Relation between aortic elasticity parameters and SYNTAX score in postmenopausal diabetic women.

BACKGROUND: Postmenopausal women are at increased risk of coronary artery disease (CAD). Diabetes Mellitus is a major risk factor for CAD. The stiffening of the aorta is associated with increased cardiovascular morbidity and mortality. We aimed to investigate the relation of aortic elasticity parameters to CAD severity assessed by SYNTAX score (SS) in diabetic postmenopausal women. The study prospectively included 200 consecutive diabetic postmenopausal women with CAD who underwent elective coronary angiography. Patients were classified into 3 groups based on SS, low-SS ≤ 22, intermediate-SS ≥ 23- ≤ 32, and high-SS ≥ 33. Echocardiographic aortic elasticity parameters, including aortic stiffness index (ASI), aortic strain (AS) (%) and aortic distensibility (AD) were obtained in all patients. RESULTS: Patients in the high SS group were older age and had a higher aortic stiffness. After adjusting different co-variates AD, AS, and ASI could be used as independent predictors of high SS with the following P-values (0.019, 0.016 and 0.010) and cut-off values (2.5, 3.6 and 2.9), respectively. CONCLUSIONS: In diabetic postmenopausal women, the simple echocardiography-derived aortic elasticity parameters might predict the severity and complexity of angiographic coronary lesions assessed by the SS.

Worsening effect of testosterone deficiency on males with heart failure with preserved ejection fraction.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF)is challenging. Patients usually have normal LV size and ejection fraction. This clinical syndrome develops from a complex interaction of several risk factors that cause organ dysfunction and clinical symptoms. There's evidence that testosterone deficiency is associated with a worse cardiometabolic profile and increased inflammatory markers. We thought that these changes might have an impact on heart failure pathogenesis. We aimed to study the relationship between testosterone level and symptoms in HFpEF. METHODS: We studied 120 male patients with HFpEF. According to New York Heart Association (NYHA), patients were classified into I, II and III classes; class IV patients were excluded. All patients were subjected to clinical and echocardiographic examinations. In addition, we measured serum testosterone, cardio-metabolic profile, intracellular adhesive molecule-1(ICAM-1), P-selectin and nitric oxide (NO) levels. RESULTS: Patients with testosterone deficiency had worse NYHA class and higher BNP P = (0.001). Additionally, they had a significantly worse metabolic profile; higher total cholesterol, triglycerides, LDL cholesterol, fasting insulin and HOMA-IR P = (0.005, 0.001, 0.001, 0.001), respectively. Also, they had higher inflammatory markers and worse endothelial functional parameters; (ICAM-1, NO and P- selectin) P = (0.001). Age, BNP and testosterone deficiency can be used as independent predictors of NYHA class III symptoms with a Testosterone cutoff value of 2.7 ng/ml. CONCLUSION: Testosterone deficiency could be used as an independent predictor of symptom severity in HFpEF, and it aggravates systemic inflammation and endothelial dysfunction in these patients.

Tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure ratio as a predictor of in-hospital mortality for acute heart failure.

BACKGROUND: Right ventricular (RV) function is an important prognostic factor in heart failure. Patients with impaired right ventricular function have a poorer prognosis. The ratio between a tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) is a simple non-invasive parameter that has shown a good correlation with invasively estimated right ventricle (RV)-pulmonary artery (PA) coupling. The current study aimed to determine the value of the non-invasive evaluation of RV-PA coupling using the TAPSE/PASP ratio in predicting in-hospital mortality in patients with acute heart failure. METHODS: We included 200 patients with (heart failure and reduced ejection fraction) HFrEF presented by acute heart failure. Echocardiographic evaluation for left ventricle systolic and diastolic function was performed at the time of admission. RV functions were evaluated by calculating the following (TAPSE, PSAP, TAPSE/PASP ratio). Data were analyzed to find the predictors of in-hospital mortality. RESULTS: The study cohort included two hundred consecutive patients who were hospitalized for a diagnosis of acute decompensation of chronic heart failure. The in-hospital mortality rate was 12%. TAPSE/PASP was an independent predictor for in-hospital mortality (odd ratio = 3.470; 95% confidence interval, 1.240-9.705, p-value = 0.018) and (odd ratio = 18.813; 95% confidence interval, 1.974-179.275, p-value = 0.011) in univariate and multivariable logistic regression analyses respectively. In ROC curve analysis, TAPSE/PASP with a cut-off value < 0.4 mm/mmHg had a sensitivity of 79.17, a specificity of 47.73, and an area under ROC curve = 0.666 for predicting in-hospital mortality. CONCLUSIONS: The non-invasive TAPSE/PASP ratio could be an independent predictor of mortality in HErEF patients presenting with acute heart failure.

The blood pressure variability in patients with cryptogenic stroke.

BACKGROUND: Increased nighttime BP variability (BPV) was associated with stroke. Left atrial (LA) enlargement is the default clinical hallmark of structural remodeling that often occurs in response to LA pressure and volume overload. Blood pressure has proven to be an essential determinant of LA enlargement. We aimed to evaluate the influence of BPV as a risk factor for cryptogenic stroke and highlight the importance of including the (APBM) in the workup for those patients and test the relation between BPV and LA remodeling in these patients, which could be used as a clue to add APM monitoring to their workup. Also, LA remodeling may be a substrate for occult atrial fibrillation (AF). We included Group I (108 consecutive patients with cryptogenic ischemic stroke) and Group II (100 consecutive adult participants without a history of stroke or any structural heart disease). We measured the maximal LA volume index (Max LAVI) and minimal LA volume index (Min LAVI). We calculated the left atrial ejection fraction (LAEF). All the participants were subjected to ABPM. RESULTS: In our prospective, cross-sectional cohort study, the patients in Group I had statistically significantly higher Min LAVI and Max LAVI and Less LA EF than Group II, with a P value of (0.001, 0.001, and 0.008), respectively. The Group I patients had higher BPV as measured by SD parameters than patients in Group II, with a P value of 0.001 for all SD parameters. The BPV parameters, as measured by SD parameters, were positively related to the LA remodeling parameters in both groups. After adjusting all variables, we found that age, night systolic SD, and night diastolic SD parameters were independent predictors of LA remodeling. CONCLUSIONS: The patients with cryptogenic stroke had higher short-term BPV, Min LAVI, and Max LAVI but lower LA EF. Careful monitoring of BPV may be of value for both primary and secondary preventions of ischemic stroke.

The impact of discontinuation of sacubitril-valsartan and shifting to angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in patients with heart failure with reduced ejection fraction.

OBJECTIVE: Many trials confirmed the role of sacubitril-valsartan in the treatment of patients with heart failure with reduced ejection fraction (HFrEF). However, there is no sufficient data to register the effect of compulsory discontinuation of sacubitril-valsartan, either because of finan-cial shortage or adverse effects, and shifting to the standard therapy, including angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB). METHODS: The patients with HFrEF (LVEF ≤35%) were included in the study. They received treatment with sacubitril-valsartan as a replacement for an ACEI or ARB. The patients were divided into two groups: the compliant group (n=111). The non-compliant group (n=82), whose members discontinued sacubitril-valsartan after ≥5 months but <6 months since their enrollment in the study. RESULTS: Initially, 199 patients with HFrEF were included in the study. All the patients were started treatment with sacubitril-valsartan in addition to the evidence-based standard therapy of heart failure. Six patients were excluded at the first follow-up visit (at 6 months). The remaining 193 patients showed initial improvement of the New York Heart Association (NYHA) class, the end-diastolic volume (EDV), and the left ventricular ejection fraction (LVEF). Five patients were excluded at the 12 months' follow-up visit. The other 188 patients were divided into two groups: Group I (n=108) patients were compliant on sacubitril-valsartan for 12 months; Group II (n=80) patients were compliant on sacubitril-valsartan for ≥5 months, but stopped it at <6 months, and were shifted to ACEI or evidence-based ARB. Group II (n=80) patients showed worsening of their NYHA class, compared to the 6 months' follow-up visit (p=0.001). LVEF and EDV were also shown to be worsened in these patients when we compared them to the values of the 6 months' follow-up appointment with p=0.001 for both parameters. CONCLUSION: The discontinuation of sacubitril-valsartan in patients with HFrEF leads to deterioration of the LVEF as well as worsening of the functional class. The decline in LVEF and NYHA functional class occurs despite being compliant with the optimal conventional therapy with ACEI or evidence-based ARB.

The Safety of The Directly Acting Antiviral Treatment For Hepatitis C Virus According To The Egyptian National Program Protocol In Patients With Midrange Ejection Fraction.

Background: The Egyptian National Committee of Viral Hepatitis program is the leading national hepatitis C virus (HCV) management program globally. However, limited data is available about the effect of the new directly acting antiviral agents on the cardiovascular system. Objectives: Our study aimed to assess the safety of the relatively new directly acting antiviral agents approved by the National Health Committee in Egypt to treat patients infected with hepatitis C virus who have midrange left ventricular ejection fraction. Methods: This multicenter study included 400 successive patients with an ejection fraction (40-49%) from May 2017 to December 2019. We classified them into two groups: Group I (Child A), who received Sofosbuvir and Daclatasvir for twelve weeks, and Group II (Child B), who received Sofosbuvir, Daclatasvir, and Ribavirin for twelve weeks. Patients were evaluated for their symptoms, ejection fraction, brain natriuretic peptide, lipid profile, fasting blood glucose, fasting insulin, Homeostatic Model Assessment of Insulin Resistance levels, and Holter monitoring (just before the start of treatment and within three days after completing therapy). Results: We found New York Heart Association Class, ejection fraction, brain natriuretic peptide, premature ventricular contractions burden, as well as highest and lowest heart rate did not show a statistically significant difference in both groups after treatment. The treatment did not cause bradycardia or non-sustained ventricular tachycardia. Fasting blood glucose and fasting insulin levels declined, with improved insulin resistance after treatment in both groups. Both low and high-density lipoprotein cholesterol increased after treatment in Group II. Conclusions: Both regimens of directly acting antiviral agents used in Egypt to treat chronic hepatitis C virus infection are safe in patients with New York Heart Association Class I and II with midrange left ventricular ejection fraction (40-49%). There are beneficial metabolic changes following HCV clearance as an improvement of insulin resistance.

Blood pressure variability in patients with angina and non-obstructive coronary artery disease.

There is a real challenge in the management of ischemia with non-obstructive coronary artery disease. So, we need to study the mechanisms of persistent angina and non-obstructive coronary artery (ANOCA) patients. One of those possible mechanisms is blood pressure variability (BPV). We aimed to study the relation between BPV and angina in patients with non-obstructive coronary artery disease. Our study included 150 patients with chest pain and positive non-invasive stress test suggestive of myocardial ischemia and normal coronary angiography or non-obstructive coronary artery disease. We used an ambulatory blood pressure monitoring device. We found a positive correlation between BPV as measured by average real variability (ARV) as well as standard deviation (SD) parameters and the severity of anginal symptoms with P values for all parameters was 0.001 except day systolic SD P-value was 0.021. We performed a regression analysis for all statistically significant parameters. We found that 24H diastolic ARV, day diastolic ARV, night diastolic ARV, 24H diastolic SD, day diastolic SD, and night diastolic SD were independent predictors of the severity of angina with P-values (0.015, 0.007, 0.011, 0.037, 0.014, and 0.029), respectively. We concluded that short-term BPV represented by ARV and SD had a consistent association with angina in patients with non-obstructive coronary artery disease. The diastolic parameters of ARV and SD were independent predictors of the severity of angina with non-obstructive coronary artery disease.

The safety of Ramadan Fasting following Percutaneous Coronary Intervention.

BACKGROUND: This work aimed to assess the safety of Ramadan Fasting following the Percutaneous Coronary Intervention. METHODS: In our two centers' Prospective Cohort Study, We included 303 patients who had successful Percutaneous Coronary Intervention before the first day of Ramadan. We advised the patients that recent Percutaneous Coronary Intervention could be a valid excuse for not fulfilling Ramadan Fasting. However, many patients intended to fast the following Ramadan, and we included them in the fasting Group I. We added the patients who decided not to fast the following Ramadan as a control Group II. We followed all the patients during Ramadan and for 6 months after Ramadan. RESULTS: The demographic data of both groups and the complexity of the coronary anatomy showed no statistically significant difference. Group I (n = 153) showed a statistically significant difference in the incidence of Major Adverse Cardiac Events compared to Group II with a P value (0.005). The logistic multivariate regression analysis showed that the duration from index PCI till the start of RF, SYNTAX score > 22, and Complex procedure were independent predictors of Major Adverse Cardiac Events in the fasting Group I with {P = 0.001, OR (2.302), P = 0.026, OR (2.419), and P = 0.032 OR (1.952)}, respectively. Major Adverse Cardiac Events in Group I occurred mainly during Ramadan Fasting, with 19 patients having Major Adverse Cardiac Events during Ramadan and four patients during the remaining of the follow-up period. The Receiver Operating Characteristic curve analysis showed the decline of the incidence of Major Adverse Cardiac Events after 90 days from Percutaneous Coronary Intervention till the start of Ramadan Fasting with Sensitivity and specificity (90% and 65%), respectively. CONCLUSIONS: We suggest that low-risk patients with a normal systolic function who underwent Percutaneous Coronary Intervention may safely fast Ramadan. At the same time, Ramadan Fasting during the first 3 months following the Percutaneous Coronary Intervention may not be safe.

Clinical and angiographic characteristics of patients with STEMI and confirmed diagnosis of COVID-19: an experience of Tanta University Hospital.

BACKGROUND: Patients with established cardiovascular diseases have a poor prognosis when affected by the coronavirus disease 2019 (COVID-19). Also, the cardiovascular system, especially the heart, is affected by COVID-19. So we aimed to evaluate the angiographic and clinical characteristics of COVID-19 patients presented by ST-elevation myocardial infarction (STEMI). RESULTS: Our retrospective study showed that STEMI patients with COVID-19 had elevated inflammatory markers with mean of their CRP (89.69 ± 30.42 mg/dl) and increased laboratory parameters of thrombosis with mean D-dimer (660.15 ± 360.11 ng/ml). In 69.2% of patients, STEMI was the first clinical presentation and symptoms suggestive of COVID-19 developed during the hospital stay; about one third of patients had a non-obstructive CAD, while patients with total occlusion had a high thrombus burden. CONCLUSION: STEMI may be the initial presentation of COVID-19. A non-obstructive CAD was found in about one third of patients; on the other hand, in patients who had a total occlusion of their culprit artery, the thrombus burden was high. Identification of the underlying mechanism responsible for the high thrombus burden in these patients is important as it may result in changes in their primary management strategy, either primary PCI, fibrinolytic therapy, or a pharmaco-invasive strategy. Furthermore, adjunctive anticoagulation and antiplatelet therapy may need to be revised.