Cardiovascular disease in women: Executive summary of the expert panel statement of women in cardiology of the hellenic cardiological society.

The perception that women represent a low-risk population for cardiovascular (CV) disease (CVD) needs to be reconsidered. Starting from risk factors, women are more likely to be susceptible to unhealthy behaviors and risk factors that have different impact on CV morbidity and mortality as compared to men. Despite the large body of evidence as regards the effect of lifestyle factors on the CVD onset, the gender-specific effect of traditional and non-traditional risk factors on the prognosis of patients with already established CVD has not been well investigated and understood. Furthermore, CVD in women is often misdiagnosed, underestimated, and undertreated. Women also experience hormonal changes from adolescence till elder life that affect CV physiology. Unfortunately, in most of the clinical trials women are underrepresented, leading to the limited knowledge of CV and systemic impact effects of several treatment modalities on women's health. Thus, in this consensus, a group of female cardiologists from the Hellenic Society of Cardiology presents the special features of CVD in women: the different needs in primary and secondary prevention, as well as therapeutic strategies that may be implemented in daily clinical practice to eliminate underestimation and undertreatment of CVD in the female population.

Redox State in Atrial Fibrillation Pathogenesis and Relevant Therapeutic Approaches.

BACKGROUND: Myocardial redox state is a critical determinant of atrial biology, regulating cardiomyocyte apoptosis, ion channel function, and cardiac hypertrophy/fibrosis and function. Nevertheless, it remains unclear whether the targeting of atrial redox state is a rational therapeutic strategy for atrial fibrillation prevention. OBJECTIVE: To review the role of atrial redox state and anti-oxidant therapies in atrial fibrillation. METHOD: Published literature in Medline was searched for experimental and clinical evidence linking myocardial redox state with atrial fibrillation pathogenesis as well as studies looking into the role of redoxtargeting therapies in the prevention of atrial fibrillation. RESULTS: Data from animal models have shown that altered myocardial nitroso-redox balance and NADPH oxidases activity are causally involved in the pathogenesis of atrial fibrillation. Similarly experimental animal data supports that increased reactive oxygen / nitrogen species formation in the atrial tissue is associated with altered electrophysiological properties of atrial myocytes and electrical remodeling, favoring atrial fibrillation development. In humans, randomized clinical studies using redox-related therapeutic approaches (e.g. statins or antioxidant agents) have not documented any benefits in the prevention of atrial fibrillation development (mainly post-operative atrial fibrillation risk). CONCLUSION: Despite strong experimental and translational data supporting the role of atrial redox state in atrial fibrillation pathogenesis, such mechanistic evidence has not been translated to clinical benefits in atrial fibrillation risk in randomized clinical studies using redox-related therapies.

Sex differences regarding the impact of physical activity on left ventricular systolic function in elderly patients with an acute coronary event.

INTRODUCTION: Regular physical activity has been associated with less severity of an acute coronary syndrome (ACS), lower in-hospital mortality rates, and an improved short term prognosis. This study evaluated the relationship between physical activity status and the development of left ventricular systolic dysfunction (LVSD) according to inflammation and sex in elderly patients who had had an ACS. METHODS: We analyzed prospectively collected data from 355 male (age 74 ± 6 years) and 137 female (76 ± 6 years) patients who were hospitalized with an ACS. LVSD was evaluated by echocardiography on the 5th day of hospitalization and physical activity status was assessed by a self-reported questionnaire. Inflammatory response was evaluated by measuring C-reactive protein levels. Logistic regression models were applied to evaluate the effect of physical activity status on the development of LVSD and inflammatory response at entry. RESULTS: Physical inactivity had a higher prevalence in women who developed LVSD than in the female patients with preserved systolic function (46% vs. 20%, p=0.02). There was a significant positive association between physical activity levels and ejection fraction in women (p=0.06), but not in men (p=0.30). Multiadjusted logistic regression showed that women who were physically active had 76% lower odds (95%CI: 1-94%) of developing LVSD compared to their sedentary counterparts. Furthermore, physical activity was inversely associated with C-reactive protein levels in both sexes (p=0.08). CONCLUSIONS: Long-term involvement in a physically active lifestyle seems to confer further cardio-protection by reducing the inflammatory response and preserving left ventricular systolic function in elderly female, but not male patients with an ACS.

Left atrial function predicts heart failure events in patients with newly diagnosed left ventricular systolic heart failure during short-term follow-up.

We assessed the effect of left atrial (LA) function index, LA ejection fraction, LA kinetic energy, and maximal LA volume on 6 months clinical outcome in patients with newly diagnosed systolic heart failure (HF). During a 36-month period, 179 consecutive patients (17% female, mean age 63 ± 14 years) were enrolled. During the follow-up, 46 patients had an event (32% event rate; 15 were fatal). Those with an adverse event were older, had lower creatinine clearance, advanced New York Heart Association stage, higher prevalence of ischemic HF, and lower values for right ventricle systolic wave in the tissue Doppler imaging evaluation, compared with those without an event. Multivariate analysis revealed that LA function and ischemic etiology of HF were the most significant prognostic indicators after index hospitalization. This study reveals the important role of LA function for the short-term prognosis of patients with newly diagnosed systolic HF in sinus rhythm.

Large left atrial myxoma in an oligosymptomatic young woman.

We present the case of a young female with a large sporadic left atrial myxoma. Interestingly, despite the tumor's large size, this patient had only mild exertional dyspnea without any embolic events or constitutional symptoms.

Longitudinal strain curves in the RV free wall differ in morphology in patients with pulmonary hypertension compared to controls.

BACKGROUND: Previous studies using speckle tracking-derived strain for quantification of right ventricular (RV) function in pulmonary hypertension (PHT) have focused on the magnitude of global and regional peak longitudinal systolic strains (PLSS) and systolic strain-related indices of dyssynchrony. The aim of our study was to investigate the pattern of RV contraction and relaxation with the use of the contour and timing of strain and velocity curves in PHT. METHODS: The study population consisted of thirty-seven patients with PHT (45 ± 18 years, 16 women) and thirty-seven controls. A complete two-dimensional echo with speckle-tracking-derived longitudinal strain of the basal RV free wall and interventricular septum (IVS) was performed and the cycle length-corrected time to PLSS (SST) and time from PLSS to 50% of PLSS (systolic strain half time-SSHT) in both regions were calculated. RESULTS: Patients with PHT had significantly reduced PLSS (-24.9 ± 2.0% vs -43.2 ± 3.0%, p<0.001) and increased SST (0.47 ± 0.02 vs 0.39 ± 0.02, p=0.043) and SSHT (0.22 ± 0.02 vs 0.16 ± 0.02, p=0.047) in the basal RV free wall compared to controls. Furthermore, peak systolic velocities were observed earlier in the cardiac cycle in both regions in patients with PHT compared to controls. CONCLUSIONS: Longitudinal strain curves in the RV free wall reach peak values later in the cardiac cycle and return slower towards the baseline in PHT. Furthermore, peak systolic velocities are observed earlier in the cardiac cycle in both the basal RV free wall and the basal IVS. The above observations effectively illustrate changes in patterns of RV contraction and relaxation caused by PHT.

Role of right ventricular systolic function on long-term outcome in patients with newly diagnosed systolic heart failure.

BACKGROUND: Right ventricular (RV) systolic function has been recognized as a prognostic factor in endstage heart failure (HF) patients and in the present study we evaluated the effect of this dysfunction on prognosis in patients with newly-diagnosed systolic HF. METHODS AND RESULTS: We enrolled 180 consecutive patients with newly diagnosed systolic HF (ischemic or dilated cardiomyopathy). Echocardiographic evaluation was performed to assess biventricular function. Pulse-wave tissue Doppler imaging (TDI) readings were obtained from the lateral tricuspid annulus and the peak systolic annular velocity (Stv) was recorded. Patients were followed for a 2-year period and events (death or HF hospitalization) were recorded. During the follow-up, 79 patients (44%) had an adverse event. An inverse relationship was observed between the height of Stv and the probability of an event (odds ratio (OR) 0.716, 95% confidence interval (CI) 0.583-0.880, P=0.001), after controlling for potential confounders. Furthermore, creatinine clearance (CrCl) was inversely associated with the outcome: a 1-unit increase in CrCl was associated with a 0.98-times lower likelihood of having an event. When the analysis was stratified by CrCl < 60 ml/min or ≥ 60 ml/min, Stv predicted adverse events in both groups (CrCl < 60 ml/min: OR 0.62, 95%CI 0.39-0.98, P = 0.04; CrCl ≥ 60 ml/min: OR 0.78, 95%CI 0.61-1.01, P=0.06). CONCLUSIONS: Pulse-wave TDI readings of peak systolic velocity at the lateral tricuspid annulus, reflecting RV systolic function, has prognostic significance in newly-diagnosed systolic HF patients.

Transcatheter aortic valve implantation, patient selection process and procedure: two centres' experience of the intervention without general anaesthesia.

INTRODUCTION: transcatheter aortic valve implantation (TAVI) is an emerging technique for the treatment of aortic stenosis. With the advent of percutaneous suture devices for the access point and prosthesis delivery systems of smaller diameter, TAVI has become a truly percutaneous procedure: percutaneous aortic valve replacement (PAVR). Thus, PAVR may be conducted without general anaesthesia (GA). METHODS: We report two centres' experience from PAVR without GA. CoreValve aortic bioprostheses were utilised. The patient selection process and PAVR procedure are described in detail. RESULTS: a total of 30 patients (pts) were treated with PAVR. In 4 pts correction of the initial malposition of the prosthesis required a special technique (2 pts: "snare"; 2 pts: "removing and reinserting"). At 1-month follow up, haemodynamic and clinical improvements were observed: left ventricular ejection fraction increased from 50.8 ± 9.3% to 54.3 ± 8.3% (p=0.02); peak aortic valve gradient decreased from 90.3 ± 26.4 mmHg to 14.8 ± 9.7 mmHg, (p<0.001); NYHA functional class decreased from 3.53 ± 0.93 to 1.45 ± 0.94 (p<0.001). Overall 1-month mortality was 3.3% (1 patient died). CONCLUSION: PAVR without general anaesthesia is a feasible technique, however the role of anaesthesiologists is still important.

Acute myocarditis from coxsackie infection, mimicking subendocardial ischaemia.

Viral myocarditis may have various clinical presentations, sometimes mimicking acute myocardial infarction or ischaemia. We describe the case of a young man presenting with acute heart failure, who had electrocardiographic changes suggesting myocardial ischaemia and an episode of sustained ventricular tachycardia. The diagnosis of acute myocarditis was confirmed using cardiac magnetic resonance imaging.

Chronic systemic inflammation accompanies impaired ventricular diastolic function, detected by Doppler imaging, in patients with newly diagnosed systolic heart failure (Hellenic Heart Failure Study).

We sought to evaluate the relationship between plasma cytokine levels (sCD14, tumor necrosis factor [TNF]-alpha, and interleukin [IL]-6) and tissue Doppler derived indices of left ventricular systolic and diastolic function in patients with newly diagnosed heart failure. We enrolled 101 consecutive patients (mean age 65+/-13 years) with newly diagnosed heart failure who were hospitalized in our institute. Echocardiographic assessment was performed in all patients during the third day of their initial hospitalization. The pulsed tissue Doppler imaging (TDI) of the systolic and diastolic function of mitral annulus was characterized by the systolic wave Smv, and the diastolic waves: Emv and Amv. Left atrial kinetic energy (LAKE), an index of left atrial function, was calculated using the equation 1/2 x LASV x 1.06 x Amv(2); where LASV is left atrial systolic volume. Furthermore the ratio E/Emv and the flow propagation velocity were also calculated; where E is the rapid mitral filling wave, detected by pulse Doppler. Soluble plasma levels of CD14, TNF-alpha, and IL-6 were measured in all patients during their third day of hospitalization. Linear regression analysis, after adjustment for sex, age, left ventricular ejection function, body mass index, arterial hypertension, smoking, physical activity, creatinine clearance, diabetes mellitus, and blood lipid levels, revealed that IL-6 levels were inversely associated with LAKE (b= - 5422.4+/-2031.5, P=0.03), Sm (b= -0.375+/-0.1, P=0.03), and flow propagation (b= -5.404+/-0.621, P=0.001). CD14 levels were inversely associated with flow propagation (b = -17.655+/-2.6, P=0.001), and positively associated with E/Emv ratio (b=2.58+/-3.6, P=0.002) and A/Amv ratio (b=0.629+/-0.6, P=0.04). TNF-alpha was inversely associated with Smv (b-1.189+/-0.3, P=0.005). This study reveals that increased plasma levels of CD14, IL-6 and TNF-alpha are associated with impaired left atrial function and more advanced left ventricular diastolic and systolic dysfunction, in patients with newly diagnosed heart failure.