Young and Older Patients with Acute Myocardial Infarction: Differences in Risk Factors and Angiographic Characteristics.

BACKGROUND: Although coronary artery disease mainly affects older individuals, the incidence of myocardial infarction (MI) among younger adults (<55 years) has increased during the past decade. Young and older MI patients have different underlying pathophysiologic characteristics, atherosclerotic plaque morphology, and risk factor profiles. METHODS: We studied 977 patients (≤ 55 years old: 322, > 55 years old: 655) who were hospitalized for MI in the previous 5 years. Patients' baseline characteristics and daily habits were recorded. Angiographic characteristics and vascular lesions were detected, and further examinations, including flow-mediated dilation (FMD), pulse wave velocity (PWV) and central augmentation index (AIx), were performed. Biomarkers of inflammation (Interleukin-6, Tumor-Necrosis factor-a, Intercellular Adhesion Molecule 1, Osteopontin) were also tested. RESULTS: The median age in the younger age group was 49 years [interquartile range (IQR: 44-53)] and 66 years (IQR): 61-73) in the older age group. Arterial hypertension was less prevalent in the young compared to the elderly with MI (47.4% vs 76.2%, p < 0.01). The younger counterparts presented significantly lower rates of diabetes mellitus (19.3% vs 30.6%, p <0.01), dyslipidemia (59% vs 70.8%, p <0.01), and atrial fibrillation (2.6% vs 9.7%, p <0.01) and were more casual smokers (49.3% vs 23.8%, p <0.01) compared to older patients with MI. In terms of arterial stiffness, lower PWV [7.3 m/s (IQR: 6.5-8.4 m/s) vs. 9 m/s (IQR: 8-10.8 m/s), p <0.01] and AIx (20.5 ± 10.8 vs 25.5 ± 7.8, p <0.01) were recorded in the young compared to the elderly with MI. Concerning angiographic characteristics, younger patients were more likely to have none or single-vessel disease (55.6% vs 45.8%, p < 0.02), whereas the older participants more frequently had three or more vessel disease (23.5% vs. 13.6% in the young, p < 0.02). Although significant disparities in blood test results were detected during the acute phase, the great majority of young MI patients were undertreated. CONCLUSION: Younger patients with MI are more likely to be smokers with impaired PWV measures, presenting with non-obstructive or single-vessel disease, while they often remain undertreated. A better knowledge of the risk factors as well as the anatomic and pathophysiologic processes in young adults will help enhance MI prevention and treatment options in this patient population.

Targeting the sympathetic nervous system with the selective imidazoline receptor agonist moxonidine for the management of hypertension: an international position statement.

Hypertension is often linked with metabolic risk factors that share common pathophysiological pathways. Despite wide-spread availability of multiple drug classes, optimal blood pressure (BP) control remains challenging. Increased central sympathetic outflow is frequently neglected as a critical regulator of both circulatory and metabolic pathways and often remains unopposed therapeutically. Selective imidazoline receptor agonists (SIRAs) effectively reduce BP with a favorable side effect profile compared with older centrally acting antihypertensive drugs. Hard outcome data in hypertension, such as prevention of stroke, heart and kidney diseases, are not available with SIRAs. However, in direct comparisons, SIRAs were as effective as angiotensin-converting enzyme inhibitors, ß-blockers, calcium channel blockers, and diuretics in lowering BP. Other beneficial effects on metabolic parameters in hypertensive patients with concomitant overweight and obesity have been documented with SIRAs. Here we review the existing evidence on the safety and efficacy of moxonidine, a widely available SIRA, compared with common antihypertensive agents and provide a consensus position statement based on inputs from 12 experts from Europe and Australia on SIRAs in hypertension management.

Prediction of heart failure patients with distinct left ventricular ejection fraction levels using circadian ECG features and machine learning.

Heart failure (HF) encompasses a diverse clinical spectrum, including instances of transient HF or HF with recovered ejection fraction, alongside persistent cases. This dynamic condition exhibits a growing prevalence and entails substantial healthcare expenditures, with anticipated escalation in the future. It is essential to classify HF patients into three groups based on their ejection fraction: reduced (HFrEF), mid-range (HFmEF), and preserved (HFpEF), such as for diagnosis, risk assessment, treatment choice, and the ongoing monitoring of heart failure. Nevertheless, obtaining a definitive prediction poses challenges, requiring the reliance on echocardiography. On the contrary, an electrocardiogram (ECG) provides a straightforward, quick, continuous assessment of the patient's cardiac rhythm, serving as a cost-effective adjunct to echocardiography. In this research, we evaluate several machine learning (ML)-based classification models, such as K-nearest neighbors (KNN), neural networks (NN), support vector machines (SVM), and decision trees (TREE), to classify left ventricular ejection fraction (LVEF) for three categories of HF patients at hourly intervals, using 24-hour ECG recordings. Information from heterogeneous group of 303 heart failure patients, encompassing HFpEF, HFmEF, or HFrEF classes, was acquired from a multicenter dataset involving both American and Greek populations. Features extracted from ECG data were employed to train the aforementioned ML classification models, with the training occurring in one-hour intervals. To optimize the classification of LVEF levels in coronary artery disease (CAD) patients, a nested cross-validation approach was employed for hyperparameter tuning. HF patients were best classified using TREE and KNN models, with an overall accuracy of 91.2% and 90.9%, and average area under the curve of the receiver operating characteristics (AUROC) of 0.98, and 0.99, respectively. Furthermore, according to the experimental findings, the time periods of midnight-1 am, 8-9 am, and 10-11 pm were the ones that contributed to the highest classification accuracy. The results pave the way for creating an automated screening system tailored for patients with CAD, utilizing optimal measurement timings aligned with their circadian cycles.

Multimodality Imaging in a Patient With Double Aortic Arch Undergoing Transcatheter Aortic Valve Implantation: J Am Coll Cardiol Case Rep 2024;29:102224.

[This retracts the article DOI: 10.1016/j.jaccas.2024.102224.].

Metaverse-based cardiac magnetic resonance imaging simulation application for overcoming claustrophobia: a preliminary feasibility trial.

Introduction: Cardiac magnetic resonance imaging (CMR) is vital, but claustrophobia affects 10% of patients. The metaverse, an immersive virtual and augmented reality environment, has healthcare potential. We present a metaverse-based CMR simulation for claustrophobic patients. Methods: Three cardiomyopathy patients, initially CMR-refusing due to claustrophobia, received training via a virtual reality headset in a metaverse-based virtual hospital. Training efficacy was assessed through questionnaires and anxiety scales. Results: The patients successfully completed metaverse-based training, adapting to the CMR simulation. On CMR day, all entered the machine without issues and with reduced anxiety. Patients found the training useful, suggesting platform familiarization. Discussion: Our study demonstrates the metaverse's potential in alleviating CMR-related claustrophobia. The immersive nature enhances patient preparation, although usability improvements are needed. Further research should compare this approach with alternatives.

Cardiac magnetic resonance imaging (CMR) is a vital tool for diagnosing heart problems, but some patients cannot undergo it due to claustrophobia. To address this, researchers are exploring new methods like hypnosis and simulations. One emerging technology, the metaverse, a 3D virtual reality (VR) environment, is being tested in healthcare. This study created a metaverse-based simulation to help claustrophobic patients prepare for CMR. Three patients with heart issues were given VR headsets to access a virtual hospital in the metaverse. Inside, they were trained for CMR step by step, experiencing the process and sounds realistically. Training was done 1 week, 3 days, and 1 day before the real CMR. Anxiety levels were measured. All patients completed the virtual training without issues. During the first simulations, some could not complete entering the virtual CMR machine due to anxiety. However, by the final simulation, all succeeded. On CMR day, all completed the scan without problems, and their anxiety levels decreased significantly from the initial training. Patients found the training helpful, but the platform's usability needed improvement. The study demonstrates that metaverse-based simulations can help patients overcome claustrophobia to successfully undergo CMR. This technology holds promise for simulating medical situations, easing patient fears, and improving preparation. However, further work is needed to make it user-friendly and accessible without assistance. This study encourages more research to assess the usefulness of the metaverse for broader patient groups, comparing it with other methods like hypnosis or sedation.

Aggressive Rhythm Control Strategy in Atrial Fibrillation Patients Presenting at the Emergency Department: The HEROMEDICUS Study Design and Initial Results.

Atrial fibrillation has progressively become a more common reason for emergency department visits, representing 0.5% of presenting reasons. Registry data have indicated that about 60% of atrial fibrillation patients who present to the emergency department are admitted, emphasizing the need for more efficient management of atrial fibrillation in the acute phase. Management of atrial fibrillation in the setting of the emergency department varies between countries and healthcare systems. The most plausible reason to justify a conservative rather than an aggressive strategy in the management of atrial fibrillation is the absence of specific guidelines from diverse societies. Several trials of atrial fibrillation treatment strategies, including cardioversion, have demonstrated that atrial fibrillation in the emergency department can be treated safely and effectively, avoiding admission. In the present study, we present the epidemiology and characteristics of atrial fibrillation patients presenting to the emergency department, as well as the impact of diverse management strategies on atrial-fibrillation-related hospital admissions. Lastly, the design and initial data of the HEROMEDICUS protocol will be presented, which constitutes an electrophysiology-based aggressive rhythm control strategy in patients with atrial fibrillation in the emergency department setting.

Real-world data on treatment patterns in at least high cardiovascular risk patients on dual and triple lipid lowering therapy in a Hellenic nationwide e-prescription database.

Background: Despite recent guidelines appropriate lipid-lowering treatment (LLT) remains suboptimal in everyday clinical practice. Aims: We aimed to describe clinical practice of use of LLT for at least high CV risk populations in a Hellenic real-world setting and assess how this relates to the European Society of Cardiology treatment guidelines. Methods: We analyzed data from a retrospective cohort study of the National Registry of patients with dyslipidemia between 1/7/2017 and 30/6/2019 who were at least of high CV risk and filled a dual or triple lipid-lowering treatment (dLLT, tLLT) prescription. The primary outcomes of interest of this analysis were to report on the patterns of LLT use in at least high CV risk patients. Results: A total of 994,255 (45.4% of Greeks on LLT) were of at least high CV risk and 120,490 (5.5%) were on dLLT or tLLT. The percentage of patients with reported statin intolerance ranged from 2 to 10%. While persistence was reported to be satisfactory (>85% for both dLLT or tLLT), adherence was low (ranging between 14 and 34% for dLLT). In 6-month intervals, the percentage of patients achieving a low-density lipoprotein cholesterol (LDL-C) target below 100 md/dL ranged from 20% to 23% for dLLT and 34%-37% for tLLT. Conclusions: The prevalence of at least high CV risk patients among patients receiving LLT in Greece is substantial. Despite the high persistence and probably due to the low adherence to treatment, LDL-C remains above targets in more than two thirds of patients.

A novel, proof-of-concept radiofrequency renal denervation strategy to improve procedural efficiency: 12-month results from the SPYRAL DYSTAL pilot study.

BACKGROUND: Catheter-based renal sympathetic denervation (RDN) reduced blood pressure (BP) in multiple randomized sham-controlled trials of patients with uncontrolled hypertension (HTN). We tested proof-of-concept for a more selective treatment strategy, exclusively targeting these areas to improve the efficiency of the procedure. METHODS: The SPYRAL DYSTAL Pilot study was designed to mirror the SPYRAL HTN-OFF MED Pivotal study, enabling comparison with a propensity score adjusted active-control group. Patients were antihypertensive medication-free for one month before undergoing BP assessment. Those with office BP of 150-180/>90 mmHg and with an ambulatory systolic BP of 140-170 mmHg were selected to undergo open label treatment, delivering energy only to the distal main renal arteries and first order branches. Patients from DYSTAL were compared with patients who underwent maximized RF RDN treatment in the prior randomized OFF MED trial at 3 months. After 3 months, patients resumed antihypertensive medications as indicated. Safety and efficacy outcomes were assessed post hoc through 12 months. RESULTS: The SPYRAL DYSTAL Pilot study treated 56 HTN patients. Baseline office systolic BP (OSBP) and 24-h ambulatory systolic BP (ASBP) were similar between DYSTAL and OFF MED patient groups. The number of ablations (32.3 ± 8.0 vs 46.6 ± 15.3, p < 0.001), procedure time (67 ± 21 min vs 99 ± 36 min; p < 0.001), and contrast volume (173 ± 77 cc vs 208 ± 96 cc; p = 0.014) were significantly lower with the simplified treatment strategy. OSBP and ASBP changes compared with baseline were -9.0 and -1.4 mmHg at 3 months, -20.3 and -13.9 mmHg at 6 months, and -20.3 and -16.6 mmHg at 12 months, respectively. During the medication up-titration phase, BP reductions among DYSTAL patients were similar to reductions observed in OFF MED through 12 months, with comparable number of drugs (1.4 and 1.5 medications, respectively (P=NS)). Two adverse events related to guidewire placement were reported. CONCLUSION: In this pilot study, focusing ablation treatment on the distal main and proximal branch renal arteries was performed, resulting in fewer RF lesions, and reduced contrast volume and procedure time. Whether BP reductions are similar between a selective vs. maximized RDN approach requires further prospective study.

Myocardial Ischemia-Reperfusion Injury: Unraveling Pathophysiology, Clinical Manifestations, and Emerging Prevention Strategies.

Myocardial ischemia-reperfusion injury (MIRI) remains a challenge in the context of reperfusion procedures for myocardial infarction (MI). While early revascularization stands as the gold standard for mitigating myocardial injury, recent insights have illuminated the paradoxical role of reperfusion, giving rise to the phenomenon known as ischemia-reperfusion injury. This comprehensive review delves into the intricate pathophysiological pathways involved in MIRI, placing a particular focus on the pivotal role of endothelium. Beyond elucidating the molecular intricacies, we explore the diverse clinical manifestations associated with MIRI, underscoring its potential to contribute substantially to the final infarct size, up to 50%. We further navigate through current preventive approaches and highlight promising emerging strategies designed to counteract the devastating effects of the phenomenon. By synthesizing current knowledge and offering a perspective on evolving preventive interventions, this review serves as a valuable resource for clinicians and researchers engaged in the dynamic field of MIRI.

Gut Microbiome and Its Role in Valvular Heart Disease: Not a "Gutted" Relationship.

The role of the gut microbiome (GM) and oral microbiome (OM) in cardiovascular disease (CVD) has been increasingly being understood in recent years. It is well known that GM is a risk factor for various CVD phenotypes, including hypertension, dyslipidemia, heart failure and atrial fibrillation. However, its role in valvular heart disease (VHD) is less well understood. Research shows that, direct, microbe-mediated and indirect, metabolite-mediated damage as a result of gut dysbiosis and environmental factors results in a subclinical, chronic, systemic inflammatory state, which promotes inflammatory cell infiltration in heart valves and subsequently, via pro-inflammatory molecules, initiates a cascade of reaction, resulting in valve calcification, fibrosis and dysfunction. This relationship between GM and VHD adds a pathophysiological link to the pathogenesis of VHD, which can be aimed therapeutically, in order to prevent or regress any risk for valvular pathologies. Therapeutic interventions include dietary modifications and lifestyle interventions, in order to influence environmental factors that can promote gut dysbiosis. Furthermore, the combination of probiotics and prebiotics, as well as fecal m transplantation and targeted treatment with inducers or inhibitors of microbial enzymes have showed promising results in animal and/or clinical studies, with the potential to reduce the inflammatory state and restore the normal gut flora in patients. This review, thus, is going to discuss the pathophysiological links behind the relationship of GM, CVD and VHD, as well as explore the recent data regarding the effect of GM-altering treatment in CVD, cardiac function and systemic inflammation.

Management of dyslipidemia in coronary artery disease: the present and the future.

Coronary artery disease (CAD) remains a leading cause of global morbidity and mortality, necessitating continuous refinement in the management of dyslipidemia, one of its major risk factors, to mitigate cardiovascular risks. Previous studies have proven the critical role of immediate and robust low-density lipoprotein cholesterol (LDL-C) reduction in the aftermath of acute coronary syndrome (ACS). Emphasizing the evidence supporting this approach, we delve into the impact of early intervention on cardiovascular outcomes and propose optimal strategies for achieving rapid LDL-C lowering, while also providing the rationale for early proprotein convertase subtilisin/kexin 9 inhibitor use after an ACS. Given the importance of the residual lipidemic risk, we present an overview of emerging therapeutic avenues poised to reshape dyslipidemia management, such as bempedoic acid, lipoprotein(a) inhibition, ApoC3 modulation, and angiopoietin-like protein 3 targeting. This comprehensive review amalgamates current evidence with future prospects, offering a holistic perspective on the management of dyslipidemia in CAD. By exploring both the urgency for immediate post-ACS LDL-C reduction and the exciting advancements on the horizon, this article provides a roadmap for clinicians navigating the intricate landscape of lipid-lowering therapies in CAD.

Circadian assessment of heart failure using explainable deep learning and novel multi-parameter polar images.

BACKGROUND AND OBJECTIVE: Heart failure (HF) is a multi-faceted and life-threatening syndrome that affects more than 64.3 million people worldwide. Current gold-standard screening technique, echocardiography, neglects cardiovascular information regulated by the circadian rhythm and does not incorporate knowledge from patient profiles. In this study, we propose a novel multi-parameter approach to assess heart failure using heart rate variability (HRV) and patient clinical information. METHODS: In this approach, features from 24-hour HRV and clinical information were combined as a single polar image and fed to a 2D deep learning model to infer the HF condition. The edges of the polar image correspond to the timely variation of different features, each of which carries information on the function of the heart, and internal illustrates color-coded patient clinical information. RESULTS: Under a leave-one-subject-out cross-validation scheme and using 7,575 polar images from a multi-center cohort (American and Greek) of 303 coronary artery disease patients (median age: 58 years [50-65], median body mass index (BMI): 27.28 kg/m2 [24.91-29.41]), the model yielded mean values for the area under the receiver operating characteristics curve (AUC), sensitivity, specificity, normalized Matthews correlation coefficient (NMCC), and accuracy of 0.883, 90.68%, 95.19%, 0.93, and 92.62%, respectively. Moreover, interpretation of the model showed proper attention to key hourly intervals and clinical information for each HF stage. CONCLUSIONS: The proposed approach could be a powerful early HF screening tool and a supplemental circadian enhancement to echocardiography which sets the basis for next-generation personalized healthcare.

Comprehensive Angiography-Derived Functional Assessment of Epicardial and Microvascular Coronary Disease. Correlation With Non-invasive Myocardial Stress Imaging.

Coronary angiography (CA) is poorly correlated with non-invasive myocardial stress imaging (NSI) and myocardial ischemia is often observed in patients with unobstructed coronary arteries. Moreover, the diagnostic performance of combined epicardial and microcirculatory angiography-derived physiological assessment and its correlation with NSI remains unknown. A total of 917 coronary vessels in 319 patients who underwent both CA and NSI were included in this multicenter observational retrospective analysis. Quantitative flow ratio (QFR) and angiography-derived index of microcirculatory resistance (IMRangio) analyses were performed to estimate coronary epicardial and microcirculatory function respectively. NSI demonstrated evidence of myocardial ischemia in 76% of the cases. IMRangio (36 [22 to 50] vs 29 [21 to 41], p <0.001) was significantly higher and QFR (0.92 [0.78 to 0.99] vs 0.97 [0.91 to 0.99], p <0.001) was significantly lower in vessels subtending ischemic territories. Overall, the diagnostic accuracy of QFR was moderate (area under the curve of receiver operating characteristic [AUCROC] 0.632 [95% confidence interval [CI] 0.589 to 0.674], p <0.0001) but it was higher in patients with normal microcirculatory function (AUCROC = 0.726 [95% CI 0.669 to 0.784], p <0.0001, p Value for AUCROC comparison = 0.009). Combined QFR/IMRangio assessment provided incremental diagnostic performance compared with the evaluation of epicardial or microcirculatory districts in isolation (p Value for AUC comparison <0.0001) and it was able to identify the predominant mechanism of myocardial ischemia in 77% of the patients with positive NSI. Our study suggests the value of a combined angiography-derived assessment of epicardial and microvascular function for the definition of the predominant mechanism of myocardial ischemia in patients with suspected coronary artery disease.

Rationale for the Inclusion of ß-Blockers Among Major Antihypertensive Drugs in the 2023 European Society of Hypertension Guidelines.

We address the reasons why, unlike other guidelines, in the 2023 guidelines of the European Society of Hypertension ß-blockers (BBs) have been regarded as major drugs for the treatment of hypertension, at the same level as diuretics, calcium channel blockers, and blockers of the renin-angiotensin system. We argue that BBs, (1) reduce blood pressure (the main factor responsible for treatment-related protection) not less than other drugs, (2) reduce pooled cardiovascular outcomes and mortality in placebo-controlled trials, in which there has also been a sizeable reduction of all major cause-specific cardiovascular outcomes, (3) have been associated with a lower global cardiovascular protection in 2 but not in several other comparison trials, in which the protective effect of BBs versus the other major drugs has been similar or even greater, with a slightly smaller or no difference of global benefit in large trial meta-analyses and a similar protective effect when comparisons extend to BBs in combination versus other drug combinations. We mention the large number of cardiac and other comorbidities for which BBs are elective drugs, and we express criticism against the exclusion of BBs because of their lower protective effect against stroke in comparison trials, because, for still uncertain reasons, differences in protection against cause-specific events (stroke, heart failure, and coronary disease) have been reported for other major drugs. These partial data cannot replace global benefits as the main deciding factor for drug choice, also because in the general hypertensive population whether and which type of event might occur is unknown.

Intravascular ultrasound-guided, lithotrispy facilitated angioplasty for treating a heavily calcified renal artery stenosis.

A 63-year-old woman with uncontrolled hypertension despite taking 5 antihypertensive medications was referred for percutaneous renal artery intervention.