Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management.

BACKGROUND AND AIMS: A routine invasive strategy is recommended in the management of higher risk patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs). However, patients with previous coronary artery bypass graft (CABG) surgery were excluded from key trials that informed these guidelines. Thus, the benefit of a routine invasive strategy is less certain in this specific subgroup. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. A comprehensive search was performed of PubMed, EMBASE, Cochrane, and ClinicalTrials.gov. Eligible studies were RCTs of routine invasive vs. a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG. Summary data were collected from the authors of each trial if not previously published. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction, and cardiac-related hospitalization. Using a random-effects model, risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. RESULTS: Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a weighted mean of 2.0 (range 0.5-10) years. A routine invasive strategy did not reduce all-cause mortality (RR 1.12, 95% CI 0.97-1.29), cardiac mortality (RR 1.05, 95% CI 0.70-1.58), myocardial infarction (RR 0.90, 95% CI 0.65-1.23), or cardiac-related hospitalization (RR 1.05, 95% CI 0.78-1.40). CONCLUSIONS: This is the first meta-analysis assessing the effect of a routine invasive strategy in patients with prior CABG who present with NSTE-ACS. The results confirm the under-representation of this patient group in RCTs of invasive management in NSTE-ACS and suggest that there is no benefit to a routine invasive strategy compared to a conservative approach with regard to major adverse cardiac events. These findings should be validated in an adequately powered RCT.

Coronary microcirculation and left ventricular diastolic function but not myocardial deformation indices are impaired early in patients with chronic kidney disease.

AIM: To investigate abnormalities in myocardial strain and classic echocardiographic indices and coronary flow reserve (CFR), in younger versus older CKD patients. METHODS: Sixty consecutive CKD patients (<60 years old n = 30, ≥60 years old n = 30) and 30 healthy controls (age- and gender-matched with younger CKD patients) were recruited. An echocardiographic assessment including myocardial strain indices (i.e. global longitudinal strain -GLS -, TWIST, UNTWIST rate) was performed at baseline and following dipyridamole administration in all participants. RESULTS: Younger CKD patients had higher E/e', left ventricular mass index and relative wall thickness and lower E' (p < .005 for all) compared to healthy controls. Older CKD patients had lower E/A and E' (p < .05 for both) compared to younger CKD patients; these differences did not remain significant after adjustment for age. CFR was higher in healthy controls compared to younger and older CKD patients (p < .05 for both) without a significant difference between CKD groups. There were no significant differences in GLS, TWIST or UNTWIST values among the three groups of patients. Dipyridamole-induced changes did not differ significantly among the three groups. CONCLUSIONS: Compared to healthy controls, impaired coronary microcirculation and left ventricular diastolic function, but not myocardial strain abnormalities, are found in young CKD patients and deteriorate with aging.

Greater decline of acute stroke admissions compared with acute coronary syndromes during COVID-19 outbreak in Greece: Cerebro/cardiovascular implications amidst a second wave surge.

BACKGROUND AND PURPOSE: A remarkable decline in admissions for acute stroke and acute coronary syndrome (ACS) has been reported in countries severely hit by the COVID-19 pandemic. However, limited data are available from countries with less COVID-19 burden focusing on concurrent stroke and ACS hospitalisation rates from the same population. METHODS: The study was conducted in three geographically and demographically representative COVID-19 referral university hospitals in Greece. We recorded the rate of stroke and ACS hospital admissions during a 6-week period of the COVID-19 outbreak in 2020 and compared them with the rates of the corresponding period in 2019. RESULTS: We found a greater relative reduction of stroke admissions (51% [35 vs. 71]; incidence rate ratio [IRR]: 0.49, p = 0.001) compared with ACS admissions (27% [123 vs. 168]; IRR: 0.73, p = 0.009) during the COVID-19 outbreak (p = 0.097). Fewer older (>65 years) patients (stroke: 34.3% vs. 45.1%, odds ratio [OR]: 0.64, p = 0.291; ACS: 39.8% vs. 54.2%, OR: 0.56, p = 0.016) were admitted during the COVID-19 compared with the control period. CONCLUSIONS: Hospitalisation rates both for stroke and ACS were reduced during the COVID-19 outbreak in a country with strict social distancing measures, low COVID-19 incidence and low population mortality. Lack of triggers for stroke and ACS during social distancing/quarantining may explain these observations. However, medical care avoidance attitudes among cerebro/cardiovascular patients should be dissipated amidst the rising second COVID-19 wave.

Conversion of Propranolol to Carvedilol Improves Renal Perfusion and Outcome in Patients With Cirrhosis and Ascites.

BACKGROUND: In recent years, concerns have been raised on the potential adverse effects of nonselective beta-blockers, and particularly carvedilol, on renal perfusion and survival in decompensated cirrhosis with ascites. We investigated the long-term impact of converting propranolol to carvedilol on systemic hemodynamics and renal function, and on the outcome of patients with stable cirrhosis and grade II/III nonrefractory ascites. PATIENTS AND METHODS: Ninety-six patients treated with propranolol for esophageal varices' bleeding prophylaxis were prospectively evaluated. These patients were randomized in a 2:1 ratio to switch to carvedilol at 12.5 mg/d (CARVE group; n=64) or continue propranolol (PROPRA group; n=32). Systemic vascular resistance, vasoactive factors, glomerular filtration rate, and renal blood flow were evaluated at baseline before switching to carvedilol and after 6 and 12 months. Further decompensation and survival were evaluated at 2 years. RESULTS: During a 12-month follow-up, carvedilol induced an ongoing improvement of systemic vascular resistance (1372±34 vs. 1254±33 dynes/c/cm5; P=0.02) along with significant decreases in plasma renin activity (4.05±0.66 vs. 6.57±0.98 ng/mL/h; P=0.01) and serum noradrenaline (76.7±8.2 vs. 101.9±10.5 pg/mL; P=0.03) and significant improvement of glomerular filtration rate (87.3±2.7 vs. 78.7±2.3 mL/min; P=0.03) and renal blood flow (703±17 vs. 631±12 mL/min; P=0.03); no significant effects were noted in the PROPRA group. The 2-year occurrence of further decompensation was significantly lower in the CARVE group than in the PROPRA group (10.5% vs. 35.9%; P=0.003); survival at 2 years was significantly higher in the CARVE group (86% vs. 64.1%; P=0.01, respectively). CONCLUSION: Carvedilol at the dose of 12.5 mg/d should be the nonselective beta-blocker treatment of choice in patients with cirrhosis and nonrefractory ascites, as it improves renal perfusion and outcome.

Platypnea orthodeoxia syndrome in a patient with patent foramen ovale and normal atrial pressure. Case report and presentation of underlying pathophysiological mechanisms.

Platypnea-orthodeoxia Syndrome is characterized by clinically significant postural hypoxia. The full spectrum of the syndrome includes intracardial and extracardial abnormalities with R->L shunt. Various concurrent underlying physiological abnormalities are usually encountered that require thorough clinical and laboratory evaluation. A high clinical suspicion in patients with unexplained dyspnea is also required to reach a firm diagnosis. We herein present a rare case of an 82-years-old patient with episodic unexplained dyspnea, patent foramen ovale with normal pulmonary pressures and we review the underlying physiologic mechanisms.

Impaired coronary microcirculation is associated with left ventricular diastolic dysfunction in end-stage chronic kidney disease patients.

INTRODUCTION: Coronary vascular dysfunction, as assessed by coronary flow reserve (CFR) in the left anterior descending coronary artery, is found in various conditions including end-stage chronic kidney disease (CKD). Currently, we investigated the associations of CFR with echocardiographic indices of systolic and diastolic cardiac function and identified independent predictors of CFR in hemodialysis patients. METHODS: End-stage CKD patients treated with hemodialysis (n = 29) without known cardiovascular disease were recruited from a Hemodialysis Unit in Northwestern Greece. A thorough echocardiographic evaluation including CFR measurement following dipyridamole infusion was performed in all participants. Arterial stiffness was assessed by measurement of carotid-femoral pulse wave velocity and aortic augmentation index. RESULTS: The mean age of the patients was 63 years, and mean duration of hemodialysis was 2.9 years. CFR was 1.60 ± 0.37 while dipyridamole caused a significant increase in E'sep , Slat , E'lat , and Stroke volume (P < .05 for all). Independent predictors of CFR were posterior wall thickness (B -0.408, P = .013) and dipyridamole-induced changes in Tei index (B -0.425, P = .007). A severely decreased CFR < 1.5 was observed in 52% of the patients. E/E' ratio (B 10.84, P = .014) was the single independent predictor of severely decreased CFR. CONCLUSIONS: In end-stage CKD patients on hemodialysis without known cardiovascular disease, impaired coronary vascular function was prevalent and related to increased left ventricular wall thickness, increased filling pressures, and dipyridamole-induced deteriorated myocardial function independently of the presence of wall-motion abnormalities. Further studies are required to clarify the prognostic role of dipyridamole-induced cardiac changes in hemodialysis patients.

The prognostic role of myocardial strain indices and dipyridamole stress test in renal transplantation patients.

INTRODUCTION: Renal transplantation (RT) increases survival in end-stage kidney disease patients but cardiovascular diseases remain the leading cause of morbidity and mortality. We evaluated the role of myocardial strain (2DSTE) indices and dipyridamole-induced (DIPSE) changes in echocardiographic parameters at baseline for the prediction of clinical events and echocardiographically assessed deterioration of cardiac function in a RT population. METHODS: Forty-five RT patients underwent an echocardiographic study at baseline including 2DSTE and DIPSE. If no cardiovascular/renal event occurred, patients were investigated at 3-year follow-up; eight patients presented a clinical event while 37 patients were re-evaluated. RESULTS: Coronary flow reserve (CFR) was abnormal in 24% of the population. DIPSE induced improvements in classic and 2DSTE systolic and diastolic echocardiographic indices including TWIST, UNTWIST, global longitudinal strain (GLS), and circumferential strain (P < .05 for all). Compared to baseline, deteriorations in E/E', LVEF, E', and TWIST were observed at follow-up (P < .05 for all). DIPSE-induced changes in GLS, global radial strain, and LVEF were associated with changes in these indices at follow-up (P < .05 for all). Higher LV mass index, E/E', and lower MAPSE, E', and CFR at baseline were associated with the occurrence of clinical events at follow-up (P < .05 for all). CONCLUSIONS: In RT patients, coronary vascular dysfunction (ie, low CFR) was associated with the occurrence of adverse events. DIPSE-induced changes in myocardial strain and classic echocardiographic indices could identify individuals with a subclinical deterioration in cardiac function at follow-up. This may indicate that DIPSE could serve as a means to assess myocardial reserve in this population.

Noninvasive CT-based hemodynamic assessment of coronary lesions derived from fast computational analysis: a comparison against fractional flow reserve.

OBJECTIVES: Application of computational fluid dynamics (CFD) to three-dimensional CTCA datasets has been shown to provide accurate assessment of the hemodynamic significance of a coronary lesion. We aim to test the feasibility of calculating a novel CTCA-based virtual functional assessment index (vFAI) of coronary stenoses > 30% and ≤ 90% by using an automated in-house-developed software and to evaluate its efficacy as compared to the invasively measured fractional flow reserve (FFR). METHODS AND RESULTS: In 63 patients with chest pain symptoms and intermediate (20-90%) pre-test likelihood of coronary artery disease undergoing CTCA and invasive coronary angiography with FFR measurement, vFAI calculations were performed after 3D reconstruction of the coronary vessels and flow simulations using the finite element method. A total of 74 vessels were analyzed. Mean CTCA processing time was 25(± 10) min. There was a strong correlation between vFAI and FFR, (R = 0.93, p < 0.001) and a very good agreement between the two parameters by the Bland-Altman method of analysis. The mean difference of measurements from the two methods was 0.03 (SD = 0.033), indicating a small systematic overestimation of the FFR by vFAI. Using a receiver-operating characteristic curve analysis, the optimal vFAI cutoff value for identifying an FFR threshold of ≤ 0.8 was ≤ 0.82 (95% CI 0.81 to 0.88). CONCLUSIONS: vFAI can be effectively derived from the application of computational fluid dynamics to three-dimensional CTCA datasets. In patients with coronary stenosis severity > 30% and ≤ 90%, vFAI performs well against FFR and may efficiently distinguish between hemodynamically significant from non-significant lesions. KEY POINTS: Virtual functional assessment index (vFAI) can be effectively derived from 3D CTCA datasets. In patients with coronary stenoses severity > 30% and ≤ 90%, vFAI performs well against FFR. vFAI may efficiently distinguish between functionally significant from non-significant lesions.

Virtual Functional Assessment of Coronary Stenoses Using Intravascular Ultrasound Imaging: A Proof-of-Concept Pilot Study.

AIMS: We aimed to investigate the performance of virtual functional assessment of coronary stenoses using intravascular ultrasound (IVUS)-based three-dimensional (3D) coronary artery reconstruction against the invasively measured fractional flow reserve (FFR). METHODS AND RESULTS: Twenty-two (22) patients with either typical symptoms of stable angina or a positive stress test, who underwent IVUS and FFR, were included in this study. Five (5) patients presented FFR values lower than the 0.80 threshold, indicating ischaemia. IVUS-based 3D reconstruction and blood flow simulation were performed and the virtual functional assessment index (vFAI) was calculated. A strong correlation between IVUS-based vFAI and FFR was observed (Spearman correlation coefficient [rs]=0.88, p<0.0001). There was a small overestimation of the FFR by the IVUS-based vFAI (mean difference=0.0196±0.037; p=0.023 for difference from zero). All cases with haemodynamically significant stenoses (FFR≤0.8) were correctly categorised by the IVUS-based vFAI (vFAI≤0.8). CONCLUSION: The proposed approach allows the complete and comprehensive assessment of coronary stenoses providing anatomic and physiologic information, pre- and post-intervention, using only an IVUS catheter without the use of a pressure wire.

Virtual Resting Pd/Pa From Coronary Angiography and Blood Flow Modelling: Diagnostic Performance Against Fractional Flow Reserve.

BACKGROUND: Fractional flow reserve (FFR) has been established as a useful diagnostic tool. The distal coronary pressure to aortic pressure (Pd/Pa) ratio at rest is a simpler physiologic index but also requires the use of the pressure wire, whereas recently proposed virtual functional indices derived from coronary imaging require complex blood flow modelling and/or are time-consuming. Our aim was to test the diagnostic performance of virtual resting Pd/Pa using routine angiographic images and a simple flow model. METHODS: Three-dimensional quantitative coronary angiography (3D-QCA) was performed in 139 vessels (120 patients) with intermediate lesions assessed by FFR. The resting Pd/Pa for each lesion was assessed by computational fluid dynamics. RESULTS: The discriminatory power of virtual resting Pd/Pa against FFR (reference: ≤0.80) was high (area under the receiver operator characteristic curve [AUC]: 90.5% [95% CI: 85.4-95.6%]). Diagnostic accuracy, sensitivity and specificity for the optimal virtual resting Pd/Pa cut-off (≤0.94) were 84.9%, 90.4% and 81.6%, respectively. Virtual resting Pd/Pa demonstrated superior performance (p<0.001) versus 3D-QCA %area stenosis (AUC: 77.5% [95% CI: 69.8-85.3%]). There was a good correlation between virtual resting Pd/Pa and FFR (r=0.69, p<0.001). CONCLUSIONS: Virtual resting Pd/Pa using routine angiographic data and a simple flow model provides fast functional assessment of coronary lesions without requiring the pressure-wire and hyperaemia induction. The high diagnostic performance of virtual resting Pd/Pa for predicting FFR shows promise for using this simple/fast virtual index in clinical practice.

Three-dimensional reconstruction of coronary arteries and plaque morphology using CT angiography--comparison and registration with IVUS.

BACKGROUND: The aim of this study is to present a new methodology for three-dimensional (3D) reconstruction of coronary arteries and plaque morphology using Computed Tomography Angiography (CTA). METHODS: The methodology is summarized in six stages: 1) pre-processing of the initial raw images, 2) rough estimation of the lumen and outer vessel wall borders and approximation of the vessel's centerline, 3) manual adaptation of plaque parameters, 4) accurate extraction of the luminal centerline, 5) detection of the lumen - outer vessel wall borders and calcium plaque region, and 6) finally 3D surface construction. RESULTS: The methodology was compared to the estimations of a recently presented Intravascular Ultrasound (IVUS) plaque characterization method. The correlation coefficients for calcium volume, surface area, length and angle vessel were 0.79, 0.86, 0.95 and 0.88, respectively. Additionally, when comparing the inner and outer vessel wall volumes of the reconstructed arteries produced by IVUS and CTA the observed correlation was 0.87 and 0.83, respectively. CONCLUSIONS: The results indicated that the proposed methodology is fast and accurate and thus it is likely in the future to have applications in research and clinical arena.

Fibroblast growth factors in cardiovascular disease: The emerging role of FGF21.

Early detection of risk factors for enhanced primary prevention and novel therapies for treating the chronic consequences of cardiovascular disease are of the utmost importance for reducing morbidity. Recently, fibroblast growth factors (FGFs) have been intensively studied as potential new molecules in the prevention and treatment of cardiovascular disease mainly attributable to metabolic effects and angiogenic actions. Members of the endocrine FGF family have been shown to increase metabolic rate, decrease adiposity, and restore glucose homeostasis, suggesting a multiple metabolic role. Serum levels of FGFs have been associated with established cardiovascular risk factors as well as with the severity and extent of coronary artery disease and could be useful for prediction of cardiovascular death. Furthermore, preclinical investigations and clinical trials have tested FGF administration for therapeutic angiogenesis in ischemic vascular disease, demonstrating a potential role in improving angina and limb function. FGF21 has lately emerged as a potent metabolic regulator with multiple effects that ultimately improve the lipoprotein profile. Early studies show that FGF21 is associated with the presence of atherosclerosis and may play a protective role against plaque formation by improving endothelial function. The present review highlights recent investigations suggesting that FGFs, in particular FGF21, may be useful as markers of cardiovascular risk and may also serve as protective/therapeutic agents in cardiovascular disease.

Role of 9p21 and 2q36 variants and arterial stiffness in the prediction of coronary artery disease.

BACKGROUND: Genetic polymorphisms and arterial stiffness indices have been associated with cardiovascular prognosis and the presence and extent of angiographic coronary artery disease (CAD). We aimed to investigate whether arterial stiffness indices and 9p21 and 2q36 variants may improve prediction of CAD presence and extent when added to classical cardiovascular risk factors in patients at high risk for CAD. MATERIALS AND METHODS: In this cross-sectional study, we enrolled 183 consecutive patients with suspected stable CAD (age 61 ± 9 years, 134 males) referred for diagnostic coronary angiography. Framingham risk score (FRS) was calculated. Arterial stiffness was assessed by carotid-femoral pulse wave velocity (PWV) and central augmentation index (AIx) using applanation tonometry. Genetic polymorphisms of 9p21 (rs1333049) and 2q36 (rs2943634) loci were also analysed. RESULTS: Higher FRS and PWV and the presence of rs2943634 risk allele were independent predictors of CAD (Nagelkerke R(2) 0·252, P < 0·001), while higher FRS and the presence of rs1333049 risk allele were independent predictors of multivessel CAD (Nagelkerke R(2) 0·190, P < 0·001). Genetic polymorphisms and vascular indices did not improve the predictive accuracy of FRS-based models (P > 0·1 for all) for CAD presence or extent. CONCLUSIONS: In these high-risk patients, 9p21 and 2q36 variants and PWV were independently associated with CAD presence and extent, but the addition of both genetic data and arterial stiffness indices to FRS did not improve the prediction of CAD compared with FRS alone. Further studies are needed to clarify the prognostic role of genetic and vascular indices in the prediction of angiographic CAD.

Endothelial dysfunction, but not structural atherosclerosis, is evident early in children with heterozygous familial hypercholesterolemia.

Children with heterozygous familial hypercholesterolemia (heFH) are prone to premature atherosclerosis. Vascular endothelial dysfunction may predict increased cardiovascular risk in children with heFH. The aim of this study was to assess for early functional and structural vascular changes in children with heFH. This cross-sectional study included 30 children with heFH (mean age 12 years) and 30 age- and sex-matched controls. Brachial artery flow-mediated dilation (FMD), carotid intima-media thickness (cIMT), carotid-femoral pulse wave velocity, and large- and small vessel compliance were measured noninvasively. HeFH children exhibited significantly greater total and LDL cholesterol, apolipoprotein B, and lipoprotein (a) levels (p < 0.05 for all) and lower FMD (6.23 ± 3.88 vs. 9.46 ± 4.54 %, p < 0.004) compared with controls. When children were divided in age subgroups, FMD was found to be significantly decreased in heFH compared with control subjects only in ages >10 years (p < 0.05). However, FMD was found to be similarly impaired in heFH children in all age subgroups (two-way analysis of variance, p = 0.39). No differences in other vascular function indices were found. In heFH patients, but not in controls, FMD was inversely correlated with cIMT (r = -0.378, p = 0.036). In conclusion, endothelial dysfunction occurs early in heFH children indicating an increased risk for premature cardiovascular disease and reflecting probably the need for early initiation of anticholesterolemic treatment. Decreased FMD is detected before structural atherosclerotic changes occur.

Is it time for a retinoic acid-eluting stent or retinoic acid-coated balloon? Insights from experimental studies of systemic and local delivery of retinoids.

Although the incidence of restenosis and stent thrombosis has substantially declined during the last decades, they still constitute the two major causes of stent failure. These complications are partially attributed to the currently used cytostatic drugs, which can cause local inflammation, delay or prevent re-endothelialization and essentially cause arterial cell toxicity. Retinoic acid (RA), a vitamin A (retinol) derivative, is a naturally occurring substance used for the treatment of cell proliferation disorders. The agent has pleiotropic effects on vascular smooth muscle cells and macrophages: it influences the proliferation, migration, and transition of smooth muscle cells to other cell types and modulates macrophage activation. These observations are supported by accumulated evidence from in vitro and in vivo experiments. In addition, systemic and topical administration of RA can decrease the development of atherosclerotic plaques and reduce or inhibit restenosis after vascular injury (caused by embolectomy, balloon catheters, or ligation of arteries) in various experimental models. Recently, an RA-drug eluting stent (DES) has been tested in an animal model. In this review, we explore the effects of RA in atherosclerosis and the potential of the local delivery of RA through an RA-DES or RA-coated balloon for targeted therapeutic percutaneous vascular interventions. Despite promising published results, further experimental study is warranted to examine the safety and efficacy of RA-eluting devices in vascular artery disease.

Absolute zero-contrast percutaneous coronary interventions: An intravascular ultrasound-guided case series and literature review.

PURPOSE: Contrast media (CM)-associated adverse effects including mainly acute kidney injury and hypersensitivity reactions still remain a significant treatment burden to vulnerable patients requiring percutaneous coronary intervention (PCI). The complete omission of CM administration accompanied by intravascular ultrasound (IVUS) guidance may offer an appropriate revascularization treatment. METHODS: We hereby present a case series of four patients with challenging coronary lesions and relative/absolute contraindications to CM use [(hypersensitivity reaction owning to CM, history of contrast-induced acute kidney injury, solitary kidney, or advanced chronic kidney disease (CKD)] who underwent absolute zero-contrast IVUS-guided PCI following a predetermined protocol. RESULTS: The initial diagnostic angiography was reviewed for landmark identification, and multiple guidewires created a metallic road map providing additional landmarks and protected side branches. IVUS imaging was performed to determine lesion length, reference segments and landing zones, assess stent expansion/apposition and identify major complications. All procedures were successfully completed without any CM administration, renal function deterioration, pericardial effusion, or stent edge dissection. CONCLUSIONS: We demonstrated the feasibility of absolute zero-contrast IVUS-guided PCI in patients with complex coronary lesions susceptible to CM-associated adverse effects. Since the safety of this strategy is well-documented in patients with CKD and challenging lesions morphology even in acute settings, evidence-based validation of this approach is capable of changing the otherwise conservative treatment of vulnerable patients where even minimum doses of CM may have detrimental effects. SUMMARY FOR THE ANNOTATED TABLE OF CONTENTS: Patients with vulnerable renal function as well as former hypersensitivity reaction to contrast media encounter a significant treatment burden regarding coronary artery disease. Zero-contrast IVUS-guided strategy based on a predetermined protocol provides a feasible alternative approach in patients susceptible to contrast media-associated adverse effects even in the presence of complex coronary lesions.

In-Hospital versus Out-of-Hospital Pulmonary Embolism: Clinical Characteristics, Biochemical Markers and Echocardiographic Indices.

BACKGROUND: A significant proportion of pulmonary embolisms (PEs) occurs in patients during hospitalisation for another reason. However, limited data regarding differences between out-of-hospital PE (OHPE) and in-hospital PE (IHPE) is available. We aimed to compare these groups regarding their clinical characteristics, biochemical markers, and echocardiographic indices. METHODS: This was a prospective, single-arm, single-centre study. Adult consecutive patients with non-COVID-related PE from September 2019 to March 2022 were included and followed up for 12 months. RESULTS: The study included 180 (84 women) patients, with 89 (49.4%) suffering from IHPE. IHPE patients were older, they more often had cancer, were diagnosed earlier after the onset of symptoms, they had less frequent pain and higher values of high sensitivity troponin I and brain natriuretic peptide levels compared to OHPE patients. Echocardiographic right ventricular (RV) dysfunction was detected in similar proportions in the 2 groups. IHPE had increased in-hospital mortality (14.6% vs. 3.3%, p = 0.008) and similar post-discharge to 12-month mortality with OHPE patients. CONCLUSIONS: In this prospective cohort study, IHPE differed from OHPE patients regarding age, comorbidities, symptoms, and levels of biomarkers associated with RV dysfunction. IHPE patients had higher in-hospital mortality compared to OHPE patients and a similar risk of death after discharge.

The Role of Prognostic Scores in Assessing the Prognosis of Patients Admitted in the Cardiac Intensive Care Unit: Emphasis on Heart Failure Patients.

Background/Objectives: Patient care in Cardiac Intensive Care Units (CICU) has evolved but data on patient characteristics and outcomes are sparse. This retrospective observational study aimed to define clinical characteristics and risk factors of CICU patients, their in-hospital and 30-day mortality, and compare it with established risk scores. Methods: Consecutive patients (n = 294, mean age 70 years, 74% males) hospitalized within 15 months were studied; APACHE II, EHMRG, GWTG-HF, and GRACE II were calculated on admission. Results: Most patients were admitted for ACS (48.3%) and acute decompensated heart failure (ADHF) (31.3%). Median duration of hospitalization was 2 days (IQR = 1, 4). In-hospital infection occurred in 20%, 18% needed mechanical ventilation, 10% renal replacement therapy and 4% percutaneous ventricular assist devices (33%, 29%, 20% and 4%, respectively, for ADHF). In-hospital and 30-day mortality was 18% and 11% for all patients (29% and 23%, respectively, for ADHF). Established scores (especially APACHE II) had a good diagnostic accuracy (area under the curve-AUC). In univariate and multivariate analyses in-hospital intubation and infection, history of coronary artery disease, hypotension, uremia and hypoxemia on admission were the most important risk factors. Based on these, a proposed new score showed a diagnostic accuracy of 0.954 (AUC) for in-hospital mortality, outperforming previous scores. Conclusions: Patients are admitted mainly with ACS or ADHF, the latter with worse prognosis. Several patients need advanced support; intubation and infections adversely affect prognosis. Established scores predict mortality satisfactorily, but larger studies are needed to develop CICU-directed scores to identify risk factors, improve prediction, guide treatment and staff training.

Patient-specific computational modeling of subendothelial LDL accumulation in a stenosed right coronary artery: effect of hemodynamic and biological factors.

Atherosclerosis is a systemic disease with local manifestations. Low-density lipoprotein (LDL) accumulation in the subendothelial layer is one of the hallmarks of atherosclerosis onset and ignites plaque development and progression. Blood flow-induced endothelial shear stress (ESS) is causally related to the heterogenic distribution of atherosclerotic lesions and critically affects LDL deposition in the vessel wall. In this work we modeled blood flow and LDL transport in the coronary arterial wall and investigated the influence of several hemodynamic and biological factors that may regulate LDL accumulation. We used a three-dimensional model of a stenosed right coronary artery reconstructed from angiographic and intravascular ultrasound patient data. We also reconstructed a second model after restoring the patency of the stenosed lumen to its nondiseased state to assess the effect of the stenosis on LDL accumulation. Furthermore, we implemented a new model for LDL penetration across the endothelial membrane, assuming that endothelial permeability depends on the local lumen LDL concentration. The results showed that the presence of the stenosis had a dramatic effect on the local ESS distribution and LDL accumulation along the artery, and areas of increased LDL accumulation were observed in the downstream region where flow recirculation and low ESS were present. Of the studied factors influencing LDL accumulation, 1) hypertension, 2) increased endothelial permeability (a surrogate of endothelial dysfunction), and 3) increased serum LDL levels, especially when the new model of variable endothelial permeability was applied, had the largest effects, thereby supporting their role as major cardiovascular risk factors.

Cerebro-/Cardiovascular Collateral Damage During the COVID-19 Pandemic: Fact or Fiction?

Numerous observational studies have identified a decline in cerebro-/cardiovascular (CV) admissions during the initial phase of the COVID-19 pandemic. Recent studies and meta-analyses indicated that the overall decrease was smaller than that found in initial studies during the first months of 2020. Two years later we still do not have clear evidence about the potential causes and impacts of the reduction of CV hospitalizations during the COVID-19 pandemic. It has becoming increasingly evident that collateral damage (i.e., incidental damage to the public and patients) from the COVID-19 outbreak is the main underlying cause that at least somewhat reflects the effects of imposed measures such as social distancing and self-isolation. However, a smaller true decline in CV events in the community due to a lack of triggers associated with such acute syndromes cannot be excluded. There is currently indirect epidemiological evidence about the immediate impact that the collateral damage had on excess mortality, but possible late consequences including a rebound increase in CV events are yet to be observed. In the present narrative review, we present the reporting milestones in the literature of the rates of CV admissions and collateral damage during the last 2 years, and discuss all possible factors contributing to the decline in CV hospitalizations during the COVID-19 pandemic. Healthcare systems need to be prepared so that they can cope with the increased hospitalization rates for CV events in the near future.