Phenotypic clustering of patients hospitalized in intensive cardiac care units: Insights from the ADDICT-ICCU study.

BACKGROUND: Intensive cardiac care units (ICCUs) were created to manage ventricular arrhythmias after acute coronary syndromes, but have diversified to include a more heterogeneous population, the characteristics of which are not well depicted by conventional methods. AIMS: To identify ICCU patient subgroups by phenotypic unsupervised clustering integrating clinical, biological, and echocardiographic data to reveal pathophysiological differences. METHODS: During 7-22 April 2021, we recruited all consecutive patients admitted to ICCUs in 39 centers. The primary outcome was in-hospital major adverse events (MAEs; death, resuscitated cardiac arrest or cardiogenic shock). A cluster analysis was performed using a Kamila algorithm. RESULTS: Of 1499 patients admitted to the ICCU (69.6% male, mean age 63.3±14.9 years), 67 (4.5%) experienced MAEs. Four phenogroups were identified: PG1 (n=535), typically patients with non-ST-segment elevation myocardial infarction; PG2 (n=444), younger smokers with ST-segment elevation myocardial infarction; PG3 (n=273), elderly patients with heart failure with preserved ejection fraction and conduction disturbances; PG4 (n=247), patients with acute heart failure with reduced ejection fraction. Compared to PG1, multivariable analysis revealed a higher risk of MAEs in PG2 (odds ratio [OR] 3.13, 95% confidence interval [CI] 1.16-10.0) and PG3 (OR 3.16, 95% CI 1.02-10.8), with the highest risk in PG4 (OR 20.5, 95% CI 8.7-60.8) (all P<0.05). CONCLUSIONS: Cluster analysis of clinical, biological, and echocardiographic variables identified four phenogroups of patients admitted to the ICCU that were associated with distinct prognostic profiles. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05063097.

Restoring Sinus Rhythm Reverses Cardiac Remodeling and Reduces Valvular Regurgitation in Patients With Atrial Fibrillation.

BACKGROUND: Cardiac chamber remodeling in atrial fibrillation (AF) reflects the progression of cardiac rhythm and may affect functional regurgitation. OBJECTIVES: The purpose of this study was to explore the 3-dimensional echocardiographic variables of cardiac cavity remodeling and the impact on functional regurgitation in patients with AF with/without sinus rhythm restoration at 12 months. METHODS: A total of 117 consecutive patients hospitalized for AF were examined using serial 3-dimensional transthoracic echocardiography at admission, at 6 months, and at 12 months (337 examinations). RESULTS: During follow-up, 47 patients with active restoration of sinus rhythm (SR) (through cardioversion and/or ablation) had a decrease in all atrial indexed volumes (Vi), end-systolic (ES) right ventricular (RV) Vi, an increase in end-diastolic (ED) left ventricular Vi, and an improvement in 4-chambers function (P < 0.05). Patients with absence/failure of restoration of SR (n = 39) had an increase in ED left atrial Vi and ED/ES RV Vi without modification of 4-chambers function, except for a decrease in left atrial emptying fraction (P < 0.05). Patients with spontaneous restoration of SR (n = 31) had no changes in Vi or function. The authors found an improvement vs baseline in severity of functional regurgitation in patients with active restoration of SR (tricuspid and mitral regurgitation) and in spontaneous restoration of SR (tricuspid regurgitation) (P < 0.05). In multivariable analysis, right atrial and/or left atrial reverse remodeling exclusively correlated with intervention (cardioversion and/or ablation) during 12-month follow-up. CONCLUSIONS: Management of AF should focus on restoration of SR to induce anatomical (all atrial Vi, ES RV Vi) and/or functional (4 chambers) cardiac cavity reverse remodeling and reduce severity of functional regurgitation. (Thromboembolic and Bleeding Risk Stratification in Patients With Non-valvular Atrial Fibrillation [FASTRHAC]; NCT02741349).

Acute Myocarditis Revealing Adult-Onset Still's Disease.

A 34-year-old man presented with fever, palpitations, maculopapular rash, pharyngitis, left cheilitis, and bilateral gonalgia. High-sensitivity troponin I concentration was 4,900 ng/l. Transthoracic echocardiogram revealed reduced global longitudinal strain. Cardiac magnetic resonance imaging showed acute myocarditis. Adult-onset Still's disease was diagnosed, and treatment with intravenous corticosteroids and tocilizumab was initiated. (Level of Difficulty: Beginner.).

Role of Cardiac Imaging in the Diagnosis of Immune Checkpoints Inhibitors Related Myocarditis.

Immune checkpoint inhibitors (ICI) have constituted a paradigm shift in the management of patients with cancer. Their administration is associated with a new spectrum of immune-related toxicities that can affect any organ. In patients treated with ICI, cardiovascular toxicities, particularly myocarditis, occur with a low incidence (<1%) but with a high fatality rate (30-50%). ICI-related myocarditis has been attributed to an immune infiltration, comprising of T-cells that are positive for CD3+, CD4+, CD8+, and macrophages that are positive for CD68. The diagnosis remains challenging and is made based on clinical syndrome, an electrocardiogram (ECG), biomarker data, and imaging criteria. In most clinical scenarios, endomyocardial biopsy plays a pivotal role in diagnosis, while cardiac magnetic resonance imaging (cMRI) has limitations that should be acknowledged. In this review, we discuss the role of medical imaging in optimizing the management of ICI related myocarditis, including diagnosis, prognostication, and treatment decisions.

Correlation between left atrial spontaneous echocardiographic contrast and 5-year stroke/death in patients with non-valvular atrial fibrillation.

BACKGROUND: Transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) can be used to detect the presence of left atrial thrombus and left atrial spontaneous echocardiographic contrast (LASEC). AIM: To evaluate the prognostic value of TTE and TOE in predicting stroke and all-cause death at 5-year follow-up in patients with non-valvular atrial fibrillation (NVAF). METHODS: This study included patients hospitalised with electrocardiography-diagnosed NVAF in Saint-Antoine University Hospital, Paris, between July 1998 and December 2011, who underwent TTE and TOE evaluation within 24hours of admission. Cox proportional-hazards models were used to identify predictors of the composite outcome (stroke or all-cause death). RESULTS: During 5 years of follow-up, stroke/death occurred in 185/903 patients (20.5%). By multivariable analysis, independent predictors of stroke/death were CHA2DS2-VASc score (hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.25-1.47; P<0.001), left atrial area>20 cm2 (HR 1.59, 95% CI 1.08-2.35; P=0.018), moderate LASEC (HR 1.72, 95% CI 1.13-2.62; P=0.012) and severe LASEC (HR 2.04, 95% CI 1.16-3.58; P=0.013). Independent protective predictors were dyslipidaemia (HR 0.60, 95% CI 0.43-0.83; P=0.002) and discharge prescription of anti-arrhythmics (HR 0.59, 95% CI 0.40-0.87; P=0.008). Adding LASEC to the CHA2DS2-VASc score modestly improved predictive accuracy and risk classification, with a C index of 0.71 vs. 0.69 (P=0.004). CONCLUSIONS: In this retrospective monocentric study, the presence of moderate/severe LASEC was an independent predictor of stroke/death at 5-year follow-up in patients with NVAF. The inclusion of LASEC in stroke risk scores could modestly improve risk stratification.

Does layer-specific strain using speckle tracking echocardiography improve the assessment of left ventricular myocardial deformation? A review.

An increasing number of studies of left ventricular myocardial deformation have been published. Layer-specific strain using speckle tracking echocardiography to evaluate left ventricular function is not recommended in clinical practice. However, evaluation of myocardial mechanics using longitudinal and circumferential layer-specific strain enables the detection of subclinical impairment of myocardial deformation in various diseases. Unfortunately, normal values for longitudinal and circumferential strain have not been clearly defined. In normal subjects, layer-specific strain decreases from the endocardial to the epicardial layer, and from the apex to the base of the left ventricle. Although various studies have tried to define normal values for each layer in healthy subjects, studies with more subjects are needed. This tool has good reproducibility in terms of intraobserver and interobserver variability, but, as with monolayer strain, it has poor intervendor variability. Efforts that aim for standardization between vendors will be required before widespread use of this technique can be advocated.

HIV Infection and Long-Term Residual Cardiovascular Risk After Acute Coronary Syndrome.

Background It is unclear whether HIV infection affects the long-term prognosis after an acute coronary syndrome (ACS). The objective of the current study was to compare rates of major adverse cardiac and cerebrovascular events after a first ACS between people living with HIV (PLHIV) and HIV-uninfected (HIV-) patients, and to identify determinants of cardiovascular prognosis. Methods and Results Consecutive PLHIV and matched HIV- patients with a first episode of ACS were enrolled in 23 coronary intensive care units in France. Patients were matched for age, sex, and ACS type. The primary end point was major adverse cardiac and cerebrovascular events (cardiac death, recurrent ACS, recurrent coronary revascularization, and stroke) at 36-month follow-up. A total of 103 PLHIV and 195 HIV- patients (mean age, 49 years [SD, 9 years]; 94.0% men) were included. After a mean of 36.6 months (SD, 6.1 months) of follow-up, the risk of major adverse cardiac and cerebrovascular events was not statistically significant between PLHIV and HIV- patients (17.8% and 15.1%, P=0.22; multivariable hazard ratio [HR], 1.60; 95% CI, 0.67-3.82 [P=0.29]). Recurrence of ACS was more frequent among PLHIV (multivariable HR, 6.31; 95% CI, 1.32-30.21 [P=0.02]). Stratified multivariable Cox models showed that HIV infection was the only independent predictor for ACS recurrence. PLHIV were less likely to stop smoking (47% versus 75%; P=0.01) and had smaller total cholesterol decreases (-22.3 versus -35.0 mg/dL; P=0.04). Conclusions Although the overall risk of major adverse cardiac and cerebrovascular events was not statistically significant between PLHIV and HIV- individuals, PLHIV had a higher rate of recurrent ACS. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT00139958.

[Cardiovascular imaging in heart failure]. / L'imagerie cardiovasculaire dans l'insuffisance cardiaque.

Transthoracic echocardiography remains the first-line cardiac imaging for diagnosis, management and screening of heart failure, whatever its phenotype (heart failure with reduced, mid-range and preserved ejection fraction). It allows anatomic characterization, systolic and diastolic functions of left and right ventricles assessment, intracardiac hemodynamic evaluation and for the assessment of valve disease. Myocardial deformation imaging (strain) is indicated in patients with heart failure for the assessment of systolic ventricles function and the diagnosis of specific heart diseases. Strain is indicated for the screening of preclinical myocardial dysfunction in patients at risk or exposed to cardiotoxic treatment. Altered global longitudinal strain is associated with a poor prognosis in heart failure. Cardiac magnetic resonance is recommended for the assessment of myocardial structure and function in subjects with poor acoustic window and patients with complex congenital heart diseases, in order to distinguish between ischemic and non-ischemic myocardial damage in patients with dilated cardiopathy and to characterize myocardial tissue in case of suspected specific heart disease.

Biatrial remodelling in atrial fibrillation: A three-dimensional and strain echocardiography insight.

BACKGROUND: Atrial remodelling has been poorly investigated in atrial fibrillation (AF), and few studies have focused on biatrial remodelling. AIM: To evaluate right atrial (RA) and left atrial (LA) remodelling in AF using global atrial reservoir strain and three-dimensional (3D) atrial volumes, according to rhythm outcome at mid-term follow-up. METHODS: Two-dimensional and 3D transthoracic echocardiography (TTE) were performed within 24hours after admission (M0) and at 6-month follow-up (M6) in patients admitted for AF. RA and LA variables were assessed: body surface area-indexed maximum 3D volume (Max 3D RA Voli, Max 3D LA Voli) and minimum 3D volume (Min 3D RA Voli, Min 3D LA Voli); atrial emptying fraction (3D RAEF, 3D LAEF); atrial expansion index (3D RAEI, 3D LAEI); and global RA and LA reservoir strain. RESULTS: Forty-eight consecutive patients were included prospectively. Three groups were identified depending on rhythm at M0 and M6: AF at M0 and sinus rhythm (SR) at M6 (AF-SR) in 25 (52.1%) patients; AF at M0 and AF at M6 (AF-AF) in 13 (27.1%) patients; and SR at M0 (spontaneous cardioversion before first TTE) and SR at M6 (SR-SR) in 10 (20.8%) patients. Between M0 and M6 in the AF-SR group, we found: significant decreases in Max 3D RA Voli (P=0.020), Min 3D RA Voli (P=0.0008), Max 3D LA Voli (P=0.001) and Min 3D LA Voli (P=0.0021); significant increases in 3D RAEF (P=0.037) and 3D RAEI (P=0.034); no significant differences in 3D LAEF and 3D LAEI; and significant increases in global RA and LA reservoir strain (both P<0.0001). There was no significant difference with regard to these variables in the AF-AF and SR-SR groups. CONCLUSION: 3D volume and strain analyses were useful in the evaluation of RA and LA reverse remodelling in successfully cardioverted patients with AF.

Use of Simulator-Based Teaching to Improve Medical Students' Knowledge and Competencies: Randomized Controlled Trial.

BACKGROUND: Simulator-based teaching for coronary angiography (CA) is an attractive educational tool for medical students to improve their knowledge and skills. Its pedagogical impact has not been fully evaluated yet. OBJECTIVE: The aim of this study was to compare traditional face-to-face teaching with a simulator-based teaching for the acquisition of coronary anatomy knowledge and CAs interpretation. METHODS: A total of 118 medical school students in their fourth to sixth year were prospectively randomized in 2 groups: (1) a control teaching group (n=59, CONT group) and (2) a simulator group (using the Mentice VIST-Lab CA simulator; n=59, SIM group). The CONT group received a PowerPoint-based course, whereas the SIM group received a simulator-based course including the same information. After the course, all students were evaluated by 40 multiple choice questions (maximum of 100 points), including questions on coronary anatomy (part 1), angiographic projections (part 2), and real CAs interpretation (part 3). Satisfaction of the students was also evaluated by a simple questionnaire. RESULTS: Student characteristics were identical in both the groups: 62/118 (52.5%) were female and age was 22.6 (SD 1.4) years. Moreover, 35.6% (42/118) were in their fourth year, 35.6% (42/118) were in the fifth year, and 28.8% (34/118) in the sixth year. During the evaluation, SIM students had higher global scores compared with CONT students, irrespective of their year of medical school (59.5 [SD 10.8] points vs 43.7 [SD 11.3] points, P<.001). The same observations were noted for each part of the test (36.9 [SD 6.6] points vs 29.6 [SD 6.9] points, P<.001; 5.9 [SD 3.0] points vs 3.1 [SD 2.8] points, P<.001; and 16.8 [SD 6.9] points vs 10.9 [SD 6.5] points, P<.001; for parts 1, 2, and 3, respectively). Student satisfaction was higher in the SIM group compared with the CONT group (98% vs 75%, P<.001). CONCLUSIONS: This study suggests that simulator-based teaching could potentially improve students' knowledge of coronary anatomy, angiography projections, and interpretation of real clinical cases, suggesting better clinical skills. These results should encourage further evaluation of simulator-based teaching in other medical specialties and how they can translate into clinical practice.