Left ventricular diastolic function is strongly correlated with active emptying of the left atrium: a novel analysis using three-dimensional echocardiography.

BACKGROUND: Increased left atrial (LA) dimensions are known to be a risk factor in predicting cardiovascular events and mortality and to be one key diagnostic tool to assess diastolic dysfunction. Currently, LA measurements are usually conducted using 2D-echocardiography, although there are well-known limitations. Real-time 3D-echocardiography is able to overcome these limitations, furthermore being a valid measurement tool compared to reference standards (e.g. cardiac magnetic resonance imaging). We investigated LA function and volume and their association to left ventricular (LV) diastolic function, using newly designed and validated software for 3D-echocardiographic analysis. This software is the first to allow for a sophisticated analysis of both passive and active LA emptying. METHODS: We analyzed 2D- and 3D-echocardiographic measurements of LA volume and function in 56 subjects and compared the results between patients with normal LV diastolic function (NDF) (n = 30, 52 ± 15 years, BMI 24.7 ± 2.6 kg/m2) and patients in which diastolic dysfunction (DDF) was suspected (n = 26, 65 ± 9 years, BMI 26.7 ± 3.7 kg/m2). RESULTS: Volumes during LA active emptying were significantly smaller in DDF compared to NDF (active atrial stroke volume (ASV): 3.0 (0.1-4.5) vs. 5.5 (2.7-7.8) ml, p = 0.005; True-EF: 7.3(0.1-11.5) vs. 16.2 (8.1-25.4) %, p = 0.002). Furthermore, ASV showed a stronger association to E/e'mean than all other measured LA volumes (ß = - 0.35, p = 0.008). Neither total stroke LA volume, nor maximum or minimum LA volume differed significantly between the groups. CONCLUSIONS: Diastolic LV dysfunction results in a reduction in active LA emptying, which is more strongly associated with LV filling pressure than other previously investigated LA parameters.

Patient knowledge about risk factors, achievement of target values and guideline adherent secondary prevention therapies 12 months after acute myocardial infarction.

AIMS: The prospective GULLIVE-R study aimed to evaluate adherence to guideline recommended secondary prevention, physicians' and patients' estimation of cardiac risk, and patients' knowledge about target values of risk factors after acute myocardial infarction (AMI). METHODS: We performed a prospective study enrolling patients 9-12 months after AMI. Guideline recommended secondary prevention therapies and physicians as well as patients' estimation about their risk, and patients' knowledge about target values were prospectively collected. RESULTS: Between 07/2019 and 06/2021 a total of 2509 outpatients were enrolled in 150 German centers 10 months after AMI. The mean age was 66 years, 26.4% were women, 45.3% had STEMI, 54.7% had NSTEMI, 93.6% had revascularization (84.0% PCI, 7.4% CABG, 1.8% both). Guideline recommended secondary drug therapies were prescribed in over 80% of patients, while only about 50% received all five recommended drugs (aspirin, P2Y12 inhibitors, statins, beta-blockers, RAAS inhibitors) and regular exercise was performed by only one third. About 90% of patients felt well informed about secondary prevention, but the correct target value for blood pressure was known in only 37.9% and for LDL-C in only 8.2%. Both, physicians and patients underestimated the objective risk for future AMIs as determined by the TIMI risk score for secondary prevention. CONCLUSIONS: There is still room for improvement in patient education and implementation of guideline recommended non-pharmacological and pharmacological secondary prevention therapies in patients in the chronic phase after AMI.

Bullet points: Between 07/2019 and 06/2021 a total of 2509 outpatients were enrolled in 150 German centers 10 months after AMI. Guideline recommended secondary drug therapies were applied in over 80% of patients, while only about 50% received all five recommended drugs (aspirin, P2Y12 inhibitors, statins, beta-blockers, RAAS inhibitors) and regular exercise was performed by only one third. About 90% of patients felt well informed about secondary prevention, but the correct target value for blood pressure was known in only 37.9% and for LDL-C in only 8.2%. ESC recommended target values for systolic blood pressure and LDL-cholesterol were achieved in 38.8% and 36.0%, respectively. There was an underestimation of risk for future AMIs as determined by the TIMI Risk Score for Secondary Prevention (TRS2P) both by physicians and patients.

Detection of atrial fibrillation using an implantable loop recorder in patients with previous cryptogenic stroke: the SPIDER-AF registry (Stroke Prevention by Increasing DEtection Rates of Atrial Fibrillation).

BACKGROUND: The use of implantable loop recorder (ILR) to detect atrial fibrillation (AF) in patients with a history of cryptogenic stroke (CS) has seldom been investigated in "real-world" settings. OBJECTIVE: This study aimed to present the results of the Stroke Prevention by Increasing DEtection Rates of Atrial Fibrillation (SPIDER-AF) registry. METHOD: SPIDER is a multicentric, observational registry, including 35 facilities all over Germany. It enrolled outpatients without AF history and with CS before ILR implantation. RESULTS: We included 500 patients (mean age 63.1 ± 12.7 years), 304 (60.8%) were males, with previous stroke (72.6%) and TIA (27.4%). After inclusion, all were followed for at least 12 months. AF was detected in 133 (26.8%), 25.3% of patients with previous stroke and 29.9% with TIA (p = 0.30). AF was detected after a median of 121.5 days (IQR 40.5-223.0). AF was primarily paroxysmal (95.7% after stroke, 100% after TIA). In 19.5% (n = 26) anticoagulation was not administered after AF detection. Mean CHA2DS2-VASc score (OR 1.22; CI 1.01-1.49; p = 0.037) and age > 70 years (OR 0.41; CI 0.19-0.88; p = 0.0020) correlated with AF. Repeat cerebrovascular events at follow-up (28; 5.6%) correlated with AF (OR = 2.17; CI 1.00-4.72; p = 0.049). AF (p = 0.91) and recurrent events (p = 0.43) occurred similarly in females and males. CONCLUSIONS: In the context of cryptogenic strokes ILRs are a valuable tool for early detection of AF. In a real-world scenario, the anticoagulation therapy remains inadequate despite diagnosed AF in a relevant subset of patients requiring optimization of patient management.

[Dual Antiplatelet Therapy in the Perioperative Period - To Continue or Discontinue Treatment?] / Duale antithrombozytäre Therapie ­ Perioperativ absetzen oder weiterführen?

Background For secondary prevention of acute coronary syndrome, guidelines recommend dual antiplatelet therapy (DAPT) with acetylsalicylic acid and a P2Y12 receptor antagonist such as clopidogrel, prasugrel or ticagrelor for a period of 12 months. Often, uncertainty exists with respect to surgical or diagnostic procedures in these high-risk patients: can the DAPT be continued without interruption? If not, what is the recommended withdrawal strategy? What should be considered for the perioperative management? Methods An interdisciplinary group of experienced experts in the fields of cardiology, cardiac surgery, gastroenterology, anaesthesiology, intensive care and haemostaseology developed recommendations relevant to daily clinical practice based on the current scientific evidence. Results These recommendations include instructions for evaluating the patient- and procedure-specific risks of bleeding and ischaemia, general recommendations regarding the DAPT withdrawal strategy, and specific guidance for frequent surgical or diagnostic procedures. Discussion This article aims to facilitate the management of patients with DAPT for all medical disciplines involved, thereby ensuring optimal care of patients during the perioperative period.

High adherence to therapy and low cardiac mortality and morbidity in patients after acute coronary syndrome systematically managed by office-based cardiologists in Germany: 1-year outcomes of the ProAcor Study.

We aimed to assess patient acceptance and effectiveness of a 12-month structured management program in patients after an acute coronary syndrome (ACS) event who were treated in a special setting of office-based cardiologists. The program comprised patient documentation with a specific tool (Bundesverband Niedergelassener Kardiologen [German Federation of Office-Based Cardiologists] cardiac pass with visit scheduling) shared by the hospital physician and the office-based cardiologist, the definition of individual treatment targets, and the systematic information of patients in order to optimize adherence to therapy. Participating centers (36 hospitals, 60 office-based cardiologists) included a total of 1,003 patients with ACS (ST-segment elevation myocardial infarction [STEMI] 44.3%, non-ST-segment elevation myocardial infarction [NSTEMI] 39.5%, unstable angina pectoris [UA] 15.2%, and unspecified 1.0%). During follow-up, treatment rates with cardiac medication remained high in all groups, with dual antiplatelet therapy in 91.0% at 3 months, 90.0% at 6 months, and 82.8% at 12 months, respectively. Twelve months after the inclusion, a total of 798 patients (79.6%) still participated in the program. Eighteen patients (1.8%) had died after discharge from hospital (6 in the STEMI, 12 in the NSTEMI group), while for 58 the status was unknown (5.8%). Based on a conservative approach that considered patients with unknown status as dead, 1-year mortality was 7.6%. Recurrent cardiac events were noted in 14.9% at 1 year, with an about equal distribution across STEMI and NSTEMI patients. In conclusion, patients' acceptance of the ProAcor program as determined by adherence rates over time was high. Treatment rates of recommended medications used for patients with coronary heart disease were excellent. The 1-year mortality rate was comparatively low.

The HAS-BLED score predicts bleedings during bridging of chronic oral anticoagulation. Results from the national multicentre BNK Online bRiDging REgistRy (BORDER).

Patients who receive long-term oral anticoagulant (OAC) therapy often require interruption of OAC for an elective invasive procedure. Current guidelines allow bridging therapy with either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Apart from the risk of embolism, bleeding is an important complication in this setting and the optimal perioperative management of such patients is still under discussion. The aims of this prospective, observational, multicentre registry of patients treated by cardiologists were: 1) to evaluate current practice of perioperative management of OAC in a large outpatient cohort, 2) to document embolic and haemorrhagic events, and 3) to identify risk factors predicting adverse events. In the years 2009 and 2010, 1,000 invasive procedures (cardiac catheterisation n=533, pacemaker implantation n = 128, surgery n = 194, other n = 145) were performed in patients with OAC. Sixty- one (6.1%) of those patients did not receive bridging therapy during interruption of OAC, 937 (93.7%) patients were treated with LMWH, two patients (0.2%) received UFH. In 22 patients (2.2%) LMWHs were given in prophylactic dose, 727 patients (72.7%) were treated with halved therapeutic (i.e. weight-adapted) LMWH doses and 188 (18.8%) received full therapeutic LMWH doses. Four thromboembolic complications were observed during 30 days of follow-up (two retinal embolisms, one stroke, one myocardial infarction; 0.4%). One major bleeding (0.1%) and 35 clinically relevant bleedings (3.5%) occurred. Rehospitalisation after bleedings was necessary in 20 patients. Independent predictors for bleedings were history of mechanical heart valve replacement (MVR) (p=0.0002) and the HAS-BLED score (<0.0001), with a cut off value ≥ 3 being the most predictive variable for haemorrhage (hazard ratio 11.8, 95% confidence interval 5.6-24.9, p<0.0001). A total of 527 patients with atrial fibrillation and a CHADS2 score ≤ 2 received halved therapeutic or full therapeutic dosages of LMWH despite a low embolic risk, whereas 49 of the patients with heart valve replacement (51%) did not receive dosages of bridging therapy as recommended in guidelines. In conclusion, in this registry of patients treated by cardiologists, 94% of patients who required interruption of OAC before invasive procedures received LMWH as a bridging therapy, of whom 73% were treated with halved therapeutic LMWH-dosages. Guideline recommendations were followed in only 31% of cases. Importantly, 69% of patients with AF were over-treated while 51% of patients with heart valve replacement were under-treated with LMWHs. A HASB-BLED score ≥ 3 was highly predictive of bleeding events.