Cardiovascular testing recovery in Latin America one year into the COVID-19 pandemic: An analysis of data from an international longitudinal survey.

Background: The COVID-19 pandemic disproportionately impacted Latin America (LATAM), significantly disrupting cardiovascular testing. This study evaluated cardiac procedure recovery in LATAM one year after the outbreak. Methods: The International Atomic Energy Agency (IAEA) surveyed 669 centers in 107 countries worldwide, including 135 facilities in 19 LATAM countries, to assess cardiovascular procedure volumes in March 2019, April 2020, and April 2021, and changes in center practices and staffing conditions one year into the COVID-19 pandemic. Findings: LATAM centers reported a 21 % decrease in procedure volumes in April 2021 from pre-pandemic-baseline, vs. a 0 % change in the rest of the world (RoW), and greater volume reductions for almost all procedure types. Centers in Central America and Mexico reported the largest procedure reductions (47 % reduction) compared to the Caribbean (15 %), and South America (14 %, p = 0.01), and this LATAM region was a significant predictor of lower procedure recovery in multivariable regression. More LATAM centers reported reduced salaries and increased layoffs of clinical staff compared to RoW, and LATAM respondents estimated that half of physician and non-physician staff experienced excess psychological stress related to the pandemic, compared to 25 % and 30 % in RoW (p < 0.001). Conclusions: Cardiovascular testing recovery in LATAM trailed behind RoW for most procedure types, with centers in Central America and Mexico reporting the greatest volume reductions. This study found lasting impacts of COVID-19 on cardiovascular care in LATAM and the need for mental health support for LATAM healthcare workers in current and future pandemics.

Focused cardiac ultrasound in pregnancy.

Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality. In many high-income countries, acquired cardiac disease is now the largest cause of maternal mortality. Given its prevalence in low- and middle-income countries (LMICs), rheumatic heart disease is the most common cause of cardiac disease in pregnancy worldwide and is associated with poor maternal outcome. The diagnosis of cardiac disease in pregnancy is often delayed resulting in excess maternal morbidity and mortality. Maternal mortality review committees have suggested that prompt recognition and treatment of heart disease in pregnancy may improve maternal outcome. Given the similarities between symptoms of normal pregnancy and those of cardiac disease, the clinical diagnosis of heart disease in pregnancy is challenging with echocardiography being the primary diagnostic modality. Focused cardiac ultrasound (FOCUS) at the point of care provides supplemental data to the history and physical examination and has been demonstrated to permit early diagnosis and improvement in the management of cardiac disease in emergency medicine, intensive care, and anesthesia. It has also been demonstrated to be useful in surveillance for rheumatic heart disease in LMICs. The use of FOCUS may allow earlier and more accurate diagnosis of cardiac disease in pregnancy with the potential to decrease morbidity and mortality in both developed and developing countries.

Social determinants and cardiovascular care: A focus on vulnerable populations and the Jamaica experience.

The concept of social determinants of health (SDOH) describes the complex interplay of social, economic, cultural, and environmental forces that influence health and illness and result in health inequities in society. In cardiovascular disease (CVD), SDOH play a significant role in contributing to the severe morbidity and mortality that various cardiovascular diseases inflict on our societies. The components of SDOH include wealth/income, employment status, education, social interactions/support, access to medical care (including mental health services), housing, transportation, physical environment (including availability of green space, water/sanitation, air pollution, noise pollution), work environment, access to good nutrition, social and community networks, access to technology and data, exposure to crime/social disorder/violence, exposure to adverse law enforcement/bad governance, and cultural norms. Leveraging reliable SDOH data is critical to addressing healthcare needs of the community. At-risk populations must be connected to the appropriate resources needed to overcome these barriers to access to achieve better health outcomes. This review explores this theme with a focus on several vulnerable populations and offers possible strategies to reduce these inequalities. The Heart Institute of the Caribbean (HIC) was founded in 2005 to improve access to quality medical and cardiovascular services, made available to everyone regardless of their socioeconomic status. HIC has encountered and learned to navigate a myriad structural, institutional, socio-economic, cultural, and behavioral barriers to appropriate CVD care for vulnerable populations in Jamaica and the wider Caribbean. The successes attained and the lessons learned by HIC can be replicated in other nations to address social determinants that impede cardiovascular and medical care in vulnerable populations and may alleviate the access gap in high-quality care in developing countries and in underserved and marginalized communities in developed countries.

Off pump surgical epicardial closure of left anterior descending to pulmonary artery fistula.

BACKGROUND: Coronary artery fistulae (CAF) are rare anomalies. Left anterior descending(LAD) to Pulmonary artery (PA) CAF, represent a minority of cases. Large fistulas, create a significant shunt and a "steal phenomenon", and can lead to myocardial ischemia and heart failure (HF) if left untreated. CASE PRESENTATION: We present a 57 years old female with a large LAD to PA fistulae. Given the rare occurrence and the predominance of low shunt of LAD to PA CAF, this case is functionally exceptional in this fistulae variant, causing a significant shunt which resulted in daily cardiac ischemic chest pain. Diagnosis work up included a nuclear stress test, Coronary Angiography and 3-D Coronary Computed Tomography Angiogram (CCTA). Traditionally, surgery has been the main therapy for symptomatic CAF, but transcatheter closure has emerged as a less invasive strategy and is a valuable alternative or even preferable if no associated cardiac conditions are present, provided the anatomical characteristics of the fistulae are appropriate. The surgical approach includes off pump epicardial interruption of the fistula or closure through a cardiac chamber (trans-cameral) or transpulmonary, or epicardial closure using Cardiopulmonary bypass. Caution must be taken in cases of CAF with Coronary Artery (CA) aneurysm in dominant CA, or drainage into the Coronary Sinus, as the possibility of ischemic complications are higher. Due to anatomical considerations and tortuosity of the fistulae, our patient was considered not amenable for percutaneous closure and surgery was opted. Epicardial closure of the fistula was performed on a beating heart, off pump. Outcome was favorable with complete resolution of ischemic symptoms. CONCLUSION: Symptomatic, high shunt CAF must be interrupted. The presence of daily ischemic symptoms in our case report patient, is worth to be remarked. Alternatives for fistulae closure are transcatheter or surgery, depending on anatomic variables and the presence of associated cardiac conditions. Surgical epicardial closure of LAD to PA fistulae variant can be done with very low mortality and morbidity, but other variants with coronary aneurysm, drainage in the coronary sinus or other concomitant cardiac defects, may result in ischemic complications and higher perioperative mortality and worse long- term outcome.

Sub-Saharan Africa Tackles COVID-19: Challenges and Opportunities.

As of May 2020, the global COVID-19 pandemic had reached 187 countries with more than 3.7 million confirmed cases and 263,000 deaths. While sub-Saharan Africa (SSA) has not been spared, the extent of disease is currently far less than in Europe or North America leading some to posit that climatic, genetic or other conditions will self-limit disease in this location. Nonetheless, infections in tropical Africa continue to rise at an alarming pace with the potential to soon exceed health resource availability and to exhaust a health care workforce that is already grossly under supported and ill-equipped. This perspective outlines the context of COVID-19 disease in Africa with a focus on the distinctive challenges faced by African nations and a potential best path forward.

COVID-19 and the heart: An update for clinicians.

SARS-CoV-2, the cause of the COVID-19 pandemic has significantly impacted cardiovascular healthcare. Patients with pre-existing cardiovascular disease are at higher risk of morbidity and mortality. The virus may affect the heart directly and indirectly with clinical syndromes of acute myocardial injury, myocarditis, acute coronary syndromes, heart failure, arrhythmias, and venous thromboembolism. Some therapeutics under investigation for COVID-19 may also have adverse cardiac effects. The involvement of the RAAS system in viral entry makes it pertinent to consider the effects of medications that modulate the system. Comprehensive knowledge of peculiar cardiovascular manifestations of COVID-19 and the role of RAAS in the prognosis of COVID-19 disease is needed for optimal patient management.

Nocturnal Non-dipping Blood Pressure Profile in Black Normotensives Is Associated with Cardiac Target Organ Damage.

PURPOSE: A non-dipping pattern of nocturnal blood pressure in hypertensive patients is an established predictor of cardiovascular risk, especially in Blacks. However, data on non-dipping normotensives and cardiovascular risk in this population is sparse. In this study, we aim to determine if a non-dipping profile in a cohort of Black normotensives is associated with cardiac target organ damage. METHODS: We studied ambulatory blood pressure patterns in 43 normotensive Black patients of Caribbean origin and classified their profiles as dippers (DP) and non-dippers (NDP) based on their nocturnal blood pressure profiles. Cardiac target organ damage was estimated from 2-D echocardiogram. RESULTS: The mean age of the cohort was 52 years. Both groups were similar with respect to baseline age, sex, weight, height, body mass index and daytime ambulatory BP. There was a statistically significant difference in nocturnal blood pressure between DP and NDP groups (112 ± 7/64 ± 2 mm Hg vs 117 ± 3/69 ± 2 mm Hg, P=.004). The NDP cohort showed evidence of cardiovascular target damage on echocardiography with a significantly increased relative wall thickness (.35 ± .07 cm vs .42 ± .05 cm, P=.001), left ventricular mass index (95 ± 14 vs 105 ± 14 g/m(2), P=.018) and left atrial volume index (26 ± 3.5 vs. 30 ± 3.4, P=.001). Left ventricular geometry in the non-dippers also showed increased concentric remodeling, concentric and eccentric hypertrophy. CONCLUSIONS: Our study demonstrates that nocturnal non-dipping of blood pressure in normotensive Blacks of Caribbean origin may be associated with cardiovascular end organ damage thereby providing new surveillance and therapeutic targets.

Myocardial Contrast Echocardiography in the Evaluation of Hypertensive Heart Disease.

Myocardial contrast echocardiography (MCE) has an established role in left ventricular assessment by improving the ventricular opacification and endocardial border definition especially in patients with sub-optimal echocardiographic images. With advances in cardiac ultrasound imaging technology and the development of new contrast agents, the clinical utility of this technique has greatly expanded to include assessment of coronary reperfusion in the setting of acute myocardial infarction, determination of myocardial viability within infarct zones as well as assessment of coronary microcirculation and flow reserve in patients with microvascular coronary disease. Improvements in image quality with intravenous contrast agents can facilitate image acquisition and enhance delineation of regional wall motion abnormalities at peak levels of exercise. Numerous studies have confirmed the clinical utility of contrast enhancement during echocardiographic studies, particularly in patients undergoing stress testing. In this paper, we explore the evidence in support of MCE and its potential clinical applications. Our review aims to summarize (1) the basic principles of myocardial contrast echocardiography including recent advances in the ultrasound technology and contrast agents (2) its clinical applications in the diagnosis of cardiovascular diseases and finally, (3) its potential role in risk stratification and assessment of microvascular perfusion in patients with hypertensive heart disease.

Death, cardiac dysfunction, and arrhythmias are increased by calmodulin kinase II in calcineurin cardiomyopathy.

BACKGROUND: Activation of cellular Ca2+ signaling molecules appears to be a fundamental step in the progression of cardiomyopathy and arrhythmias. Myocardial overexpression of the constitutively active Ca2+-dependent phosphatase calcineurin (CAN) causes severe cardiomyopathy marked by left ventricular (LV) dysfunction, arrhythmias, and increased mortality rate, but CAN antagonist drugs primarily reduce hypertrophy without improving LV function or risk of death. METHODS AND RESULTS: We found that activity and expression of a second Ca2+-activated signaling molecule, calmodulin kinase II (CaMKII), were increased in hearts from CAN transgenic mice and that CaMKII-inhibitory drugs improved LV function and suppressed arrhythmias. We devised a genetic approach to "clamp" CaMKII activity in CAN mice to control levels by interbreeding CAN transgenic mice with mice expressing a specific CaMKII inhibitor in cardiomyocytes. We developed transgenic control mice by interbreeding CAN transgenic mice with mice expressing an inactive version of the CaMKII-inhibitory peptide. CAN mice with CaMKII inhibition had reduced risk of death and increased LV and ventricular myocyte function and were less susceptible to arrhythmias. CaMKII inhibition did not reduce transgenic overexpression of CAN or expression of endogenous CaMKII protein or significantly reduce most measures of cardiac hypertrophy. CONCLUSIONS: CaMKII is a downstream signal in CAN cardiomyopathy, and increased CaMKII activity contributes to cardiac dysfunction, arrhythmia susceptibility, and longevity during CAN overexpression.

Calmodulin kinase II inhibition protects against structural heart disease.

Beta-adrenergic receptor (betaAR) stimulation increases cytosolic Ca(2+) to physiologically augment cardiac contraction, whereas excessive betaAR activation causes adverse cardiac remodeling, including myocardial hypertrophy, dilation and dysfunction, in individuals with myocardial infarction. The Ca(2+)-calmodulin-dependent protein kinase II (CaMKII) is a recently identified downstream element of the betaAR-initiated signaling cascade that is linked to pathological myocardial remodeling and to regulation of key proteins involved in cardiac excitation-contraction coupling. We developed a genetic mouse model of cardiac CaMKII inhibition to test the role of CaMKII in betaAR signaling in vivo. Here we show CaMKII inhibition substantially prevented maladaptive remodeling from excessive betaAR stimulation and myocardial infarction, and induced balanced changes in excitation-contraction coupling that preserved baseline and betaAR-stimulated physiological increases in cardiac function. These findings mark CaMKII as a determinant of clinically important heart disease phenotypes, and suggest CaMKII inhibition can be a highly selective approach for targeting adverse myocardial remodeling linked to betaAR signaling.

Arterial stiffness and wave reflections in patients with sickle cell disease.

We tested the hypothesis that lower blood pressure and increased vasodilatation reported in sickle cell disease (SCD) patients with hemoglobin SS genotype (SS) are translated by lower arterial stiffness determined by pulse wave velocity (PWV) and wave reflections assessed by augmentation index (AI). We enrolled 20 SS (8 females; 12 male) patients closely matched for age, gender, height, and body mass index to 20 subjects with hemoglobin AA genotype (AA). Carotid-femoral PWV (PWV(CF)) and carotid-radial PWV (PWV(CR)) were recorded with the Complior device. Aortic AI was derived from pressure wave analysis (SphygmocoR). PWV(CF) and PWV(CR) were lower in SS than in AA (4.5+/-0.7 m/s versus 6.9+/-0.9 m/s, P<0.0001 and 6.6+/-1.2 m/s versus 9.5+/-1.4 m/s, P<0.0001, respectively). AI was lower in SS than in AA (2+/-14% versus 11+/-8%, P=0.02). Multivariate analysis revealed that both PWV(CF) and PWV(CR) were negatively associated with hemoglobin SS type and positively related to mean arterial pressure (MAP), whereas AI was positively associated with MAP and total cholesterol (all P<0.0001). Multivariate analysis restricted to SS indicated a positive association between PWV(CF) and PWV(CR) with age but a negative association with MAP (R2=0.57 and 0.51, respectively, both P<0.001), whereas MAP and heart rate were independently associated with AI (R2=0.65, P<0.001). This study provides the first evidence that SCD is associated with both lower arterial stiffness and wave reflections. SS patients have a paradoxical negative association between PWV and MAP, suggesting that low MAP does not protect them against arterial stiffness impairment.

Temporal changes in ventricular function assessed echocardiographically in conscious and anesthetized mice.

The mouse is an important model system for cardiovascular biology, with echocardiography a critical tool for noninvasive measurement of cardiac morphology and function. The feasibility and short-term temporal consistency of repeated echocardiographic measurements in conscious mice has not been previously evaluated. We performed serial 2-dimensional guided M-mode transthoracic echocardiographic measurements at 5- to 10-minute intervals over 60 minutes in conscious mice and in mice treated with 1 of 3 anesthetic regimens: ketamine and acepromazine (n = 14); pentobarbital (n = 14); and ketamine and xylazine (n = 13). Unanesthetized mice received intraperitoneal saline (n = 6) or no injection (n = 7). In sequentially repeated measurements over 1 hour in conscious mice, none of the measured or derived echocardiographic parameters differed from baseline, whereas all 3 anesthetic regimens produced significant, prolonged, and temporally variable decreases in heart rate and fractional shortening. The relationship between heart rate and fractional shortening was not altered by anesthetic choice. Serial echocardiographic assessments of cardiac function, dimension, and mass can be performed with high reproducibility in conscious mice.

Improving cardiovascular disease prevention and management in Africa: issues to consider for the 21st century.

There is substantial evidence that cardiovascular diseases, and their associated risk factors, are becoming an increasing threat to the health of a large portion of the populace in many areas of Africa, particularly sub-Saharan Africa. If not adequately addressed, this epidemic will place an even greater burden on the poor economies and weak public health infrastructures of this continent. Important strategies for curtailing this epidemic will include primordial, primary, and secondary prevention, population-based prevention programs, improved research and surveillance, and increased governmental accountability for the adequate appropriation of public health.

Signal-averaged P-wave analysis of normal controls and patients with paroxysmal atrial fibrillation: a study in gender differences, age dependence, and reproducibility.

BACKGROUND: Atrial fibrillation is often first recognized after a complication such as embolic stroke has occurred. Limited data are available for the prospective identification of patients at risk for developing atrial fibrillation. HYPOTHESIS: Demonstration of areas of slow conduction in the atrium by means of P-wave signal averaging may identify individuals at risk for atrial fibrillation. METHODS: P-wave signal averaging from the surface electrocardiogram was performed in 199 normal controls and 81 patients with paroxysmal atrial fibrillation using an automated, P-triggered, high-resolution signal for analysis. RESULTS: Of the variables measured, the filtered P-wave duration and P-wave integral were significantly different between controls and patients (filtered P-wave duration 120 +/- 9 vs. 145 +/- 21 and P-wave integral 666 +/- 208 vs. 868 +/- 352), whereas the terminal root-mean-square (RMS) voltages (RMS 20, RMS 30, RMS 40) showed no significant differences between the two groups. Regression analysis of the first and second measurement of the filtered P-wave duration obtained during consecutive tests showed excellent reproducibility (r and r2 of 0.96 and 0.92). The duration of the filtered P wave showed no age dependence but was shorter in women. CONCLUSION: Utilizing the 90th percentile value of the filtered P-wave duration of 133 ms in men and 130 ms in women, the sensitivity was 80 and 81%, the specificity 92 and 90%, the positive predictive value 84 and 73%, and the negative predictive value 90 and 93%, respectively.