: Fourteen patients (8.8%) developed a friction rub and 11 patients (6.9%) had a mild pericardial effusion. Six patients (4.0%) had both a friction rub and pericardial effusion. Two patients had a friction rub for more than 7 days. Pleuropericardial chest pain was present in 31 patients (19.5%) but only 7 of them had a friction rub. The in-hospital mortality rate was 1.3% and no mortality was observed in the acute pericarditis group. CONCLUSION: The incidence of signs associated with acute pericarditis was lower in MI patients treated with thrombolysis, compared with historical controls, when a friction rub and/or pericardial effusion was present. There was no significant reduction in the incidence of pleuropericardial chest pain.