The effect of the COVID-19 pandemic on acute coronary syndrome hospitalizations and out-of-hospital cardiac arrest in Greece.

OBJECTIVES: After coronavirus disease 2019 (COVID-19) outbreak, striking decreases in the number of hospital admissions for acute coronary syndromes (ACSs) and rises in rates of out-of-hospital cardiac arrest (OHCA) have been noted. STUDY DESIGN: This is an analysis of prospectively collected data from a cardiology department in a single, large volume hospital of the National Health System of the Metropolitan area of Athens. METHODS: We investigated the numbers of OHCA and hospital admissions for ACS during a 1-year period and made comparisons between the pre-COVID-19 and the COVID-19 outbreak periods. RESULTS: One hundred and eighty five patients were admitted during the total period of observation with the diagnosis of ACS. The mean monthly number of admissions for ACS for the pre-COVID-19 era was significantly higher than that for the post-COVID-19 era (20.1 ± 7.8 vs 8.8 ± 6.5 admissions, Ρ = 0.024). The cases of OHCA which were transferred to our emergency room department by emergency medical services during the same period were nominally lower in the prepandemic compared with the postpandemic era (1.9 ± 1.7 vs 4.0 ± 4.6, P = 0.28). CONCLUSIONS: The present study provides hints on the potential unintended consequences of the pandemic in countries characterized by fewer COVID-19 cases and fatalities but prompt measures of social contact restrictions and lockdown.

Hospital attendance and admission trends for cardiac diseases during the COVID-19 outbreak and lockdown in Greece.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) outbreak, along with implementation of lockdown and strict public movement restrictions, in Greece has affected hospital visits and admissions. We aimed to investigate trends of cardiac disease admissions during the outbreak of the pandemic and possible associations with the applied restrictive measures. STUDY DESIGN: This is a retrospective observational study. METHODS: Data for 4970 patients admitted via the cardiology emergency department (ED) across 3 large-volume urban hospitals in Athens and 2 regional/rural hospitals from February 3, 2020, up to April 12 were recorded. Data from the equivalent (for the COVID-19 outbreak) time period of 2019 and from the postlockdown time period were also collected. RESULTS: A falling trend of cardiology ED visits and hospital admissions was observed starting from the week when the restrictive measures due to COVID-19 were implemented. Compared with the pre-COVID-19 outbreak time period, acute coronary syndrome (ACS) [145 (29/week) vs. 60 (12/week), -59%, P < 0.001], ST elevation myocardial infarction [46 (9.2/week) vs. 21 (4.2/week), -54%, P = 0.002], and non-ST elevation ACS [99 cases (19.8/week) vs. 39 (7.8/week), -60% P < 0.001] were reduced at the COVID-19 outbreak time period. Reductions were also noted for heart failure worsening and arrhythmias. The ED visits in the postlockdown period were significantly higher than in the COVID-19 outbreak time period (1511 vs 660; P < 0.05). CONCLUSION: Our data show significant drops in cardiology visits and admissions during the COVID-19 outbreak time period. Whether this results from restrictive measures or depicts a true reduction of cardiac disease cases warrants further investigation.

Thermal heterogeneity of carotid arteries as a novel biomarker in patients with diabetes mellitus assessed for coronary artery disease.

BACKGROUND: Vulnerable plaque plays crucial role in prognosis of diabetes mellitus (DM). Microwave radiometry (MWR) allows measurement of the temperature of tissues, thus indirectly reflecting inflammation, a characteristic of atherosclerotic plaque stability. Aim of the study was to evaluate the relation of carotid artery inflammation with glycemic control and presence of coronary artery disease (CAD). METHODS: We included 112 patients (65 ±â€¯9 years, 30 ±â€¯5 kg/m2, 74 DM and 38 non-DM, with a 2:1 ratio) that were referred for scheduled coronary angiography (CA) for evaluation of their clinical condition. We measured thermal heterogeneity, expressed as temperature difference (ΔT) along each carotid artery, with MWR and maximum temperature difference between the 2 carotid arteries (ΔΤmax). RESULTS: Patients with DM presented higher ΔTmax comparing to patients without DM (0.91 ±â€¯0.29 vs 0.71 ±â€¯0.25 °C, p < 0.001). Glycaemia over time was associated with thermal heterogeneity of carotids (HbA1c: <6.5: 0.78 ±â€¯0.23, HbA1c: 6.5-7: 0.87 ±â€¯0.24, HbA1c: 7-8: 0.99 ±â€¯0.30, HbA1c: >8: 1.15 ±â€¯0.35 °C, p = 0.003). Patients with CAD presented higher ΔΤmax comparing to patients with normal CA (0.93 ±â€¯0.24 vs 0.68 ±â€¯0.25 °C, p < 0.001) and patients that underwent coronary revascularization presented higher ΔTmax (0.95 ±â€¯0.25 vs 0.76 ±â€¯0.26 °C, p < 0.001). A ΔTmax ≥ 0.9 (received by ROC analysis) was an independent predictor for revascularization in DM patients (odds ratio 3.29, 95% CI: 1.07-10.16; p = 0.039) when adjusted for sex, age and the established risk factors of CAD. CONCLUSION: Local inflammatory activation of carotid arteries is more pronounced in patients with DM and is associated with the glycemic control. Carotids' thermal heterogeneity is associated with need for revascularization supporting its predictive value in DM patients assessed for CAD.

Heparin induced thrombocytopenia. Contemporary therapeutic approaches in light of the new oral anticoagulants.

Heparin induced thrombocytopenia (HIT) is a prothrombotic syndrome initiated by platelet-activating auto-antibodies with potentially devastating complications. Once the diagnosis of HIT is suspected, discontinuation of heparin and treatment with an alternative anticoagulant are mandatory. While established drugs for HIT are no longer available, parenteral factor Xa inhibitors, thrombin inhibitors and perhaps the direct oral anticoagulants provide additional treatment options. The aim of this review was to highlight the current clinical aspects regarding HIT focusing on the role of novel medications.

Association between serum cystatin C, monocytes and other inflammatory markers.

BACKGROUND: Cystatin C is a marker of renal function that appears to be associated with inflammation. The aim of the present study was to investigate whether there is any relationship between cystatin C, total and differential leukocyte count and other inflammatory markers. METHODS: Cystatin C, creatinine, high sensitivity C-reactive protein (hs-CRP), haptoglobin, ferritin, serum albumin, glucose, total cholesterol, HDL and triglycerides together with total and differential leukocyte count were determined in 490 adults (46 ± 16 years, 40% men) who underwent a typical health examination. Glomerular filtration rate was estimated by the simplified Modification of Diet in Renal Disease formula. Anthropometric and lifestyle characteristics were also recorded. RESULTS: After adjustment for demographic risk factors, comorbid health conditions and renal function, a positive and independent relationship of serum cystatin C levels with peripheral monocyte blood count (regression coefficient ± SE: 12 ± 3.38, P < 0.001) and white blood count (0.616 ± 0.278, P= 0.027) was evident. In this multiple linear regression analysis, other inflammatory markers (i.e. hs-CRP, haptoglobin, ferritin, albumin) did not seem to affect cystatin C blood levels. CONCLUSION: The results of this study demonstrated that monocytes, which play an important role in chronic inflammation and atherosclerosis, were independently related with cystatin C concentrations. This finding may provide a plausible link for the usefulness of cystatin C in predicting increased cardiovascular risk.

Development, repeatability and validity regarding energy and macronutrient intake of a semi-quantitative food frequency questionnaire: methodological considerations.

BACKGROUND AND AIM: The aim of this work was to evaluate the repeatability and the validity of a food frequency questionnaire (FFQ), and to discuss the methodological framework of such procedures. METHODS AND RESULTS: The semi-quantitative FFQ included 69 questions regarding the frequency of consumption of all main food groups and beverages usually consumed and 7 questions regarding eating behaviors. Five hundred individuals (37 ± 15 yrs, 38% males) were recruited for the repeatability process, while another 432 (46 ± 16 yrs, 40% males) also completed 3-Day Diaries (3DD) for the validation process. The repeatability of the FFQ was adequate for all food items tested (Kendall's tau-b: 0.26-0.67, p < 0.05), energy and macronutrients intake (energy adjusted correlation coefficients ranged between 0.56-0.69, p < 0.05). Moderate validity of the FFQ was observed for "dairy products", "fruit", "alcohol" and "stimulants" (tau-b: 0.31-0.60, p < 0.05), whereas low agreement was shown for "starchy products", "legumes", "vegetables", "meat", "fish", "sweets", "eggs", "fats and oils" (tau-b < 0.30, p < 0.05). The FFQ was also valid regarding energy and macronutrients intake. Sensitivity analyses by sex and BMI category (< or ≥25 kg/m(2)) showed similar validity of the FFQ for all food groups (apart from "fats and oils" intake), as well as energy and nutrient intake. CONCLUSION: The proposed FFQ has proven repeatable and relatively valid for foods' intake, and could therefore be used for nutritional assessment purposes.

Usefulness of transthoracic echocardiography in detecting significant prosthetic mitral valve regurgitation.

To identify the transthoracic echo-Doppler (TTE) variables most predictive of significant mitral regurgitation (MR) of mechanical prosthetic valves, TTE and trans-esophageal echo (TEE) studies were independently reviewed in 57 patients (mean age [+/-SD] 59+/-12.5 years) undergoing both studies within 2+/-3 days. Several 2-dimensional and Doppler hemodynamic variables from the TTE studies were derived. Prosthetic MR was significant (moderate or severe) by TEE in 20 patients, whereas mild or no MR was seen in 37 patients. The best univariate predictors of significant MR by TTE were peak velocity of mitral inflow, mean gradient, tricuspid regurgitation velocity, isovolumic relaxation time, and ratio of time velocity integral of mitral inflow to time velocity integral in the left ventricular outflow (TVI(MV)/TVI(LVO)). Peak mitral velocity and TVI(MV)/TVI(LVO) were the best predictors of significant MR and performed similarly (area under the receiver-operating characteristic curve: 0.97 for both). A peak velocity of > or =1.9 m/s was 90% sensitive and 89% specific for significant prosthetic MR, whereas a TVI(MV)/TVI(LVO) > or =2.5 had a sensitivity and specificity of 89% and 91%, respectively. A decision tree was constructed to assess the conditional probabilities of having significant MR given all the possible outcomes of the 2 best predictors. None of the patients with peak velocity < 1.9 m/s and TVI(MV)/TVI(LVO) <2.5 by TTE had significant MR. Conversely, all patients with peak velocity > or =1.9 m/s and TVI(MV)/TVI(LVO) > or =2.5 had significant MR. The use of more complex algorithms did not further improve the results. Thus, measurements of hemodynamic Doppler variables on TTE examination can accurately identify a large number of patients without significant prosthetic MR, thereby reducing the need for further investigation with TEE.

Differentiating thrombus from pannus formation in obstructed mechanical prosthetic valves: an evaluation of clinical, transthoracic and transesophageal echocardiographic parameters.

OBJECTIVES: We sought to determine the clinical and echocardiographic parameters that differentiate thrombus from pannus formation as the etiology of obstructed mechanical prosthetic valves. BACKGROUND: Distinction of thrombus from pannus on obstructed prosthetic valves is essential because thrombolytic therapy has emerged as an alternative to reoperation. METHODS: We analyzed clinical, transthoracic and transesophageal echocardiography (TEE) data in 23 patients presenting with 24 obstructed prosthetic valves and compared the findings to pathology at surgery. RESULTS: Fourteen valves had thrombus and 10 had pannus formation. Patients with thrombus had a shorter duration from time of valve insertion to malfunction, shorter duration of symptoms, but similar New York Heart Association functional class at the time of operation. Patients with thrombus had a lower rate of adequate anticoagulation (21% vs. 89%; p=0.0028). Pannus formation was more common in the aortic position (70% vs. 21%; p=0.035). Abnormal prosthetic valve motion was detected by TEE in all cases with thrombus formation but in 60% with pannus (p=0.0198). Thrombi were larger than pannuses (total length 2.8+/-2.47 cm vs. 1.17+/-0.43 cm; p=0.038). This was mostly due to extension of thrombi into the left atrium in prosthetic mitral valves. Thrombi appeared as a soft mass on the valve in 92% of cases, whereas 29% of pannuses had a soft echo density (p= 0.007). Ultrasound video intensity ratio, derived as the videointensity of the mass to that of the prosthetic valve, was lower in the thrombus group (0.46+/-0.14 vs. 0.71+/-0.17, p=0.006). A videointensity ratio of <0.70 had a positive predictive value of 87% and a negative predictive value of 89% for thrombus. Duration from onset of symptoms to reoperation of <1 month separated thrombus from pannus formation. The best objective clinical parameter for prediction of thrombus was inadequate anticoagulation, whereas the best TEE parameters were qualitative and quantitative ultrasound intensity of the mass. The presence of either inadequate anticoagulation or a soft mass by TEE improved the predictive power of either parameter alone and was similar to that of ultrasound videointensity ratio. CONCLUSIONS: Duration of symptoms, anticoagulation status and qualitative and quantitative ultrasound intensity of the mass obstructing a mechanical prosthetic valve can help differentiate pannus formation from thrombus and may therefore be of value in refining the selection of patients for thrombolytic therapy of prosthetic valve obstruction.

Hypertrophic cardiomyopathy in Greece: clinical course and outcome.

OBJECTIVE: Evaluation of clinical course and outcome of hypertrophic cardiomyopathy in a representative Greek population. BACKGROUND: Hypertrophic cardiomyopathy is characterized by unexplained left ventricular hypertrophy and varied clinical expression. Recent studies suggest ethnic differences. MATERIALS AND METHODS: One hundred seventy-four consecutive Greek patients (117 male, 57 female, age 47+/-16 years) from 143 different families were assessed at the Department of Cardiology of the University of Athens, Greece, and the State Cardiac Department, Hippokration Hospital, both located in Athens, Greece. To reduce selection bias, referral was based on disease diagnosis irrespective of clinical status or treatment needs. All patients were examined clinically, echocardiographically, and by ECG ambulatory monitoring at 6-month intervals for a period of 74+/-22 months (range, 8 to 108 months). RESULTS: Most patients (n = 156, 89.7%) were in New York Heart Association (NYHA) functional class I or II. The disease was familial (at least one affected first-degree relative) in 81 of the 143 families (56.6%), and in 19 of these (13.3%) there was familial history of sudden cardiac death. At initial examination, intraventricular septal thickness was 17.3+/-4.1 mm and posterior wall thickness was 13.7+/-3.8 mm and a left ventricular outflow gradient >30 mm Hg was present in 58 patients (33.3%). Similar were the findings during the last examination (17.5+/-4.3 mm, 13.5+/-4.4 mm, and 56 (32.2%, respectively, p = not significant). Episodes of nonsustained ventricular tachycardia were noted in 15 patients (8.6%). There were eight deaths during follow-up: four sudden deaths and four from intractable heart failure. Syncope was reported by all patients who died. The annual mortality in this study was 1%. Syncope and NYHA class were the only predictors of outcome. CONCLUSIONS: In this representative Greek patient cohort with hypertrophic cardiomyopathy, the arrhythmogenic substrate was modest and the clinical course benign. Sudden cardiac death was infrequent and syncope, functional class, and ventricular arrhythmias were the only predictors of a poor outcome.

Evaluation of prosthetic valve function and associated complications.

Significant advances in imaging modalities have occurred to evaluate prosthetic valve function and associated complications. These developments involve predominantly the introduction of Doppler technology for the non-invasive determination of gradients and valve areas and TEE for an improved assessment of valve structure, function, and associated complications. The current role of cinefluoroscopy is mostly to complement TEE in the evaluation of motion of mechanical prosthetic valves in the aortic position. Cardiac catheterization is now rarely needed to assess valve function. Diagnosis of prosthetic valve obstruction can be performed in the majority of cases with transthoracic Doppler echocardiography. Differentiation of valve obstruction from normal valve function in small valves with high flow conditions, however, may be difficult. Because of this and the variability in normal valves among different prostheses, knowledge of the type and size of the implanted valve is essential. Patients and ultrasound laboratories are encouraged to seek and provide this information on a routine basis. Although transthoracic echocardiography is the main diagnostic modality for the serial evaluation of prosthetic valve function, it is important to recognize its limitations in assessing prosthetic mitral regurgitation and evaluating structural abnormalities of prosthetic valves. These are the situations in which TEE has the most impact. A summary of general indications of TEE in prosthetic valves is provided in Table 6. Finally, a baseline transthoracic Doppler study is essential in the overall follow-up and serial evaluation of valve function. For future comparisons, the best indices of valve functions are those obtained for patients as their own control, from a baseline Doppler echocardiographic study performed early after the operation.

Role of transesophageal echocardiography in the diagnosis of infected retained pacing lead.

A 68-year-old woman had a transvenous pacemaker implanted 6 years ago. One year after the procedure the pulse generator was removed due to generator site infection. Efforts to remove the lead resulted in fracture of the tip, which was abandoned in the right cardiac cavities. After this the patient suffered intermittent episodes of fever and chills, which responded to antibiotic therapy. At her recent admission, transesophageal echocardiography revealed a large mass attached to the free end of the fractured lead suggestive of the existence of a vegetation on the pacing lead. The diagnosis was confirmed at surgery.

Clinical and echocardiographic features of a ruptured DeVega tricuspid annuloplasty.

In this case, we describe the clinical and echocardiographic features of an unusual complication, the rupture of a DeVega tricuspid annuloplasty. Transthoracic and transesophageal echocardiographic examinations established the diagnosis, and the patient underwent successful surgical treatment.

Effects of pravastatin on thoracic aortic atherosclerosis in patients with heterozygous familial hypercholesterolemia.

Data regarding the effects of plasma lipid lowering on the evolution of thoracic aortic atherosclerosis (TAA) are scarce. In this study, we performed transesophageal echocardiography to characterize TAA in 16 newly diagnosed patients with heterozygous familial hypercholesterolemia and to follow its evolution after 2 years of statin treatment. TAA was graded as follows: grade I = normal intima; grade II = increased intimal echo density without thickening; grade IIIA = increased intimal echo density with single atheromatous plaque < or = 3 mm; grade IIIB = multiple plaques < or = 3mm; grade IV = > or = 1 plaque >3 mm; and grade V = mobile or ulcerated plaques. Baseline aortic intimal morphology was grade I in one patient, grade II in 4, grade IIIA in 6, grade IIIB in 3, and grade IV in 2 patients. Hypolipidemic treatment resulted in significant reductions in plasma total cholesterol and low-density lipoprotein (LDL) cholesterol. Follow-up aortic morphology was grade I in 5 patients, grade II in 2, grade IIIA in 3, grade IIIB in 3, and grade IV in 3 patients. TAA remained stable in 7 patients, progressed in 3, and regressed in 6 patients. TAA evolved in a uniform manner in the ascending aorta, aortic arch, and descending aorta. Patients with TAA regression were younger (39+/-14 vs 52+/-8 years, p=0.038) and had a greater decrease in plasma LDL cholesterol as a result of treatment (138+/-56 vs 73+/-55 mg/dl, p=0.036) than patients with TAA stability or progression. These observations support the hypothesis that hypolipidemic treatment may favorably affect the course of TAA in patients with heterozygous familial hypercholesterolemia.

Application of the continuity equation and valve resistance to the evaluation of St. Jude Medical prosthetic aortic valve dysfunction.

Doppler echocardiography was applied to the assessment of patients with surgically documented St. Jude medical aortic valve dysfunction. Derivation of effective orifice area and Doppler velocity index with the continuity equation and calculation of valve resistance accurately differentiated stenotic from regurgitant and normal valves.

Comparison of frequency of left atrial thrombus in patients with mechanical prosthetic cardiac valves and stroke versus transient ischemic attacks.

Transesophageal echocardiography performed in a group of 36 patients who had a first cerebral embolic event after implantation of a mechanical cardiac valvular prosthesis revealed that stroke is associated with the presence of left atrial thrombi more frequently than transient ischemic attacks. Intracardiac embolic sources other than thrombi are possibly related more often to the latter type of cerebral embolism in this patient population.

Changes in phasic coronary blood flow velocity profile and relative coronary flow reserve in patients with hypertrophic obstructive cardiomyopathy.

BACKGROUND: In this study, we both investigated coronary flow velocity in hypertrophic obstructive cardiomyopathy (HOCM) and tested the hypothesis of differing coronary flow reserve (CFR) of coronary arteries perfusing left ventricular regions with nonuniform myocardial hypertrophy by measuring the relative CFR. METHODS AND RESULTS: Coronary flow velocity was assessed in left anterior descending coronary (LAD) and left circumflex (LCX) arteries in 18 patients with HOCM and marked hypertrophy only in the ventricular septum, in 13 patients without obstruction (HCM), and in 9 age- and sex-matched normal subjects at rest, during rapid atrial pacing, and after dobutamine infusion (5 to 30 microg/kg per minute). Relative CFR was estimated as the ratio between absolute CFR of the LAD and absolute CFR of the LCX (LAD/LCX(CF)). At the peak of rapid atrial pacing and during dobutamine stress, LAD/LCX(CF) was reversed in HOCM patients (from 1.25+/-0.11 to 0.82+/-0.07 and 0.79+/-0.06, respectively), whereas it remained unchanged in control subjects (from 1.0+/-0.1 to 1.0+/-0.05 and 1.0+/-0.05, respectively; P<.001). In HCM patients, LAD/LCX(CF) at rest was 1.10+/-0.11, whereas during rapid atrial pacing and dobutamine stress, it was 0.92+/-0.08 and 0.90+/-0.09, respectively. Relative CFR was 0.62+/-0.05 in HOCM patients and 1.05+/-0.05 (P<.001) in normal subjects. There was an inverse correlation between relative CFR and peak systolic outflow tract gradient (r2=.74, P<.001). CONCLUSIONS: Regional distribution of hypertrophy in some patients with HOCM resulted in regional impairment of coronary flow. Relative CFR can be used to estimate regional disturbances of coronary flow and may help in patient selection for new interventional therapeutic techniques.

Echocardiographic features of left atrium in elite male athletes.

In athletes, an increase in left atrial volumes is observed, associated with decreased atrial contractile performance and enhanced conduit function.

Sex differences in the anatomy of coronary artery disease.

In a prospective study, the extent and severity of coronary artery disease (CAD) as well as the location of coronary stenoses were studied comparatively, in relation to age and sex, in 192 consecutive women vs 543 selected men, who all underwent coronary angiography during the same time period, and who were found to have significant CAD. Overall, the age of women (59 +/- 8 years) was higher than that of men (55 +/- 8 years), p < 0.001. Also, the prevalence of smoking was higher in men (81% vs 31%, p = 0.0000) and that of diabetes mellitus in women (29% vs 12%, p = 4 x 10(-6)). In addition, women over 50 years old had a higher incidence of hypertension (51% vs 32%, p = 6 x 10(-5)). Although in both sexes the prevalence of multivessel CAD increased with age, the prevalence of one-vessel CAD was significantly more and that of three-vessel CAD significantly less common in women than in men, both overall (35% vs 16%, p = 4 x 10(-8) and 36% vs 54%, p = 2 x 10(-5), respectively) and in all age subgroups. However, the location of coronary stenoses did not show important differences between men and women with the left anterior descending being the most frequently involved artery. Furthermore, the calculated Gensini index, which reflects cumulatively the extent, severity and location of coronary stenoses, was significantly higher in men (59.2 +/- 34.6 vs 52.2 +/- 36.2, p = 0.03), implying more severe and extensive CAD.(ABSTRACT TRUNCATED AT 250 WORDS)