Risk of recurrent stroke and mortality after cryptogenic stroke in diabetic patients.

BACKGROUND: Diabetes mellitus is a highly prevalent and growing chronic disease that is associated with increased risk of recurrence among several stroke subtypes. However, evidence on the prognostic role of diabetes in the setting of cryptogenic stroke (CS) remains scarce. METHODS: From April 2019 to November 2021, we recruited prospectively 78 consecutive patients with CS. Patients were classified according to the presence of diabetes. Main outcome was the composite of stroke recurrence and death. Secondary outcome was stroke recurrence. RESULTS: Mean age of the cohort was 78 ± 7.7 years and 18 patients (23%) had diabetes. After a median clinical follow-up of 23 months the incidence of stroke recurrence and mortality [HR 5.8 (95% CI 1.9-19), p = 0.002] and the incidence of stroke recurrence [HR 16.6 (95% CI 1.8-149), p = 0.012], were higher in patients with diabetes. After adjusting for potential confounders diabetes was identified as an independent predictor of stroke recurrence and death in patients with CS [HR 33.8 (95% CI 2.1-551), p = 0.013]. Other independent predictors of stroke recurrence and mortality were hypertension [HR 31.4 (95% CI 1.8-550), p = 0.018], NTproBNP [HR 1.002 (95% CI 1.001-1.004), p = 0.013] and chronic kidney disease (CKD) [HR 27.4 (95% CI 1.4-549) p = 0.03]. Furthermore, diabetes was an independent predictor of stroke recurrence [HR 103 (95% CI 1.3-8261), p = 0.038]. CONCLUSION: Diabetic patients with CS are at higher risk of stroke recurrence and death. Hypertension CKD and NTproBNP are also independent predictors of stroke recurrence and death after CS.

Electrocardiogram and CMR to differentiate tachycardia-induced cardiomyopathy from dilated cardiomyopathy in patients admitted for heart failure.

In patients admitted for heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and a concomitant supraventricular tachyarrhythmia (SVT) it is a challenge to predict LVEF recovery and differentiate tachycardia-induced cardiomyopathy (TIC) from dilated cardiomyopathy (DCM). The role of the electrocardiogram (ECG) and cardiac magnetic resonance (CMR) and in this acute setting remains unsettled. Forty-three consecutive patients admitted for HF due to SVT and LVEF < 50% undergoing CMR in the acute phase, were retrospectively included. Those who had LVEF > 50% at follow up were classified as TIC and those with LVEF < 50% were classified as DCM. Clinical, CMR and ECG findings were analyzed to predict LVEF recovery. Twenty-five (58%) patients were classified as TIC. Patients with DCM had wider QRS (121.2 ± 26 vs 97.7 ± 17.35 ms; p = 0.003). On CRM the TIC group presented with higher LVEF (33.4 ± 11 vs 26.9 ± 6.4%; p = 0.019) whereas late gadolinium enhancement (LGE) was more frequent in DCM group (61 vs 16%; p = 0.004). On multivariate analysis, QRS duration ≥ 100 ms (p = 0.027), LVEF < 40% on CMR (p = 0.047) and presence of LGE (p = 0.03) were independent predictors of lack of LVEF recovery. Furthermore, during follow-up (median 60 months) DCM patients were admitted more frequently for HF (44 vs 0%; p < 0.001) than TIC patients. In patients with reduced LVEF admitted for HF due to SVT, QRS ≥ 100 ms, LVEF < 40% and LGE are independently associated with lack of LVEF recovery and worse clinical outcome.

A Comprehensive Model to Predict Atrial Fibrillation in Cryptogenic Stroke: The Decryptoring Score.

OBJETIVE: Cryptogenic stroke (CS) represents up to 30% of ischemic strokes (IS). Since atrial fibrillation (AF) can be detected in up to 30% of CS, there is a clinical need for estimating the probability of underlying AF in CS to guide the optimal secondary prevention strategy. The aim of the study was to develop the first comprehensive predictive score including clinical conditions, biomarkers, and left atrial strain (LAS), to predict AF detection in this setting. METHODS: Sixty-three consecutive patients with IS or transient ischemic attack with ABCD2 scale ≥ 4 of unknown etiology were prospectively recruited. Clinical, laboratory, and echocardiographic variables were collected. All patients underwent 15 days wearable Holter-ECG monitoring. Main objective was the Decryptoring score creation to predict AF in CS. Score variables were selected by a univariate analysis and, thereafter, score points were derived according to a multivariant analysis. RESULTS: AF was detected in 15 patients (24%). Age > 75 (9 points), hypertension (1 point), Troponin T > 40 ng/L (8.5 points), NTproBNP > 200 pg/ml (0.5 points), LAS reservoir < 25.3% (24.5 points) and LAS conduct < 10.4% (0.5 points) were included in the score. The rate of AF detection was 0% among patients with a score of < 10 and 80% among patients with a score > 35. The comparison of the predictive validity between the proposed score and AF-ESUS score resulted in an AUC of 0.94 for Decryptoring score and of 0.65 for the AF-ESUS score(p < 0.001). CONCLUSION: This novel score offers an accurate AF prediction in patients with CS; however these results will require validation in an independent cohort using this model before they may be translated into clinical practice.

Anterior ST-segment elevation secondary to right coronary occlusion: The sheep in wolf's clothing.

We present a case of an anterior ST-segment elevation acute coronary syndrome secondary to occlusion of a non-dominant right coronary artery. Usually, an anterior ST-segment elevation corresponds to a left anterior descending artery occlusion; however, in rare cases it can be secondary to a non-dominant right coronary artery occlusion. The two causal entities may be adequately differentiated by the detailed analysis of the ECG. The electrocardiographic criteria that allow the proper prediction of the culprit artery in anterior ST-segment elevation acute coronary syndrome are reviewed.

Spike or not a spike? That is the question in a patient with single lead pacemaker.

Dual-chamber pacing is feasible via the floating atrial sensor electrodes of a single-pass VDD lead but the atrial lead threshold is higher than the accepted clinical standard. Furthermore, due to the floating nature of the system, atrial sensing and pacing thresholds may vary during the follow up. For these reasons this strategy is seldom considered a common pacing solution in routine clinical practice. Alternatively, this phenomenon is likely to be observed as a result of incorrect generator configuration. As shown in our case, this inadequate setting can be suspected just by the analysis of the surface ECG and the post implantation chest X-ray.

Left Atrial Strain Predicts Stroke Recurrence and Death in Patients With Cryptogenic Stroke.

Left atrial strain (LAS) has been widely studied as a predictor of atrial fibrillation (AF) after cryptogenic stroke (CS). However, the evidence about its prognostic role in terms of stroke recurrence and death in this setting remains scarce. A total of 92 consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography, including LAS was performed during admission. The primary outcome measure was the composite of stroke recurrence or death. The mean age was 77.5 ± 7.7, and 58% of patients were female. After a median follow up of 28 months, the primary outcome measure occurred in 15 patients (16%). The primary outcome was more frequent in patients with diabetes (53% vs 21%, p = 0.02), chronic kidney disease (33% vs 10%, p = 0.034), and a history of heart failure (13% vs 0%, p = 0.025). LAS reservoir (LASr) and LAS conduit (LAScd) were lower in patients developing the primary outcome (21% ± 7% vs 28.8% ± 11%, p = 0.017 and 7.7% ± 3.9% vs 13.7% ± 7%, p = 0.007, respectively). On multivariate analysis, LASr (hazard ratio 0.9, 95% confidence interval 0.85 to 0.99, p = 0.048) and diabetes (hazard ratio 3.3, 95% confidence interval 1.03 to 10.4, p = 0.045) were associated with stroke recurrence or all-cause death after CS. On the log-rank test (using the discriminatory cut-off value of LASr <23%), LASr (p = 0.009) was associated with higher risk of the primary outcome. In conclusion, lower values of the LAS reservoir were associated with a higher risk of stroke recurrence or death after CS. LAS may identify patients at higher risk of thromboembolism and stress conditions.

Intracoronary thrombus assessment with cardiac computed tomography angiography in a deferred stenting strategy: the MATURE prospective study (MSCT to Assess ThrombUs REsolution).

BACKGROUND: Cardiac computed tomography angiography (CCTA) is precise in noninvasive coronary atherosclerosis characterization but its value in the diagnosis of intracoronary thrombus remains unknown. Therefore, our aim was to evaluate CCTA for intracoronary thrombus and stenosis detection in patients with acute coronary syndromes with high thrombus burden selected for a deferred stenting strategy. METHODS: We systematically performed a CCTA in consecutive patients following a deferred stenting strategy, 24 h before the scheduled repeated coronary angiography including optical coherence tomography (OCT) imaging. Intracoronary thrombus and residual stenosis were blindly and independently evaluated by both techniques. Agreement was determined per lesion using the weighted Kappa ( K ) coefficient and absolute intraclass correlation coefficient (ICC). A stratified analysis according to OCT-detected thrombus burden was also performed. RESULTS: Thirty lesions in 28 consecutive patients were analyzed. Concordance between CCTA and repeated coronary angiography in thrombus detection was good ( K = 0.554; P < 0.001), but both showed poor agreement with OCT. CCTA needed >11.5% thrombus burden on OCT to obtain adequate diagnostic accuracy. The lesions detected by angiography were more frequently classified as red thrombus (76.5 vs. 33.3%; P = 0.087) on OCT. CCTA showed an excellent concordance with coronary angiography in diameter measurement (ICC = 0.85; P < 0.001) and was able to identify all the patients with severe residual stenosis. CONCLUSIONS: Although CCTA showed just a good concordance with angiography in intracoronary thrombus detection, the agreement in residual stenosis was excellent. Thus, in patients with a high-thrombus burden selected for a deferred stenting strategy CCTA may substitute repeat angiography.

Pulmonary artery sarcoma with extensive leiomyosarcoma differentiation and heterologous osteosarcomatous elements.

Pulmonary artery sarcomas are exceptionally unusual. Their clinic, diagnosis and treatment play a very important role in the ultimate outcome and long-term survival. We present the case of a 70-year-old gentleman diagnosed with a leiomyosarcoma of the pulmonary artery with osteosarcoma differentiation that underwent surgical resection and subsequent chemotherapy, with good recovery at 9 months follow-up. Late diagnosis and incomplete surgical resection will worsen the short- and long-term prognosis of these patients.

Usefulness of Tissue Tracking by Cardiac Magnetic Resonance to Predict Events in Patients With Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HC) is the most common cardiovascular inherited disease, and it is associated with arrhythmic events, heart failure, and death. Strain analysis by tissue tracking (TT) techniques on cardiac magnetic resonance (CMR) is a novel noninvasive diagnostic tool. However, the usefulness of CMR-TT to identify patients with HC at risk of adverse outcomes remains unknown. CMR strain parameters by CMR-TT were prospectively measured in a cohort of 136 consecutive patients with HC. Clinical (death or readmission for heart failure) and arrhythmic (any ventricular tachycardia) events during follow-up were prospectively recorded. Global radial systolic strain rate and global radial diastolic strain rate showed the best area under the receiver operating characteristic curve (ROC curve) to predict adverse clinical events. On Cox multivariate regression models, a global radial systolic strain rate value <1.4/s and a global radial diastolic strain rate value ≥ -1.38/s were independently associated with clinical events at follow-up (adjusted hazard ratio 6.57, 95% confidence interval [CI] 2.01 to 21.49, p = 0.002; adjusted hazard ratio 5.96, 95% CI 1.79 to 19.89, p = 0.004, respectively). Regarding arrhythmic events, global radial peak strain <27% showed the best area under the ROC curve and remained independently associated with ventricular tachycardia after adjustment for confounders (odds ratio 7.33, 95% CI 1.07 to 50.41, p = 0.043). CMR strain parameters by TT predict clinical and arrhythmic events in patients with HC.

Environment and cardiovascular health: causes, consequences and opportunities in prevention and treatment.

The environment is a strong determinant of cardiovascular health. Environmental cardiology studies the contribution of environmental exposures with the aim of minimizing the harmful influences of pollution and promoting cardiovascular health through specific preventive or therapeutic strategies. The present review focuses on particulate matter and metals, which are the pollutants with the strongest level of scientific evidence, and includes possible interventions. Legislation, mitigation and control of pollutants in air, water and food, as well as environmental policies for heart-healthy spaces, are key measures for cardiovascular health. Individual strategies include the chelation of divalent metals such as lead and cadmium, metals that can only be removed from the body via chelation. The TACT (Trial to Assess Chelation Therapy, NCT00044213) clinical trial demonstrated cardiovascular benefit in patients with a previous myocardial infarction, especially in those with diabetes. Currently, the TACT2 trial (NCT02733185) is replicating the TACT results in people with diabetes. Data from the United States and Argentina have also shown the potential usefulness of chelation in severe peripheral arterial disease. More research and action in environmental cardiology could substantially help to improve the prevention and treatment of cardiovascular disease.

[Environment and cardiovascular health: causes, consequences and opportunities in prevention and treatment]. / Medio ambiente y salud cardiovascular: causas, consecuencias y oportunidades en prevención y tratamiento.

The environment is a strong determinant of cardiovascular health. Environmental cardiology studies the contribution of environmental exposures with the aim of minimizing the harmful influences of pollution and promoting cardiovascular health through specific preventive or therapeutic strategies. The present review focuses on particulate matter and metals, which are the pollutants with the strongest level of scientific evidence, and includes possible interventions. Legislation, mitigation and control of pollutants in air, water and food, as well as environmental policies for heart-healthy spaces, are key measures for cardiovascular health. Individual strategies include the chelation of divalent metals such as lead and cadmium, metals that can only be removed from the body via chelation. The TACT (Trial to Assess Chelation Therapy, NCT00044213) clinical trial demonstrated cardiovascular benefit in patients with a previous myocardial infarction, especially in those with diabetes. Currently, the TACT2 trial (NCT02733185) is replicating the TACT results in people with diabetes. Data from the United States and Argentina have also shown the potential usefulness of chelation in severe peripheral arterial disease. More research and action in environmental cardiology could substantially help to improve the prevention and treatment of cardiovascular disease.

Advanced Echocardiography With Left Atrial Strain and Indexed Left Atrial Three-Dimensional Volume for Predicting Underlying Atrial Fibrillation After Cryptogenic Stroke.

Cryptogenic stroke (CS) represents 1/3 of ischemic strokes. Atrial fibrillation (AF) can be detected in up to 30% of CS. Therefore, there is a clinical need for predicting AF to guide the optimal secondary prevention strategy. The evidence about the role of advanced echocardiography, including left atrial 3-dimensional (3D) index volume and left atrial strain (LAS) techniques, to predict underlying AF in this setting is lacking. From April 2019 to November 2021, 78 consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography was performed during admission. All patients underwent 15 days of wearable Holter monitoring. The primary outcome measure was AF detection during follow-up. Twenty-two patients (28%) developed AF. Patients in the AF group were older (81 ± 6.3 vs 76.5 ± 7.8 years; p = 0.012). Left atrial (LA) diastolic indexed volume was higher in the AF group (37.2 ± 12.8 vs 29.7 ± 11 ml/m2 p = 0.01). Three-D LA indexed volume was also higher in patients with AF (41.4 ± 14 vs 32.2 ± 10 ml/m2 p = 0.009). LAS reservoir, LAS conduct, and LAS contraction (LASct) were significantly lower in patients with AF (19 ± 5.6 vs 32% ± 10.3%; 9 ± 4.5 vs 15 ± 7.6; 10 ± 5.3 vs 17 ± 6.4, respectively, all p <0.001). On multivariate analysis, LASct <13.5% and LA 3D indexed volume >44.5 ml/m2 were independent predictors of AF (odds ratio 10.9 [95% confidence interval 1.09 to 108.2], p = 0.042). In conclusion, LASct <13.5% and LA 3D indexed volume >44.5 ml/m2 are independent predictors of underlying AF in patients with CS. Our results show the usefulness of advanced echocardiography in this challenging clinical setting.

Influence of air pollutants on circulating inflammatory cells and microRNA expression in acute myocardial infarction.

Air pollutants increase the risk and mortality of myocardial infarction (MI). The aim of this study was to assess the inflammatory changes in circulating immune cells and microRNAs in MIs related to short-term exposure to air pollutants. We studied 192 patients with acute coronary syndromes and 57 controls with stable angina. For each patient, air pollution exposure in the 24-h before admission, was collected. All patients underwent systematic circulating inflammatory cell analyses. According to PM2.5 exposure, 31 patients were selected for microRNA analyses. STEMI patients exposed to PM2.5 showed a reduction of CD4+ regulatory T cells. Furthermore, in STEMI patients the exposure to PM2.5 was associated with an increase of miR-146a-5p and miR-423-3p. In STEMI and NSTEMI patients PM2.5 exposure was associated with an increase of miR-let-7f-5p. STEMI related to PM2.5 short-term exposure is associated with changes involving regulatory T cells, miR-146a-5p and miR-423-3p.