QT Interval Monitoring with Handheld Heart Rhythm ECG Device in COVID-19 Patients.

Background: QTc prolongation is an adverse effect of COVID-19 therapies. The use of a handheld device in this scenario has not been addressed. Objectives: To evaluate the feasibility of QTc monitoring with a smart device in COVID-19 patients receiving QTc-interfering therapies. Methods: Prospective study of consecutive COVID-19 patients treated with hydroxychloroquine ± azithromycin ± lopinavir-ritonavir. ECG monitoring was performed with 12-lead ECG or with KardiaMobile-6L. Both registries were also sequentially obtained in a cohort of healthy patients. We evaluated differences in QTc in COVID-19 patients between three different monitoring strategies: 12-lead ECG at baseline and follow-up (A), 12-lead ECG at baseline and follow-up with the smart device (B), and fully monitored with handheld 6-lead ECG (group C). Time needed to obtain an ECG registry was also documented. Results: One hundred and eighty-two COVID-19 patients were included (A: 119(65.4%); B: 50(27.5%); C: 13(7.1%). QTc peak during hospitalization did significantly increase in all groups. No differences were observed between the three monitoring strategies in QTc prolongation (p = 0.864). In the control group, all but one ECG registry with the smart device allowed QTc measurement and mean QTc did not differ between both techniques (p = 0.612), displaying a moderate reliability (ICC 0.56 [0.19-0.76]). Time of ECG registry was significantly longer for the 12-lead ECG than for handheld device in both cohorts (p < 0.001). Conclusion: QTc monitoring with KardiaMobile-6L in COVID-19 patients was feasible. Time of ECG registration was significantly lower with the smart device, which may offer an important advantage for prevention of virus dissemination among healthcare providers.

Diagnostic accuracy of regadenoson stress echocardiography: concordance with gated-spect myocardial perfusion imaging.

Regadenoson Stress Echocardiography (RSE) can detect myocardial ischemia, and its diagnostic accuracy should be evaluated. We sought to investigate the agreement between RSE and gated-SPECT myocardial perfusion imaging (MPI) and appraise its diagnostic accuracy. Consecutive patients (n = 202) referred for non-invasive evaluation of myocardial ischemia, with (38.6%) or without a previous coronary artery disease (CAD) diagnosis, were enrolled. Both tests were performed simultaneously. Invasive coronary angiography (CA) is considered the gold standard. The mean age was 70.9 (9.8) years, and 59.9% were male. The prevalence of cardiovascular risk factors (arterial hypertension [81.7%], diabetes mellitus [37.6%], hypercholesterolemia [71.8%], and smoking [18.8%]) was high. Forty-four patients (21.8%) had a non-interpretable electrocardiogram, 15 (34.1%) of them were a result of ventricular paced-rhythm, while 29 (65.9%) were a result of advanced left ventricular branch block. The overall agreement between both diagnostic techniques was good: Gwet's AC1 0.66 (CI95% 0.55 to 0.76), and it was higher in patients without a previous CAD diagnosis: 0.76 (CI95% 0.65 to 0.87). In the biased sample (those who underwent CA), RSE and nuclear study sensitivity was 0.50 and 0.78 and specificity was 0.75 and 0.75, respectively. We noted a dramatic reduction in sensitivity for RSE after debiasing (debiased sensitivity of 0.16), and the negative predictive value was similar to the biased and debiased samples. RSE is in strong agreement with gated-SPECT MPI. However, its low sensitivity and negative predictive value preclude its use as a bedside test to detect myocardial ischemia.

Percutaneous Mitral Valve Repair Vs. Stand-Alone Medical Therapy in Patients with Functional Mitral Regurgitation and Heart Failure.

BACKGROUND: Functional mitral regurgitation (FMR) is a common finding among patients with heart failure (HF) and it is related to adverse events. Outcomes in patients undergoing transcatheter mitral valve repair (TMVR) are still a matter of debate. We performed a meta-analysis to assess mid- and long-term outcomes of patients with FMR treated with MitraClip® compared to medical management. METHODS: We conducted an electronic database search of all published data PubMed Central, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar databases. The primary end-point was all-cause mortality. The secondary end-points were hospitalizations for HF, need for heart transplantation or left ventricular assist device, unplanned mitral valve surgery, myocardial infarction and stroke. RESULTS: Five studies (n = 1513 patients) were included in the analysis. The summary estimate including all the available studies showed a statistically significant reduction in all-cause mortality favoring MitraClip® (HR 0.56, CI 95% [0.38-0.84]) and HF hospitalizations (HR 0.65; CI 95% [0.46-0.92]). A significant reduction in the indication for advanced HF therapies (OR 0.48; CI 95% [0.25-0.90]) or the need for unplanned mitral valve surgery (OR 0.20; CI 95% [0.07-0.57]) was also found in the group of patients that underwent TMVR. No differences in the incidence of myocardial infarction or stroke were found between both groups of treatment. No publication bias was detected. CONCLUSION: TMVR with MitraClip® system was related to a significant reduction in all-cause mortality, hospitalizations for HF and the need for HF transplant, left ventricular assist device or unplanned surgery beyond 1-year follow up.

Scaling Echocardiographic Cardiac Dimensions to Body Size: A Bayesian Analysis in Healthy Men and Women.

BACKGROUND: Proper scaling of cardiac dimensions is of paramount importance in making correct decisions in clinical cardiology. The usual normalization of cardiac dimensions to overall body size assumes an isometric relationship. We sought to investigate these relationships to obtain the best allometric coefficient (AC) for scaling. METHODS: Ninety-seven healthy volunteers were included. The dimensions to be scaled were the left atrial volume, the end-diastolic and end-systolic left ventricular volumes, and the diameter of the tricuspid annulus. A Bayesian statistical analysis was applied with isometric coefficients as priors. RESULTS: The linear correlations between cardiac dimensions and body size were modest, ranging from 0.12 (-0.10-0.32) for the left atrial volume and height to 0.70 (0.58-0.80) for the end-diastolic volume and height. The ACs varied across the different cardiac dimensions and body size measurements. For the best linear relationships, the isometric coefficients were outside the 95% highest density interval of the posterior distribution for the left atrial volume-weight (AC: 0.7; 0.4-0.9) and end-diastolic volume-height (AC: 2.3; 1.7-2.9), whereas they were different from 1 for the left atrial volume-weight, end-diastolic volume, and diameter of the tricuspid annulus-body surface area (AC: 0.6; 0.3-0.8). Not scaling the cardiac dimensions to their corresponding ACs can lead to important errors in size estimations of cardiac structure. CONCLUSIONS: The ACs found in this study are somewhat different from the corresponding isometric coefficients and often different from 1. This finding should be considered when normalizing cardiac structures to body size when making clinical decisions.

Previously diagnosed cancer and mortality after ST-segment elevation acute myocardial infarction treated with primary angioplasty.

OBJECTIVE: We investigated if a previous cancer diagnosis influences the outcome of patients with STEMI treated with primary coronary intervention (PCI). BACKGROUND: ST-segment myocardial infarction (STEMI) and a history of cancer can coexist because both have a high incidence and prevalence. METHODS: Prospective cohort observational study, The primary end-point was total mortality. RESULTS: We included 917 patients, 53 of them (5.8%) were cancer survivors. During follow-up (median, 643 days [interquartile range, 258 to 1,015 days]), 100 patients died, 88 (10.2%) patients without a cancer diagnosis and 12 (22.6%) patients with a previous cancer diagnosis, which was significantly different (log-rank test = 8.4, p = .004). Cancer patients were older (73.4 (11.5) vs. 65.2 (13.8) years, p < .001), with a lower prevalence of previous stroke (1.1% vs. 2.2%, p = .002). Their hemoglobin concentration was also lower (13.4 (2.1) vs. 14.4 (1.7) g/L, p = .001). A trend towards a lower use of coronary stents in cancer survivors was noted (p = .061). Cancer was associated with a high probability of death (HR = 2.37, 95% confidence interval [CI] 1.30-4.34, p = .005). When confounding variables were included, this association was no longer significant (HR = 1.63, 95% CI 0.84-3.18, p = .150). CONCLUSIONS: Patients with a previous cancer diagnosis who had an acute STEMI treated by primary PCI did not seem to have a worse prognosis. The difference in the crude mortality rate can be explained by the baseline differences between both groups. Previous cancer diagnosis should not be included in the clinical decision process when a patient is having an acute STEMI.

MitraClip improves cardiopulmonary exercise test in patients with systolic heart failure and functional mitral regurgitation.

AIMS: The aim of this study is to evaluate changes in cardiopulmonary exercise test (CPET) after percutaneous mitral valve repair (PMVR) with MitraClip in patients with heart failure with reduced ejection fraction who are potentially candidates for heart transplantation or destination left ventricular assist device. METHODS AND RESULTS: Prospective registry of all consecutive patients with heart failure with reduced ejection fraction and functional mitral regurgitation (MR) underwent elective PMVR between October 2015 and March 2018 in our institution. Patients with preserved or mid-range left ventricular ejection fraction (>40%), advanced age (>75 years old), or severe co-morbidities (end-stage organ damage) were not included. Treadmill exercise testing with respiratory gas exchange analysis was carried out in 11 patients (male, 72.7%; median age, 67 years old) within the month prior to the procedure and at 6 month follow-up. PMVR was successfully performed in all patients. At 6 month follow-up, PMVR was associated with an improvement in New York Heart Association functional class (P = 0.021) and a reduction in MR severity (P = 0.013) and N-terminal pro-brain natriuretic peptide levels (2805 [1878-5022] vs. 1485 [654-3032] pg/mL; P = 0.012). All patients completed pre-procedural and post-procedural CPET, and all the studies showed a respiratory exchange ratio ≥1 and were consistent with sufficient exercise effort. Compared with pre-procedural CPET, patients showed a significant increase in exercise time (295 [110-335] vs. 405 [261-540] s; P = 0.047), VO2 (9.8 [9.1-13.4] vs. 13.5 [12.1-16.8] mL/kg/min; P = 0.033), ventilatory anaerobic threshold (510 [430-950] vs. 850 [670-1070] mL/kg/min; P = 0.033), peak O2 pulse (7.2 [4.3-8.6] vs. 8.3 [6.2-11.8] mL/beat; P = 0.033), and workload (5 [3-6] vs. 6 [5-8] metabolic equivalents; P = 0.049). CONCLUSIONS: Percutaneous mitral valve repair with MitraClip was associated with an enhancement in cardiopulmonary performance in patients with systolic heart failure and secondary MR.

Incidence and prognostic implications of late bleeding events after percutaneous mitral valve repair.

OBJECTIVES: MitraClip is an established therapy for patients with mitral regurgitation (MR) that are considered of high-risk or inoperable. However, late bleeding events (BE) after hospital discharge and their impact on prognosis in this cohort of patients have been poorly investigated. Our purpose is to address the incidence, related factors and clinical implications of BE after hospital discharge in patients treated with MitraClip. METHODS: Prospective registry of all consecutive patients (n = 80) who underwent MitraClip implantation in our Institution between June 2014 and December 2017. BE were defined according to MVARC definitions. A combined clinical end-point including admission for heart failure (HF) and all-cause mortality was established to analyze prognostic implications of BE. RESULTS: During a median follow up of 523.5 days, 41 BE were reported in 21 patients. Atrial fibrillation (AF, HR 4.54, CI95% 1.20-17.10) and combined antithrombotic therapy at discharge (HR 3.52, CI95% 1.03-11.34) were independently associated with BE. In the study period, 15 (18.8%) patients died, 20 (25%) were admitted for HF and 29 (36.3%) presented the combined end-point. After multivariable adjustment BE remained independently associated with an adverse outcome (HR 3.80, CI 95% 1.66-8.72). In the subgroup of patients with AF, HAS-BLED score was higher among subjects with BE (3.1 ±â€¯1.3 vs 2.1 ±â€¯0.9, p = 0.003). HAS-BLED score had a significant discrimination power for the occurrence BE (AUC: 0.677 [0.507-0.848]) in this subgroup. CONCLUSIONS: BE are common after MitraClip and are associated with an impaired outcome. Strategies to reduce bleeding events are paramount in this cohort of patients.

Survival Advantage of MitraClip® Over Medical Treatment in Patients with Mitral Regurgitation: A Meta-Analysis.

BACKGROUND: The MitraClip® system is a percutaneous treatment for mitral regurgitation (MR) that has shown promising results in patients who are inoperable or at high risk for mitral surgery. Data on the efficacy of the system over optimal medical therapy, above all in patients with functional MR, are scarce. The study aim was to assess the effect of MitraClip on the survival of patients with moderate/severe or severe MR compared to medical therapy, using meta-analytical techniques. METHODS: Independently, reviewers searched electronically for relevant articles based on predefined criteria and end-points. Only articles with a comparison between MitraClip and conservative therapy were included. Standard meta-analysis techniques were used. The primary outcomes were 30-day and one-year mortalities. RESULTS: Five observational reports were included that enrolled a total of 1,271 patients: 720 patients underwent percutaneous mitral valve repair (PMVR) with the MitraClip device, and 551 were managed conservatively. A total of 49 all-cause mortality events was reported at 30 days: 3.05% (22/720) in the PMVR arm, and 4.90% (27/510) in the conservative group, with no significant differences in all-cause mortality (OR 0.64; 95% CI 0.36-1.14). A total of 269 all-cause mortality events at one year was reported: 15.14% (109/720) in the PMVR arm, and 29.04% (160/551) in the conservative group. A significant difference favoring PMVR with the MitraClip system over medical therapy alone was observed (OR 0.44; 95% CI 0.30-0.64, p <0.0001). Neither significance between study heterogeneity (p = 0.18) nor publication bias was detected (p = 0.3). CONCLUSIONS: PMVR with the MitraClip system may be associated with an improvement in one-year survival compared to stand-alone medical management.

Efficacy of Oral Anticoagulation in Stroke Prevention among Sinus-Rhythm Patients Who Lack Left Atrial Mechanical Contraction after Cryoablation.

The customary recommendation is that oral anticoagulation be withdrawn a few months after cryoablation for atrial fibrillation, independently of left atrial mechanical contraction in patients in sinus rhythm. Recently, a 5-fold increase in stroke has been described in sinus-rhythm patients who lack atrial mechanical contraction. One aim of this study was to evaluate the efficacy of oral anticoagulation in preventing postoperative stroke in such patients. This prospective study divided 154 sinus-rhythm patients into 2 groups, depending on the presence (108 patients) or absence (46 patients) of left atrial mechanical contraction at 6 months after surgery, and monitored them annually for 5 years. Those without left atrial contraction were maintained on acenocumarol. The primary endpoint was the occurrence of ischemic stroke. The median follow-up period was 29 ± 16 months; 4 patients (2.5%), all belonging to the group with preserved atrial contraction, had ischemic stroke; the group of patients without left atrial contraction had no episodes of stroke during follow-up. Logistic binary regression analyses showed no evidence of factors independently predictive of stroke. Among anticoagulated patients in sinus rhythm without left atrial contraction, we found the incidence of stroke to be zero. In a small, nonrandomized group such as this, we cannot discount the element of chance, yet we suggest that maintaining anticoagulation might lower the incidence of stroke in this population.

Contribution of right ventricular dysfunction to heart failure mortality: a meta-analysis.

Right ventricular systolic dysfunction (RVSD) has been related to prognosis in patients with heart failure (HF) and/or left ventricular systolic dysfunction. However, most of the studies addressing this issue are not large enough, have different inclusion criteria, and use different methods to evaluate RV function to draw definite conclusions. We sought to investigate the association between RVSD and outcomes in patients with left ventricular dysfunction. Eleven studies of 40 (27.5%), with 4732 patients, were included in the meta-analysis. RVSD was present in 2234 patients (47.2%). Four of the studies had admission for HF as an endpoint. We found a significant association between RVSD and overall mortality with significant between-studies heterogeneity and presence of publication bias (funnel plot). A significant association was found between RVSD and admission for HF. RVSD is associated with overall mortality and admission for HF during follow-up. Significant between-studies heterogeneity and publication bias must be taken into account when interpreting this information.

Emergency nontraumatic chest pain: use of stress echocardiography to detect significant coronary artery stenosis.

OBJECTIVE: We sought to assess the usefulness of stress echocardiography in a chest pain department. METHODS: Consecutive patients (n = 487) with nontraumatic chest pain, with no signs of myocardial ischemia on arrival to the emergency department, 6 and 12 hours later, were recruited. RESULTS: The sensitivity and specificity of stress echocardiography in the biased sample were 74% (95% confidence interval [CI] 63-85%) and 65% (95% CI 44-86%). After application of the method of Begg and Greenes to debias the sample, the calculated sensitivity was 24% (95% CI 19-29%) and specificity was 94% (95% CI 91-97%). After application of Diamond's method, sensitivity was 32% (95% CI 21-44%) and specificity (normalcy rate) was 99% (95% CI 88-100%). CONCLUSIONS: Stress echocardiography is an insensitive test when used to detect significant coronary artery stenosis in patients presenting with nontraumatic chest pain with no objective signs of myocardial ischemia.

Coronary clearance frame count: a new index of microvascular perfusion.

BACKGROUND: The angiographic data of myocardial perfusion obtained following direct angioplasty in acute myocardial infarction (AMI) can be evaluated only by qualitative methods: the myocardial blush grade (MBG) or the TIMI myocardial perfusion grade (TMPG). To minimize the subjective nature of this evaluation, we describe a quantitative index, the "coronary clearance frame count" (CCFC); and have tested it against known indices. METHODS: All patients with AMI treated with direct angioplasty in a single center over 2 years were prospectively analyzed. All films were assessed off-line to determine the traditional indices of TIMI flow grade, TIMI frame count, MBG and TMPG. To define CCFC, we used the first frame in which the contrast is cleared from the ostium of the artery as "frame 0" and that in which contrast begins to wash-in into the same coronary artery distal landmark proposed by TIMI Group, as the "last frame". RESULTS: Of the 147 patients studied, 110 had films that were technically adequate for measuring qualitative and quantitative indices of myocardial perfusion. CCFC showed a good correlation with MBG (p=0.045) and with TMPG (p<0.001). CCFC was strongly related to the presence of TMPG 2 or 3 (p<0.001). A cut-off value of 45 frames has a sensitivity of 75% and specificity of 70% to predict a TMPG 2 or 3. CONCLUSION: Coronary clearance frame count has a good correlation with known indices of reperfusion and has the advantage of being an objective, quantitative index that is efficient even in inexperienced hands. Abbreviated Abstract. The angiographic quality of myocardial perfusion data obtained following direct angioplasty in acute myocardial infarction can only be evaluated by qualitative methods: the myocardial blush grade or the TIMI myocardial perfusion grade. To minimize the subjective nature of these methods, we describe a quantitative index (the "coronary clearance frame count") which we evaluated against the other well-established indices, and have observed it to be efficient even in the hands of inexperienced practitioners.

[In-hospital mortality and early preinfarction angina: a meta-analysis of published studies]. / Mortalidad intrahospitalaria y angina preinfarto temprana: metaanálisis de los estudios publicados.

INTRODUCTION AND OBJECTIVES: The occurrence of preinfarction angina (PA) reduces the extent of myocardial necrosis, increases the volume of viable myocardium, and improves left ventricular function. However, there is no agreement about the effect of PA on mortality. The objective of this study was to determine whether PA is associated with in-hospital mortality. METHOD: A meta-analysis (fixed effects model) of all published reports evaluating in-hospital mortality in patients with acute myocardial infarction according to the presence or absence of PA was performed. PA was defined as the occurrence of angina in the 24 hours before onset of the infarction. We searched the Medline and Embase databases in June 2004 using <> as search terms. Six studies involving a total of 3497 patients were finally identified. RESULTS: Only one study reported that PA had a statistically significant beneficial effect on in-hospital mortality. However, combining the data showed that the presence of PA was associated with a significant decrease in the probability of in-hospital death (odds ratio=0.61; 95% CI: 0.48-0.78; P<.0001. We did not detect any significant heterogeneity between the studies (chi2=5.92; P=.31). CONCLUSIONS: The occurrence of preinfarction angina in the 24 hours before the onset of myocardial infarction was associated with a significant reduction in in-hospital mortality of 39%.

Preinfarction angina limits myocardial infarction size in nondiabetic patients treated with primary coronary angioplasty.

OBJECTIVE: To evaluate myocardial necrosis extent after myocardial infarction (MI) and reperfusion with primary coronary angioplasty in nondiabetic patients and the relationship with unstable preinfarction angina (PA). DESIGN: Prospective cohort study. SETTING: Studies suggest PA limits infarct size. This effect is questioned in patients treated with primary coronary angioplasty. PATIENTS: Seventy-eight, nondiabetic, consecutive MI patients. INTERVENTIONS: Primary coronary angioplasty and scintigraphic study to assess the myocardial infarct size. MAIN OUTCOME MEASURES: Scintigraphic myocardial infarct size. RESULTS: There were 32 patients with PA (PA +) and 46 without PA (PA -) in the 24-h period prior to MI onset. There were no significant differences in the baseline characteristics between the two groups. The scintigraphy indicated myocardial infarct size significantly smaller in PA + patients: mean, 18.0% (SD, 14.7) vs 27.0% (SD, 20.1) [p = 0.033]. This occurs even though Thrombolysis in Myocardial Infarction grade 3 flow achieved in both groups was similar (84.8% vs 84.4%, p = 1.000). We found a higher percentage of ST-segment resolution (>/= 70%) in PA + patients (65.6% vs 45.7%, p = 0.082) together with a lower incidence of left ventricular systolic dysfunction (3.2% vs 18.6%, p = 0.071). CONCLUSIONS: PA exerts a beneficial effect in nondiabetic patients with ST-segment elevation acute MI even when treated with primary PCI. The infarct size is limited, and left ventricular systolic function is preserved. The effects may be related to a better preservation of tissue reperfusion in patients with PA.

[Tricuspid stenosis after pacemaker implantation without evidence of bacterial endocarditis. A case report]. / Estenosis tricúspide tras la implantación de marcapasos intracavitario sin evidenica de endocarditis. a propósito de un caso.

Tricuspid stenosis related to endocardial pacemaker leads is uncommon. We report the case of a patient with severe tricuspid stenosis documented 15 years after the implantation of a permanent DDD pacemaker for symptomatic congenital heart block. The atrial and ventricular leads both had a loop at the level of the tricuspid valve that may have caused endothelial damage and, eventually, tricuspid stenosis.

[Chest pain units. Organization and protocol for the diagnosis of acute coronary syndromes]. / Unidades de dolor torácico. Organización y protocolo para el diagnóstico de los síndromes coronarios agudos.

The two main goals of chest pain units are the early, accurate diagnosis of acute coronary syndromes and the rapid, efficient recognition of low-risk patients who do not need hospital admission. Many clinical, practical, and economic reasons support the establishment of such units. Patients with chest pain account for a substantial proportion of emergency room turnover and their care is still far from optimal: 8% of patients sent home are later diagnosed of acute coronary syndrome and 60% of admissions for chest pain eventually prove to have been unnecessary.We present a systematic approach to create and manage a chest pain unit employing specialists headed by a cardiologist. The unit may be functional or located in a separate area of the emergency room. Initial triage is based on the clinical characteristics, the ECG and biomarkers of myocardial infarct. Risk stratification in the second phase selects patients to be admitted to the chest pain unit for 6-12 h. Finally, we propose treadmill testing before discharge to rule out the presence of acute myocardial ischemia or damage in patients with negative biomarkers and non-diagnostic serial ECGs.