Left atrial strain and ventricular global longitudinal strain in cirrhotic patients using the new criteria of Cirrhotic Cardiomyopathy Consortium.

BACKGROUND: The new criteria of Cirrhotic Cardiomyopathy Consortium (CCC) propose the use of left ventricular global longitudinal strain (LV-GLS) for evaluation of systolic function in patients with cirrhosis. The aim of this study was to evaluate LV-GLS and left atrial (LA) strain in association with the severity of liver disease and to assess the characteristics of cirrhotic cardiomyopathy (CCM). METHODS: One hundred and thirty-five cirrhotic patients were included. Standard echocardiography and speckle tracking echocardiography (2D-STE) were performed, and dual X-ray absorptiometry was used to quantify the total and regional fat mass. CCM was defined, based on the criteria of CCC, as having advanced diastolic dysfunction, left ventricular ejection fraction ≤50% and/or a GLS <18%. RESULTS: LV-GLS lower or higher than the absolute mean value (22.7%) was not associated with mortality (logrank, p = 0.96). LV-GLS was higher in patients with Model for end stage liver disease (MELD) score ≥15 compared to MELD score <15 (p = 0.004). MELD score was the only factor independently associated with systolic function (LV-GLS <22.7% vs. ≥22.7%) (Odds Ratio:1.141, p = 0.032). Patients with CCM (n = 11) had higher values of estimated volume of visceral adipose tissue compared with patients without CCM (median: 735 vs. 641 cm3 , p = 0.039). On multivariable Cox regression analysis, MELD score [Hazard Ratio (HR):1.26, p < 0.001] and LA reservoir strain (HR:0.96, p = 0.017) were the only factors independently associated with the outcome. CONCLUSION: In our study, absolute LV-GLS was higher in more severe liver disease, and LA reservoir strain was significantly associated with the outcome in patients with end-stage liver disease.

Association of loop diuretics use and dose with outcomes in outpatients with heart failure: a systematic review and meta-analysis of observational studies involving 96,959 patients.

There is ongoing controversy regarding the association between loop diuretics (LD), especially in high doses, and adverse clinical outcomes in outpatients with heart failure (HF). We performed a systematic review of the evidence for LD in outpatients with HF. We searched MEDLINE, EMBASE, and Cochrane Clinical Trial Collection to identify controlled studies, evaluating the association between LD and morbidity and mortality in patients with HF. The primary endpoint was all-cause mortality and secondary endpoint HF hospitalizations. Quantitative analysis was performed by generating forest plots and pooling adjusted risk estimates across studies using random effects models. Between-study heterogeneity was assessed through Q and I2 statistics. Twenty-four studies with a total of 96,959 patients were included. No randomized studies were identified. Use of LD was associated with increased all-cause mortality compared with non-use (pooled adjusted risk estimates, 1.18; P = 0.001) and increased HF hospitalization rates (pooled adjusted risk estimates, 1.81; P < 0.001). These associations remained significant after excluding studies that included HF patients at discharge from hospital (pooled adjusted risk estimates, 1.31 and 1.89, respectively; P < 0.001 for both). High-dose LD (median dose 80 mg) were also associated with increased all-cause mortality (pooled adjusted risk estimates, 1.99; P < 0.001) compared with low-dose LD. Again, this association remained significant after excluding studies that included HF patients at discharge from hospital (pooled adjusted risk estimates, 1.33; P < 0.001). Existing evidence indicates that LD, especially in high doses, are associated with increased all-cause mortality and HF hospitalization rates. For this reason, prospective, randomized studies are warranted to clarify whether these associations indicate causality or are merely an epiphenomenon due to disease severity. Systematic review registration: PROSPERO database registration number CRD42020153239. Date of registration: 28 April 2020.

Cardiac adiposity as a modulator of cardiovascular disease in HIV.

BACKGROUND: With the number of people living with human immunodeficiency virus (HIV) steadily increasing, cardiovascular disease has emerged as a leading cause of non-HIV related mortality. People living with HIV (PLWH) appear to be at increased risk of coronary artery disease and heart failure (HF), while the underlying mechanism appears to be multifactorial. In the general population, ectopic cardiac adiposity has been highlighted as an important modulator of accelerated coronary artery atherosclerosis, arrhythmogenesis and HF with preserved ejection fraction (HFpEF). Cardiac adiposity is also strongly linked with obesity, especially with visceral adipose tissue accumulation. AIMS: This review aims to summarize the possible role of cardiac fat depositions, assessed by imaging modalities,as potential contributors to the increased cardiac morbidity and mortality seen in PLWH, as well as therapeutic targets in the current ART era. MATERIALS & METHODS: Review of contemporary literature on this topic. DISCUSSION: Despite antiretroviral therapy (ART), PLWH have evidence of persistent, HIV-related systemic inflammation and body fat alterations. Cardiac adiposity can play an additional role in the pathogenesis of cardiovascular disease in the HIV setting. Imaging modalities such as echocardiography, cardiac multidetector computed tomography and cardiac magnetic resonance have demonstrated increased adipose tissue. Studies show that high cardiac fat depots play an additive role in promoting coronary artery atherosclerosis and HFpEF in PLWH. Systemic inflammation due to HIV infection, metabolic adverse effects of ART, adipose alterations in the ageing HIV population, inflammation and immune activation are likely important mechanisms for adipose dysfunction and disproportionately occurrence of ectopic fat depots in the heart among PLWH. CONCLUSIONS: High cardiac adiposity seems to plays an additive role in promoting coronary artery atherosclerosis and HFpEF in PLWH. The underlying mechanisms are multiple and warrant further investigation. Improved understanding of the regulating mechanisms that increase cardiovascular risk in HIV infection may give rise to more tailored therapeutic strategies targeting cardiac fat depots.

Imaging modalities for cardiovascular phenotyping in asymptomatic people living with HIV.

Cardiovascular disease (CVD) has emerged as a leading cause of non-HIV-related mortality among people living with HIV (PLWH). Despite the growing CVD burden in PLWH, there is concern that general population risk score models may underestimate CVD risk in these patients. Imaging modalities have received mounting attention lately to better understand the pathophysiology of subclinical CVD and provide improved risk assessment in this population. To date, traditional and well-established techniques such as echocardiography, pulse wave velocity, and carotid intima thickness continue to be the basis for the diagnosis and subsequent monitoring of vascular atherosclerosis and heart failure. Furthermore, novel imaging tools such as cardiac computed tomography (CT) and cardiac CT angiography (CCTA), positron emission tomography/CT (PET/CT), and cardiac magnetic resonance (CMR) have provided new insights into accelerated cardiovascular abnormalities in PLWH and are currently evaluated with regards to their potential to improve risk stratification.

Pulmonary Embolism Prophylaxis in Patients With COVID-19: An Emerging Issue.

Severe acute respiratory syndrome (SARS)-CoV-2 virus disease (coronavirus disease 2019; COVID-19) is associated with increased coagulation activity, resulting in an excessive risk of venous thromboembolism (VTE) and poor prognosis. The most common manifestation of VTE is pulmonary embolism (PE), with approximately one in five hospitalised patients being at risk. These reports led to the empirical use of prophylactic anticoagulation, even in the absence of established or clinically suspected disease. This review summarises current aspects and recommendations regarding the use of thromboprophylaxis for PE in patients with COVID-19.

Diagnosis and treatment complications of primary cardiac lymphoma in an immunocompetent 28-year old man: a case report.

BACKGROUND: Primary cardiac lymphomas (PCL) represent extremely rare cardiac tumors which are accompanied by poor prognosis, unless they are timely diagnosed and treated. CASE PRESENTATION: Herein we present a 28-year-old, immunocompetent man who presented to our hospital due to progressively worsening symptoms and signs of superior vena cava syndrome. Multi-modality imaging demonstrated a large intracardiac tumor, which was proven, by biopsy, to be a PCL. The patient received targeted chemotherapy which led to total remission of his disease, with no relapse over a 15-month follow-up period. CONCLUSIONS: Although PCLs are rare, they should always be kept in mind in the differential diagnosis of cardiac tumors. Timely diagnosis of PCLs and appropriate chemotherapy, alone or in combination with radiotherapy, seems to provide the best results.

Ibrutinib-related atrial fibrillation: Therapeutic challenges.

Ibrutinib is a drug used in several lymphohyperplastic diseases. Its use is associated with an increased risk of atrial fibrillation. New-onset atrial fibrillation in this setting is a true challenge as several antiarrhythmic drugs are not indicated and long-term anticoagulation has several limitations. Herein, we describe our experience in treating a 55-year-old patient receiving ibrutinib who presented with new-onset atrial fibrillation and borderline arterial pressure. Since first-line therapies, electrical cardioversion and ablation, could not be performed, rhythm control with intravenous administration of amiodarone was attempted and led to prompt sinus rhythm restoration. We discuss the therapeutic challenges related to sinus rhythm restoration and anticoagulation in this group of atrial fibrillation patients.

Cardiac Surgery for Carcinoid Heart Disease: A Weapon Not to Be Misused.

Carcinoid heart disease (CHD) complicates approximately 25% of patients with a carcinoid tumor and carcinoid syndrome and leads to heart valve degeneration with mixed-stenotic and regurgitation pathology and consequent heart failure (HF) leading to significant morbidity and mortality. Cardiac surgery in symptomatic, severe CHD leads to significantly better functional capacity and prolonged survival when compared to medical treatment alone. Recent studies have shown improvement in postoperative outcomes of patients undergoing surgery for CHD over the last decades. The trend for early diagnosis and application of surgery prior to the manifestation of HF symptoms, which tended to develop during the previous years, does not seem justifiable based on the findings of recent studies. Therefore, the optimal timing of intervention in CHD and the type of valve that should preferably be used remain issues of controversy. This review comprehensively examines the existing literature on the treatment options for patients with CHD, with a special focus on short- and long-term survival after cardiac surgery, and discusses the selection of the exact patient profile and intervention timing that are more likely to optimize the benefit-to-risk ratio for surgical intervention.

Inverse Relationship between Adherence to the Mediterranean Diet and Serum Cystatin C Levels.

OBJECTIVE: The aim of the present study was to examine serum cystatin C levels in association with the Mediterranean diet in a healthy Greek population. METHODS: Cystatin C together with basic clinical chemistry tests was measured in a total of 490 adults (46±16 years, 40% of males), who underwent an annual health check. Demographic, anthropometric and lifestyle characteristics were recorded, while adherence to the Mediterranean diet was evaluated through the MedDietScore (0-55). RESULTS: The mean level of serum cystatin C was 0.84 mg/L, while men had increased serum cystatin C levels compared to women (0.86 mg/L vs. 0.83 mg/L, respectively, 0.017). After adjusting for age, gender, body mass index, smoking status, hypertension, diabetes, hypercholesterolemia, estimated glomerular filtration rate (eGFR), albumin and ferritin levels, each unit increase in MedDietScore led to 0.002 mg/dL drop off in cystatin C serum levels. CONCLUSIONS: We have demonstrated an inverse relationship between the MedDietScore and serum cystatin C levels. Our finding that increases in MedDietScore are associated with decreases in serum cystatin C levels could imply that adherence to the Mediterranean diet may reduce the cardiovascular risk, as assessed by cystatin C, a prognostic marker of the cardiometabolic risk. This notion could have a great impact on public health.

Diagnosis and Treatment of Left-Sided Prosthetic Paravalvular Regurgitation.

Paravalvular leak (PVL) is a complication related to the surgical implantation of left-sided prosthetic valves. The prevalence of paravalvular regurgitation ranges between 5 and 20%. Left-sided prosthetic paravalvular regurgitation presents with a wide constellation of signs and symptoms ranging from asymptomatic murmur to heart failure, hemolysis and cardiac cachexia. Echocardiography plays a key role in imaging the PVL and can help in guiding the closure procedure with both transesophageal and intracardiac probes. Transcatheter closure of paravalvular regurgitations is an appealing prospect.

Triple prosthetic valve dysfunction 30 years after surgery.

Triple prosthetic valve operation carries a high peri-procedural risk and is associated with decreased long-term survival. Herein is reported the case of a 59-year-old female with a 30-year history of successful triple-valve replacement for rheumatic heart disease, who presented with symptomatic valvular dysfunction and rhythm disturbances. The patient was one of the few who had survived more than 30 years after triple-valve surgery. Illustrative echocardiograms and cinefluoroscopic images are provided, and issues regarding prosthetic valve dysfunction and rhythm disturbance management in operated patients are briefly discussed.

Right heart thrombus causing syncope in an elderly patient.

Pulmonary embolism and thromboembolic disease carry a high mortality if not recognised and managed appropriately. Herein we illustrate the case of a dehydrated elderly female patient with recurrent syncope who proved to have high risk pulmonary embolism and a free floating right heart thrombus. The echocardiographic findings of right heart thrombus and possible thrombi 'in transit' within a low flow inferior vena cava, guided a life-saving treatment in this frail elderly patient.

Real-World Data from the Use of Ranolazine in Patients with Stable Angina Pectoris: The RANGER Study.

Background: Although ranolazine has been available for years as a second-line treatment to reduce angina attacks in patients with stable angina pectoris, real-world data on the effectiveness, tolerability, and safety of ranolazine are limited. Methods: A non-interventional, prospective study was conducted to assess the effectiveness and safety of ranolazine. Patients eligible for enrolment had a baseline assessment between one and fourteen days after initiating ranolazine for the first time and a follow-up visit three months later. The primary endpoints comprised the weekly frequency of angina attacks, total adverse events, and ranolazine discontinuation rate. The secondary endpoints included the use of short-acting nitrates, changes on the Canadian Cardiovascular Society (CCS) angina classification score and quality of life scale score (QoL). Results: In total, 1101 patients were enrolled at 214 sites. Mean weekly angina attacks were reduced from 3.6 ± 2.9 to 0.4 ± 0.9 (p < 0.0001) and the mean weekly consumption of short-acting nitrates decreased by 1.7 ± 2.2 (p < 0.0001). CCS class and QoL were also improved (p < 0.0001). Adverse events were reported by 11 (1%) patients in total, while 2 of them (0.2%) were characterised as serious. Treatment was discontinued for various reasons in 23 patients (2.1%) after the follow-up period. Ranolazine treatment was equally effective in all subgroups tested, with larger benefits observed in patients with more frequent angina and CCS angina class III and IV. Up-titration of ranolazine during the study improved the outcomes. Conclusions: Ranolazine was well tolerated and effectively reduced angina attacks, with simultaneous improvement of the CCS class and QoL score in patients with stable angina.

Neck circumference is correlated with triglycerides and inversely related with HDL cholesterol beyond BMI and waist circumference.

BACKGROUND: Neck circumference, beyond a measure of obesity, is a unique fat depot with increasing significance. This study aimed to investigate the association between neck circumference and biomarkers, indicators of cardiovascular risk. METHODS: During 2009, 490 volunteers (46 ± 16 years, 40% men) were consecutively enrolled to the study (participation rate 85%). Biochemical analyses were performed through established procedures, and after 12-h fasting and glucose, total cholesterol, high-density lipoprotein and low-density lipoprotein cholesterol, triglycerides, cystatin C, uric acid and high-sensitivity C-reactive protein were measured. Anthropometric, lifestyle and dietary characteristics were also recorded to account for potential confounders. Additive linear and logistic regression models were used to evaluate the association between neck circumference and biomarkers of cardiometabolic risk. RESULTS: A positive association between neck circumference and systolic and diastolic blood pressure, glucose, triglycerides, uric acid and high-sensitivity C-reactive protein, and a negative association with high-density lipoprotein cholesterol were revealed (all ps < 0.05); models were adjusted for age, gender, years of school, smoking, physical activity status, MedDietScore and alcohol intake. The relationship between neck circumference and high-density lipoprotein cholesterol, glucose, triglycerides and uric acid remained significant when models were further stratified by body mass index class and abnormal waist circumference. CONCLUSION: Neck circumference was found to be a powerful indicator of atherogenic dyslipidaemia above and beyond central obesity indicators.

Influence of protein intake from haem and non-haem animals and plant origin on inflammatory biomarkers among apparently-healthy adults in Greece.

Intake of different types of protein may be associated with differences in biomarkers among various populations. This work investigated the influence of protein intake from haem and non-haem animals as well as protein from plants on haematological and biochemical parameters in inflammation among apparently-healthy adults living in Greece, a Mediterranean country. Four hundred and ninety apparently-healthy subjects (46 +/- 16 years, 40% men), who consecutively visited Polykliniki General Hospital for routine examinations, voluntarily agreed to participate in the study (participation rate 85%). Demographic, anthropometric and lifestyle characteristics were recorded. Participants completed a valid, semi-quantitative food frequency questionnaire. Protein intake was classified into three sources: protein from haem animals, protein from non-haem animals, and protein from plant origin. Fasting blood samples were taken from all participants; uric acid, creatinine, lipids, cystatin C, haptoglobin, haemoglobin, haematocrit, iron, ferritin, white blood cells, monocytes, platelets, and C-reactive protein were measured. Protein intake from only haem animals was associated with increased haemoglobin and haematocrit levels (p < 0.05) whereas intake of protein from non-haem animals and plant origin was not associated with the investigated haematological and biochemical markers of low-grade chronic inflammation when lifestyle factors and overall dietary habits were taken into account. Intake of protein from only haem animals seems to be consistently associated with haematological markers. The confounding role of dietary habits and lifestyle variables on the tested parameters deserves further attention in future research.