Prevalence of Inflammatory Heart Disease Among Professional Athletes With Prior COVID-19 Infection Who Received Systematic Return-to-Play Cardiac Screening.

Importance: The major North American professional sports leagues were among the first to return to full-scale sport activity during the coronavirus disease 2019 (COVID-19) pandemic. Given the unknown incidence of adverse cardiac sequelae after COVID-19 infection in athletes, these leagues implemented a conservative return-to-play (RTP) cardiac testing program aligned with American College of Cardiology recommendations for all athletes testing positive for COVID-19. Objective: To assess the prevalence of detectable inflammatory heart disease in professional athletes with prior COVID-19 infection, using current RTP screening recommendations. Design, Setting, and Participants: This cross-sectional study reviewed RTP cardiac testing performed between May and October 2020 on professional athletes who had tested positive for COVID-19. The professional sports leagues (Major League Soccer, Major League Baseball, National Hockey League, National Football League, and the men's and women's National Basketball Association) implemented mandatory cardiac screening requirements for all players who had tested positive for COVID-19 prior to resumption of team-organized sports activities. Exposures: Troponin testing, electrocardiography (ECG), and resting echocardiography were performed after a positive COVID-19 test result. Interleague, deidentified cardiac data were pooled for collective analysis. Those with abnormal screening test results were referred for additional testing, including cardiac magnetic resonance imaging and/or stress echocardiography. Main Outcomes and Measures: The prevalence of abnormal RTP test results potentially representing COVID-19-associated cardiac injury, and results and outcomes of additional testing generated by the initial screening process. Results: The study included 789 professional athletes (mean [SD] age, 25 [3] years; 777 men [98.5%]). A total of 460 athletes (58.3%) had prior symptomatic COVID-19 illness, and 329 (41.7%) were asymptomatic or paucisymptomatic (minimally symptomatic). Testing was performed a mean (SD) of 19 (17) days (range, 3-156 days) after a positive test result. Abnormal screening results were identified in 30 athletes (3.8%; troponin, 6 athletes [0.8%]; ECG, 10 athletes [1.3%]; echocardiography, 20 athletes [2.5%]), necessitating additional testing; 5 athletes (0.6%) ultimately had cardiac magnetic resonance imaging findings suggesting inflammatory heart disease (myocarditis, 3; pericarditis, 2) that resulted in restriction from play. No adverse cardiac events occurred in athletes who underwent cardiac screening and resumed professional sport participation. Conclusions and Relevance: This study provides large-scale data assessing the prevalence of relevant COVID-19-associated cardiac pathology with implementation of current RTP screening recommendations. While long-term follow-up is ongoing, few cases of inflammatory heart disease have been detected, and a safe return to professional sports activity has thus far been achieved.

Preparticipation Cardiac Evaluation Findings in a Cohort of Collegiate Female Athletes.

Knowledge of cardiovascular adaptations in athletes has predominantly focused on males, with limited data available on females who compromise a substantial percentage of all collegiate athletes. A multicenter retrospective cohort review of preparticipation cardiovascular screening data of 329 National Collegiate Athletic Association Division I female athletes was performed. This included physical exams, electrocardiograms, and echocardiograms. Female athletes in class IB sports had elevated systolic blood pressure (p = 0.01). For electrocardiograms, 7 (2%) had abnormal findings: 100% were white; 6 of 7 (86%) participated in IIC sports. Black athletes had longer PR intervals (p ≤ 0.001), whereas white athletes had longer QTc and QRS durations (p = 0.02 and 0.01, respectively). Athletes in IC and IIC sports had longer QTc intervals (p = 0.01). For echocardiographic parameters, no differences were noted based on race. However, significant differences were noted based on classification of sport: athletes in class IC sports had higher left-atrial volume indexes and E/A ratios. Athletes in class IB and IIC had increased left-ventricular wall thicknesses and aortic root dimensions. In conclusion, among one of the largest cohorts of collegiate female athlete preparticipation cardiac screening data to date, significant differences in various parameters based on classification of sport and race were observed. These categorizations should be considered when interpreting cardiovascular screening in female collegiate athletes to improve screening and guide future research.

Screening of Potential Cardiac Involvement in Competitive Athletes Recovering From COVID-19: An Expert Consensus Statement.

As our understanding of the complications of coronavirus disease-2019 (COVID-19) evolve, subclinical cardiac pathology such as myocarditis, pericarditis, and right ventricular dysfunction in the absence of significant clinical symptoms represents a concern. The potential implications of these findings in athletes are significant given the concern that exercise, during the acute phase of viral myocarditis, may exacerbate myocardial injury and precipitate malignant ventricular arrhythmias. Such concerns have led to the development and publication of expert consensus documents aimed at providing guidance for the evaluation of athletes after contracting COVID-19 in order to permit safe return to play. Cardiac imaging is at the center of these evaluations. This review seeks to evaluate the current evidence regarding COVID-19-associated cardiovascular disease and how multimodality imaging may be useful in the screening and clinical evaluation of athletes with suspected cardiovascular complications of infection. Guidance is provided with diagnostic "red flags" that raise the suspicion of pathology. Specific emphasis is placed on the unique challenges posed in distinguishing athletic cardiac remodeling from subclinical cardiac disease. The strengths and limitations of different imaging modalities are discussed and an approach to return to play decision making for athletes post-COVID-19, as informed by multimodality imaging, is provided.

Trends in Hospitalization for Hypertensive Emergency, and Relationship of End-Organ Damage With In-Hospital Mortality.

BACKGROUND: There are no comprehensive guidelines on management of hypertensive emergency (HTNE) and complications. Despite advances in antihypertensive medications HTNE is accompanied with significant morbidity and mortality. METHODS: We queried the 2002-2012 nationwide inpatient sample database to identify patients with HTNE. Trends in incidence of HTNE and in-hospital mortality were analyzed. Logistic regression analysis was used to assess the relationship between end-organ complications and in-hospital mortality. RESULTS: Between 2002 and 2012, 129,914 admissions were included. Six hundred and thirty (0.48%) patients died during their hospital stay. There was an increase in the number of HTNE admissions (9,511-15,479; Ptrend < 0.001) with concurrent reduction of in-hospital mortality (0.8-0.3%; Ptrend < 0.001) by the year 2012 compared to 2002. Patients who died during hospitalization were older, had longer length of stay, higher cost of stay, more comorbidities, and higher risk scores. Presence of acute cardiorespiratory failure [adjusted odds ratio (OR), 15.8; 95% confidence interval (CI), 13.2-18.9], stroke or transient ischemia attack (TIA) (adjusted OR, 7.9; 95% CI, 6.3-9.9), chest pain (adjusted OR, 5.9; 95% CI, 4.4-7.7), stroke/TIA (adjusted OR, 5.9; 95% CI, 4.5-7.7), and aortic dissection (adjusted OR, 5.9; 95% CI, 2.8-12.4) were most predictive of higher in-hospital mortality in addition to factors such as age, aortic dissection, acute myocardial infarction, acute renal failure, and presence of neurological symptoms. CONCLUSION: A rising trend in hospitalization for HTNE, with an overall decrease in in-hospital mortality was observed from 2002 to 2012, possibly related to changes in coding practices and improved management. Presence of acute cardiorespiratory failure, stroke/TIA, chest pain, and aortic dissection were most predictive of higher hospital mortality.

Paradoxical embolism interrupted.

A 41 year-old African-American male presented with syncope preceded by shortness of breath at outside facility and transferred to us for management of extensive pulmonary embolism with unstable vital signs. Electrocardiogram showed sinus tachycardia with S1Q3T3 pattern. A transthoracic echocardiogram revealed a freely mobile strand like mass in the left atrium. A transoesophageal echocardiogram showed a very large freely mobile thrombus extending from a patent foramen ovale in to the left atrium. He underwent emergent surgery for the extraction of clot followed by thromboembolectomy from both pulmonary arteries. He made a remarkable recovery and was discharged after seven days of hospital stay.

Breast artery calcium noted on screening mammography is predictive of high risk coronary calcium in asymptomatic women: a case control study.

BACKGROUND: The relationship between breast artery calcification (BAC) noted on mammography and both coronary artery disease and cardiovascular risk remains controversial. Few studies have examined the clinical significance of BAC in asymptomatic women. In the present study we evaluated the relationship between BAC and coronary artery calcium (CAC) as identified by multi-slice CT scanning (MSCT). PATIENTS AND METHODS: Consecutive women (n = 98) with BAC noted on routine mammography but without known coronary artery disease (CAD) were assessed for CAD risk factors and had assessment of coronary calcium by MSCT. A control cohort of consecutive women who were BAC(-) (n = 104) underwent an identical assessment. RESULTS: Women who were BAC(+) were older than those who were BAC(-); otherwise, there were no differences between the 2 groups with regard to traditional cardiac risk factors. Significantly more BAC(+) vs. BAC(-) women were found to have “high risk” CAC scores, defined as CAC > 400 (11.2 % vs. 1.0 %, p = 0.006). However, the rates of CAC scores of 0 were not different between the two groups (50.0 % vs. 54.8 % for BAC(+) and BAC(-) , respectively, p = 0.586). When examined in a multivariate model including the traditional risk factors of diabetes, increasing age, smoking, hyperlipidemia, and family history of CAD, the presence of BAC remained significantly associated with CAC > 400 (OR = 22.6, 95 % CI = 2.1 - 237.1). CONCLUSIONS: The presence of breast artery calcium on screening mammography was a strong independent predictor (odds ratio > 22) of high risk coronary artery calcium scores (defined as CAC > 400). The presence of BAC in those with significant CAD risk factors may warrant further evaluation.

Fabry's disease with LVOT obstruction: diagnosis and management.

A 46-year-old male was diagnosed with hypertrophic cardiomyopathy (HCM) and severe left ventricular outflow tract (LVOT) obstruction. Genetic testing revealed that this was a "mimic of HCM" and the true diagnosis was Fabry's disease, although there were no other clinical features of Fabry's. Despite maximal medical therapy he remained symptomatic from the outflow tract gradient and required surgical myectomy for symptom relief. This case illustrates the diagnosis of an HCM mimic by genetic testing.

Giant saphenous vein graft pseudoaneurysm: treatment with a vascular occlusion device.

We report the case of a 74-year old male who was evaluated for progressively enlarging right heart border on serial chest radiographs. Computed tomography of the chest revealed a pseudoaneurysm arising from the saphenous vein graft (SVG) to the posterior descending artery with mass effect on the right atrium. Coronary angiography showed severely compromised distal flow and an angiographically small territory at risk. Using a minimally invasive, catheter-based approach, an Amplatzer Vascular Plug II occlusion device was utilized successfully for embolizing the SVG pseudoaneurysm.

Atrial fibrillation following cardiac surgery: established and emerging strategies of prevention.

More than 250,000 patients undergo cardiac surgery every year. Although advances in surgical techniques have reduced the peri-operative morbidity and mortality in these patients, atrial fibrillation persists to commonly occur following these surgeries. Traditional therapies have reduced their occurrence; however there are still a significant number of patients who develop this complication. Newer and non-conventional medications are being studied to reduce this cardiac arrhythmia. This review will elaborate on the patho-physiology, and prevention of this arrhythmia. We also aim to summarize recent investigated and patented medications which may result in more effective strategies for prophylaxis against this cardiac arrhythmia.

ECG-gated dual-source CT for detection of left atrial appendage thrombus in patients undergoing catheter ablation for atrial fibrillation.

PURPOSE: Left atrial ablation is increasingly used to treat patients with symptomatic atrial fibrillation (AF). Prior to ablation, exclusion of left atrial appendage (LAA) thrombus is important. Whether ECG-gated dual-source computed tomography (DSCT) provides a sensitive means of detecting LAA thrombus in patients undergoing percutaneous AF ablation is unknown. Thus, we sought to determine the utility of ECG-gated DSCT in detecting LAA thrombus in patients with AF. METHODS: A total of 255 patients (age 58 ± 11 years, 78% male, ejection fraction 58 ± 9%) who underwent ECG-gated DSCT and transesophageal echocardiography (TEE) prior to AF ablation between February 2006 and October 2007 were included. CHADS2 score and demographic data were obtained prospectively. Gated DSCT images were independently reviewed by two cardiac imagers blinded to TEE findings. The LAA was either defined as normal (fully opacified) or abnormal (under-filled) by DSCT. RESULTS: An under-filled LAA was identified in 33 patients (12.9%), of whom four had thrombus confirmed by TEE. All patients diagnosed with LAA thrombus using TEE also had an abnormal LAA by gated DSCT. Thus, sensitivity and specificity for gated DSCT were 100% and 88%, respectively. No cases of LAA filling defects were observed in patients <51 years old with a CHADS2 of 0. CONCLUSION: In patients referred for AF ablation, thrombus is uncommon in the absence of additional risk factors. Gated DSCT provides excellent sensitivity for the detection of thrombus. Thus, in AF patients with a CHADS2 of 0, gated DSCT may provide a useful stand-alone imaging modality.

Computed tomography of cardiac pseudotumors and neoplasms.

Important features of cardiac masses can be clearly delineated on cardiac computed tomography (CT) imaging. This modality is useful in identifying the presence of a mass, its relationship with cardiac and extracardiac structures, and the features that distinguish one type of mass from another. A multimodality approach to the evaluation of cardiac tumors is advocated, with the use of echocardiography, CT imaging and magnetic resonance imaging as appropriately indicated. In this article, various cardiac masses are described, including pseudotumors and true cardiac neoplasms, and the CT imaging findings that may be useful in distinguishing these rare entities are presented.

Ranolazine--treatment of ventricular tachycardia and symptomatic ventricular premature beats in ischemic cardiomyopathy.

Premature ventricular complexes (PVCs) are a frequent occurrence in the presence of ischemic heart disease. A very high PVC load can be symptomatic or occasionally result in a cardiomyopathy (CMP). Treatment options include pharmacologic agents and radiofrequency ablation (RFA). RFA has been successful in treating PVCs in symptomatic patients or in the presence of unexplained CMP. Ranolazine is a piperazine derivative used for treating chronic stable angina. It also has antiarrhythmic properties. We report a patient with ischemic CMP, symptomatic PVCs, and monomorphic ventricular tachycardia (VT) despite attempts to control symptoms with two antiarrhythmic drugs. Initiation of ranolazine led to marked reduction in PVCs along with control of VT and symptoms.

Role of cardiac magnetic resonance imaging in the detection of cardiac amyloidosis.

OBJECTIVES: Our aim was to evaluate the role and mechanism of late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) in identifying cardiac amyloidosis (CA) and to investigate associations between LGE and clinical, morphologic, functional, and biochemical features. BACKGROUND: CA can be challenging to diagnose by echocardiography. Recent studies have demonstrated an emerging role for LGE-CMR. METHODS: LGE-CMR was performed in 120 patients with amyloidosis. Cardiac histology was available in 35 patients. The remaining 85 patients were divided into those with and without echocardiographic evidence of CA. RESULTS: Of the 35 patients with histologically verified CA, abnormal LGE was present in 34 (97%) patients and increased echocardiographic left ventricular wall thickness in 32 (91%) patients. Global transmural or subendocardial LGE (83%) was most common and was associated with greater interstitial amyloid deposition (p = 0.03). Suboptimal myocardial nulling (8%) and patchy focal LGE (6%) were also observed. LGE distribution matched the deposition pattern of interstitial amyloid. Among patients without cardiac histology, LGE was present in 86% of those with evidence of CA by echocardiography and in 47% of those without evidence of CA by echocardiography. In patients without echocardiographic evidence of CA, the presence of LGE was associated with worse clinical, electrocardiographic (ECG), and cardiac biomarker profiles. In all patients, LGE presence and pattern was associated with New York Heart Association functional class, ECG voltage, left ventricular mass index, right ventricular wall thickness, troponin-T, and B-type natriuretic peptide levels. CONCLUSIONS: LGE is common in CA and detects interstitial expansion from amyloid deposition. Global transmural or subendocardial LGE is most common, but suboptimal myocardial nulling and focal patchy LGE are also observed. LGE-CMR may detect early cardiac abnormalities in patients with amyloidosis with normal left ventricular thickness. The presence and pattern of LGE is strongly associated with clinical, morphologic, functional, and biochemical markers of prognosis.

Atrial fibrillation--advances in drug therapy.

The prevalence of atrial fibrillation (AF) continues to increase worldwide. It is projected that by 2050, between 5 and 15 million Americans will have AF. Such predictions necessitate new advances in drug therapy. AF is associated with changes in ionic currents. Atrial fibrosis, changes in gap junctions and cell membranes act in concert to initiate and maintain AF. Significant advances in understanding the pathophysiology of this condition have led to numerous new drug discoveries in the last decade. We discuss newly patented molecules that act as sodium and potassium channel blockers, gap junction and intracellular calcium modulators, stretch receptor antagonists, ischemic ion current inhibitors and adenosine receptor agonists.