The effect of the COVID-19 pandemic on acute coronary syndrome hospitalizations and out-of-hospital cardiac arrest in Greece.

OBJECTIVES: After coronavirus disease 2019 (COVID-19) outbreak, striking decreases in the number of hospital admissions for acute coronary syndromes (ACSs) and rises in rates of out-of-hospital cardiac arrest (OHCA) have been noted. STUDY DESIGN: This is an analysis of prospectively collected data from a cardiology department in a single, large volume hospital of the National Health System of the Metropolitan area of Athens. METHODS: We investigated the numbers of OHCA and hospital admissions for ACS during a 1-year period and made comparisons between the pre-COVID-19 and the COVID-19 outbreak periods. RESULTS: One hundred and eighty five patients were admitted during the total period of observation with the diagnosis of ACS. The mean monthly number of admissions for ACS for the pre-COVID-19 era was significantly higher than that for the post-COVID-19 era (20.1 ± 7.8 vs 8.8 ± 6.5 admissions, Ρ = 0.024). The cases of OHCA which were transferred to our emergency room department by emergency medical services during the same period were nominally lower in the prepandemic compared with the postpandemic era (1.9 ± 1.7 vs 4.0 ± 4.6, P = 0.28). CONCLUSIONS: The present study provides hints on the potential unintended consequences of the pandemic in countries characterized by fewer COVID-19 cases and fatalities but prompt measures of social contact restrictions and lockdown.

Thermal heterogeneity of carotid arteries as a novel biomarker in patients with diabetes mellitus assessed for coronary artery disease.

BACKGROUND: Vulnerable plaque plays crucial role in prognosis of diabetes mellitus (DM). Microwave radiometry (MWR) allows measurement of the temperature of tissues, thus indirectly reflecting inflammation, a characteristic of atherosclerotic plaque stability. Aim of the study was to evaluate the relation of carotid artery inflammation with glycemic control and presence of coronary artery disease (CAD). METHODS: We included 112 patients (65 ±â€¯9 years, 30 ±â€¯5 kg/m2, 74 DM and 38 non-DM, with a 2:1 ratio) that were referred for scheduled coronary angiography (CA) for evaluation of their clinical condition. We measured thermal heterogeneity, expressed as temperature difference (ΔT) along each carotid artery, with MWR and maximum temperature difference between the 2 carotid arteries (ΔΤmax). RESULTS: Patients with DM presented higher ΔTmax comparing to patients without DM (0.91 ±â€¯0.29 vs 0.71 ±â€¯0.25 °C, p < 0.001). Glycaemia over time was associated with thermal heterogeneity of carotids (HbA1c: <6.5: 0.78 ±â€¯0.23, HbA1c: 6.5-7: 0.87 ±â€¯0.24, HbA1c: 7-8: 0.99 ±â€¯0.30, HbA1c: >8: 1.15 ±â€¯0.35 °C, p = 0.003). Patients with CAD presented higher ΔΤmax comparing to patients with normal CA (0.93 ±â€¯0.24 vs 0.68 ±â€¯0.25 °C, p < 0.001) and patients that underwent coronary revascularization presented higher ΔTmax (0.95 ±â€¯0.25 vs 0.76 ±â€¯0.26 °C, p < 0.001). A ΔTmax ≥ 0.9 (received by ROC analysis) was an independent predictor for revascularization in DM patients (odds ratio 3.29, 95% CI: 1.07-10.16; p = 0.039) when adjusted for sex, age and the established risk factors of CAD. CONCLUSION: Local inflammatory activation of carotid arteries is more pronounced in patients with DM and is associated with the glycemic control. Carotids' thermal heterogeneity is associated with need for revascularization supporting its predictive value in DM patients assessed for CAD.

Association between serum cystatin C, monocytes and other inflammatory markers.

BACKGROUND: Cystatin C is a marker of renal function that appears to be associated with inflammation. The aim of the present study was to investigate whether there is any relationship between cystatin C, total and differential leukocyte count and other inflammatory markers. METHODS: Cystatin C, creatinine, high sensitivity C-reactive protein (hs-CRP), haptoglobin, ferritin, serum albumin, glucose, total cholesterol, HDL and triglycerides together with total and differential leukocyte count were determined in 490 adults (46 ± 16 years, 40% men) who underwent a typical health examination. Glomerular filtration rate was estimated by the simplified Modification of Diet in Renal Disease formula. Anthropometric and lifestyle characteristics were also recorded. RESULTS: After adjustment for demographic risk factors, comorbid health conditions and renal function, a positive and independent relationship of serum cystatin C levels with peripheral monocyte blood count (regression coefficient ± SE: 12 ± 3.38, P < 0.001) and white blood count (0.616 ± 0.278, P= 0.027) was evident. In this multiple linear regression analysis, other inflammatory markers (i.e. hs-CRP, haptoglobin, ferritin, albumin) did not seem to affect cystatin C blood levels. CONCLUSION: The results of this study demonstrated that monocytes, which play an important role in chronic inflammation and atherosclerosis, were independently related with cystatin C concentrations. This finding may provide a plausible link for the usefulness of cystatin C in predicting increased cardiovascular risk.

Development, repeatability and validity regarding energy and macronutrient intake of a semi-quantitative food frequency questionnaire: methodological considerations.

BACKGROUND AND AIM: The aim of this work was to evaluate the repeatability and the validity of a food frequency questionnaire (FFQ), and to discuss the methodological framework of such procedures. METHODS AND RESULTS: The semi-quantitative FFQ included 69 questions regarding the frequency of consumption of all main food groups and beverages usually consumed and 7 questions regarding eating behaviors. Five hundred individuals (37 ± 15 yrs, 38% males) were recruited for the repeatability process, while another 432 (46 ± 16 yrs, 40% males) also completed 3-Day Diaries (3DD) for the validation process. The repeatability of the FFQ was adequate for all food items tested (Kendall's tau-b: 0.26-0.67, p < 0.05), energy and macronutrients intake (energy adjusted correlation coefficients ranged between 0.56-0.69, p < 0.05). Moderate validity of the FFQ was observed for "dairy products", "fruit", "alcohol" and "stimulants" (tau-b: 0.31-0.60, p < 0.05), whereas low agreement was shown for "starchy products", "legumes", "vegetables", "meat", "fish", "sweets", "eggs", "fats and oils" (tau-b < 0.30, p < 0.05). The FFQ was also valid regarding energy and macronutrients intake. Sensitivity analyses by sex and BMI category (< or ≥25 kg/m(2)) showed similar validity of the FFQ for all food groups (apart from "fats and oils" intake), as well as energy and nutrient intake. CONCLUSION: The proposed FFQ has proven repeatable and relatively valid for foods' intake, and could therefore be used for nutritional assessment purposes.

Functional and prognostic significance of silent ischemia during dobutamine stress echocardiography in the elderly.

BACKGROUND: The functional and prognostic significance of silent ischemia relative to symptomatic ischemia during non-invasive testing remains controversial. DESIGN: The aim of this prospective study was to assess whether the presence of dobutamine-induced silent ischemia was associated with the amount of myocardial ischemic burden and to determine the prognostic significance of painless ischemia in elderly people with stable coronary artery disease. METHODS: A cohort of 289 patients > or =70 years of age with positive dobutamine stress echocardiography result and significant coronary artery disease proven by coronary arteriography, were followed up during a 35 +/- 13 month period for the development of cardiac events. RESULTS: The prevalence of silent ischemia during dobutamine infusion was 63%. Patients with painful ischemia were more likely to have lower peak heart rate (P < 0.01) and showed ST segment depression more frequently during the dobutamine stress test than did patients with painless ischemia (52 versus 31%, P < 0.05). There was no significant difference between the patients with and without angina according to wall motion score index at rest (1.35 +/- 0.29 versus 1.32 +/- 0.37) and at peak stress (1.61 +/- 0.35 versus 1.58 +/- 0.44), stress-rest wall motion index difference (0.27 +/- 0.09 versus 0.25 +/- 0.08), the presence of dyskinesia at peak stress (36 versus 31%), the number of segments with regional > or =2 point change from rest to peak stress (38 versus 29%) and the decrease of left ventricular end systolic volume at peak stress (89 versus 86%). During the follow-up period a total of 269 patients developed 153 (57%) cardiac events: 15 cardiac deaths, 19 non-fatal myocardial infarctions, 119 episodes of unstable angina. No significant difference in cardiac mortality and in total cardiac event rate was observed between patients with or without angina (6 versus 5% and 60 versus 55%, respectively). CONCLUSIONS: Our data demonstrate that the magnitude of myocardial dysfunction assessed by dobutamine stress echocardiography is comparable in elderly patients with or without anginal chest pain. The presence of painful ischemia is not accompanied by an increased risk for subsequent cardiac events in this cohort of patients.

New method for placement of intracoronary stents in order to avoid their embolization in the intravascular space.

Stent dislodgment from the delivery catheter is a well-known complication of angioplasty with stent implantation. The aim of our study was to investigate the feasibility, effectiveness, and safety of a new technique of intracoronary stent implantation in order to avoid stent loss in the intravascular space. Fifty consecutive patients were candidates for angioplasty and stent placement. During angioplasty, a technique was followed according to which the guide wire "hindered" the dislodgment of the stent from the balloon catheter. Successful angioplasty and stent placement were performed in 46 out of 50 patients (92% success rate). In three cases of failure of stent implantation, the stent moved onto the balloon catheter; however, this was impeded by the guide wire. One non-Q-wave myocardial infarction occurred. No major complications (Q-wave myocardial infarction, CABG, or death) were observed. In conclusion, the technique applied was feasible enough, safe, and effective. However, the appropriate modification of its "hardware" will render it even more feasible and user-friendly.

Stress echocardiography using adenosine combined with nitroglycerin-dobutamine in the detection of viable myocardium in patients with previous myocardial infarction.

The aim of this study was to assess the value of adenosine (A) and the combination of nitroglycerin (N) with dobutamine (D) stress echocardiography (SE) in the identification of viable myocardium. The clinical and electrocardiographic (ECG) effects of both tests were also evaluated. Fifty-two coronary artery disease patients, aged 56.4 +/- 8 years, with left ventricular dysfunction due to a previous myocardial infarction (mean ejection fraction: 49 +/- 8%) were included in the study. Cardiac catheterization was performed in all patients before A (140 micrograms/kg/minute for five minutes) and the combination of N with D (5-10 micrograms/kg/minute) stress echocardiography. On the echocardiogram, the left ventricle was divided into 16 segments and wall motion was graded semiquantitatively from 1 (normal) to 4 (dyskinesia). The echocardiographic index was also estimated. A segment was considered viable during A infusion when resting asynergy showed deterioration of one grade or more. In contrast, segmental viability was considered to be present during the combination of N with D infusion when resting asynergy showed improvement of one grade or more. A thallium 201 single photon emission computed tomography (SPECT) with reinjection was performed as reference standard for the identification of viable myocardium. Stress echocardiography during infusion of A was associated with short-duration angina attacks in 3 (5.8%) patients and transient complete atrioventricular (AV) block in 1 (1.9%), whereas during the combination of N with D infusion, 6 (11.5%) patients experienced ventricular bigeminy lasting for a short period. ST segment elevation greater than 1 mm was recorded in those leads having a Q wave, in 19 (36.5%) patients. In 10 of these 19 (52.6%), viable myocardium was present in SPECT, as it was in 33 patients (63.5%) having no ST segment elevation (P = NS). Of a total of 832 segments that were graded during A-SE, 276 exhibited resting asynergy and the remaining 556 had normal motion and thickening at rest. The echocardiographic index during A infusion increased from 1.52 +/- 0.22 to 1.71 +/- 0.24 (P < 0.001), whereas during D and N infusion it decreased from 1.53 +/- 0.31 to 1.30 +/- 0.42 (P < 0.001). With SPECT considered as the gold standard for the identification of viable myocardium, sensitivity, specificity, and positive and negative predictive values of A-SE in detecting viable myocardium were 54%, 86%, 65% and 80%, respectively. The respective values for the combination of nitroglycerin with D-SE were 91%, 89%, 78%, and 96%, respectively. Stress echocardiography during A, and the combination of N with D, constitute safe methods in the identification of viable myocardium. The detection of ST segment elevation in the ECG leads with a Q wave during the combined infusion of nitroglycerin and dobutamine is not related to the presence of viable myocardial tissue. The A-SE provide moderate diagnostic accuracy, while the combination of N with D during SE is much superior in detecting viable myocardium.

Echocardiographic detection of the extent of coronary artery disease in the elderly using dobutamine and adenosine infusion.

BACKGROUND: The high prevalence of asymptomatic multivessel disease in the elderly and the fact that most of them can not carry out an exercise stress testing renders the application of other stress modalities necessary. The aim of this study is to compare the diagnostic value of dobutamine and adenosine stress echocardiography and their accuracy in determining the extent of coronary artery disease in elderly people. METHODS: Dobutamine and adenosine stress echocardiography were performed in 128 consecutive patients > or = 70 years-of-age with known or suspected coronary artery disease. All patients underwent coronary angiography within 2 weeks of the stress tests. RESULTS: The presence of any echocardiographic abnormality on dobutamine (odds ratio 30.8) and adenosine (odds ratio 18.1) test, the need for cessation of dobutamine test and the ST depression during dobutamine infusion, were independent predictors of significant coronary artery disease. Both tests proved more sensitive for detecting multivessel disease (89% for dobutamine, 74% for adenosine test), than one-vessel disease (74 and 39%, respectively). This difference was statistically significant only for the adenosine echocardiography test (P = 0.008). In patients with localized resting wall motion abnormalities, the accuracy of dobutamine test to predict a remotely diseased vessel (70%), was statistically superior to the accuracy of adenosine test (57%, P = 0.008). Patients with multivessel disease showed delayed resolution of test-induced wall motion abnormalities, during the recovery period after both tests, compared with those who suffered from one-vessel disease. CONCLUSIONS: Dobutamine echocardiography was more sensitive and accurate than adenosine echocardiography in detecting and determining the extent and the severity of coronary artery disease in the elderly. A positive adenosine echocardiography result reflected the presence of advanced coronary artery disease. The two tests, combined with clinical data, could classify the elderly into low- and high-risk subgroups for ischemic heart disease.

Stress echocardiography in elderly patients with coronary artery disease: applicability, safety and prognostic value of dobutamine and adenosine echocardiography in elderly patients.

OBJECTIVES: Our aim was to determine the applicability, safety and prognostic value of adenosine and dobutamine stress echocardiography in patients > or = 70 years old. BACKGROUND: These tests are sometimes mandatory because of difficulties and inaccuracies in interpreting traditional electrocardiographic stress tests. Furthermore, if these tests could be used to avoid coronary arteriography and cardiac catheterization, they would become essential in the care of the elderly, whose numbers are increasing. METHODS: We performed coronary arteriography and dobutamine and adenosine stress echocardiographic tests in 120 patients (72 men) > or = 70 years old who entered the hospital because of chest pain and had known or suspected coronary artery disease. The stress tests were performed on separate days, within 2 weeks of coronary arteriography. Both the arteriograms and the echocardiograms were analyzed by two experts who had no knowledge of the patients' other data or the other interpreter's report. Tests were judged to have positive or negative results, and the patients were followed up for the development of cardiac events. Univariate and multivariate analyses and other statistical modalities were applied for comparisons. RESULTS: Documented coronary artery disease was found in 89 patients. During the 14 +/- 7 of follow-up, cardiac events developed in 50 patients, including 3 (7.9%) of 38 patients with negative dobutamine and 12 (20.7%) of 58 patients with negative adenosine test results. Demonstration of any abnormality on stress echocardiography was an independent factor for cardiac events, both for dobutamine (relative risk 7.3) and for adenosine (relative risk 3.0). Both cessation of dobutamine or adenosine tests and diagnosis of disease in two or more coronary vessels were also independent predictors. ST segment depression > or = 1mm was related to future events only with the dobutamine test. CONCLUSIONS: These echocardiographic stress tests proved safe and well tolerated. They successfully stratified this cohort of elderly patients with coronary artery disease to low or high risk subgroups for subsequent cardiac events.

Dobutamine-induced transmural myocardial ischemia in a patient with mild coronary lesions.

A 70-year-old man was admitted for evaluation of retrosternal pain at rest. During infusion of dobutamine (25 micrograms/kg/min) the patient developed angina, ST-segment elevation in the inferior leads, and echocardiographic hypokinesia in the inferior-basal myocardial wall. Coronary angiography revealed insignificant (20-30%) stenosis of the right coronary artery and a normal remaining tree. This case suggests that dobutamine may induce transmural myocardial ischemia in patients with mild coronary lesions, probably by producing occlusive coronary spasm on a substrate of arterial endothelial dysfunction.