Comprehensive imaging in patients with suspected pulmonary arterial hypertension.

Currently, several imaging techniques are being used for a comprehensive evaluation of patients with suspected pulmonary hypertension (PH), in order to provide information that may clarify the presence and identify the aetiology of this complex pathology. The current paper is focused on recent updates regarding the importance of comprehensive imaging techniques for patients with suspected PH. Transthoracic echocardiography that can mainly detect right ventricle pressure overload and dysfunction is the cornerstone of imaging evaluation, while right heart catheterisation remains the gold standard assessment method. Chest radiography that may exclude pleuroparenchymal lung diseases, CT, the primary imaging modality for the assessment of lung parenchyma and CT pulmonary angiography, that allows for the non-invasive assessment of the pulmonary arteries, are equally important. Imaging techniques like dual-energy CT, single photon emission CT and ventilation perfusion scan may provide accurate diagnostic information for patients with chronic thromboembolic PH. Cardiac MRI provides the most accurate three-dimensional characterisation of the right ventricle. Accurate use of diagnostic imaging algorithms allows early detection of the disease, with the constant goal of improved PH patients prognosis.

Usefulness of the Edmonton Frail Scale in Assessing the Impact of Heart Failure on Frailty.

BACKGROUND/AIM: The association of frailty with heart failure (HF) is common in the elderly, and its presence is a poor prognostic factor; it increases the risk of falls, disability, hospitalization, and mortality. The aim of this prospective study was to assess the incidence of physical frailty in patients with HF and the role of physical exercise in improving physical performance. PATIENTS AND METHODS: A total of 141 patients with musculoskeletal pathology, aged over 65 years, who followed a specific physical training program were included. The patients were assigned to two groups: HF patients -group HF (n=53) and patients without HF -group N-HF (n=88). RESULTS: At cohort level, mild and moderate frailty was detected in 20.56% of patients enrolled in the study (n=29). Severe form of frailty was identified in 2.83% of cases (n=4). The prevalence of mild, moderate, and severe frailty in the two groups differed significantly (p<0.05). Patients with mild frailty and moderate frailty in the HF group represented 24.52% compared to 18.18% in the N-HF group (p=0.007). Severe frailty was present in 5.66% in the HF group, not significantly different from the N-HF group (1.13%), p=0.317. The values obtained in the functional independence and functional performance domains were significantly improved at the reassessment after 6 months. CONCLUSION: Exercise-based rehabilitation is a primary therapy for improving physical performance, reflected by increased independence related to daily activities and functional performance in HF patients.

Body size influences heart rate in children aged 6 to 18 years old.

Previous research established age-related normal limits for children's heart rates (HRs). However, children of the same age can have significantly different HRs, depending on whether they are overweight or underweight, tall or short. Studies on children HR have failed to find a clear correlation between HR and body size. The goal of our study was to create Z scores for HR based on weight (W), height (H), body mass index (BMI), and body surface area (BSA) and compare them to normal age-related HR limits. Electrocardiograms were recorded from a total of 22,460 healthy children ranging in age from 6 to 18 years old using BTL machines. A comparison was made between different age groups, in function of W, H, BMI, and BSA, based on the HR that was automatically detected by using the digitally stored electrocardiogram. Z scores were computed for each of the categories that were mentioned. Incremental Z score values between -2.5 and 2.5 were calculated to establish upper and lower limits of HR. The BSA's estimation of HR is the most accurate of the available methods and can be utilized with accuracy in clinical practice. Z scores for HR in children differ in function of the age, W, H, BMI and BSA. The best estimation is based on BSA. The novelty of our study is that we developed Z scores for HR in relation to body size, age and sex, producing a standardized, consistent, and reproducible result without requiring practitioners to learn and remember cutoff values for a wide range of variables across age groups and sexes. Z scores minimize observer and institutional bias, hence generating uniform and reproducible standards.

Low Atrial Rhythm in a Large Cohort of Children from Transylvania, Romania.

Low atrial rhythm (LAR) is an ectopic rhythm originating in the lower part of the right or left atrium. Prior observational studies attempted to quantify the prevalence of low atrial rhythm in the pediatric population, but the observed prevalence was highly variable with relatively small sample sizes. We aimed to characterize low atrial rhythm and determine its prevalence in a large population of 24,316 asymptomatic children from northwestern Transylvania. We found a prevalence of 0.6% (145 children) for low atrial rhythm. Children with LAR had a significantly lower heart rate (mean 78.6 ± 8.3 bpm), than the control sinus rhythm group (85.02 ± 4.5 bpm). Furthermore, a shorter PR interval was seen in children with LAR (132.7 ± 12.7 ms) than in the children from the control group (141.7 ± 5.4; p = 0.0001).There was no significant association between gender and the presence of left LAR (LLAR) or right LAR (RLAR) (p = 0.5876). The heart rate of children with LLAR was significantly higher (81.7 ± 11.6 bpm) than that of the children with LRAR (77.6 ± 11.1 bpm) (p = 0.037). Pediatric cardiologists should recognize low atrial rhythm and be aware that asymptomatic, healthy children can exhibit this pattern, which does not require therapeutic intervention.

The Role of Hypomagnesemia in Cardiac Arrhythmias: A Clinical Perspective.

The importance of magnesium (Mg2+), a micronutrient implicated in maintaining and establishing a normal heart rhythm, is still controversial. It is known that magnesium is the cofactor of 600 and the activator of another 200 enzymatic reactions in the human organism. Hypomagnesemia can be linked to many factors, causing disturbances in energy metabolism, ion channel exchanges, action potential alteration and myocardial cell instability, all mostly leading to ventricular arrhythmia. This review article focuses on identifying evidence-based implications of Mg2+ in cardiac arrhythmias. The main identified benefits of magnesemia correction are linked to controlling ventricular response in atrial fibrillation, decreasing the recurrence of ventricular ectopies and stopping episodes of the particular form of ventricular arrhythmia called torsade de pointes. Magnesium has also been described to have beneficial effects on the incidence of polymorphic ventricular tachycardia and supraventricular tachycardia. The implication of hypomagnesemia in the genesis of atrial fibrillation is well established; however, even if magnesium supplementation for rhythm control, cardioversion facility or cardioversion success/recurrence of AF after cardiac surgery and rate control during AF showed some benefit, it remains controversial. Although small randomised clinical trials showed a reduction in mortality when magnesium was administered to patients with acute myocardial infarction, the large randomised clinical trials failed to show any benefit of the administration of intravenous magnesium over placebo.

Betablockers and Ivabradine Titration According to Exercise Test in LV Only Fusion CRT Pacing.

Background: Betablockers (BB)/ivabradine titration in fusion CRT pacing (CRTP) is understudied. Aim: To assess drug optimization using systematic exercise tests (ET) in fusion CRTP with preserved atrioventricular conduction (AVc). Methods: Changes in drug management were assessed during systematic follow-ups in CRTP patients without right ventricle lead. Shorter AVc (PR interval) allowed BB up-titration, while longer AVc needed BB down-titration, favoring ivabradine. Constant fusion pacing was the goal to improve outcomes. Results: 64 patients, 62.5 ± 9.5 y.o divided into three groups: shorter PR (<160 ms), normal (160−200 ms), longer (200−240 ms); follow-up 59 ± 26 months. Drugs were titrated in case of: capture loss due to AVc shortening (14%), AVc lengthening (5%), chronotropic incompetence (11%), maximum tracking rate issues (9%), brady/tachyarrhythmias (8%). Interventions: BB up-titration (78% shorter PR, 19% normal PR, 5% longer PR), BB down-titration (22% shorter PR, 14% normal PR), BB exclusion (16% longer PR), adding/up-titration ivabradine (22% shorter PR, 19% normal PR, 5% longer PR), ivabradine down-titration (22% shorter PR, 3% normal PR), ivabradine exclusion (11% normal PR, 5% longer PR). Drug strategy was changed in 165 follow-ups from 371 recorded (42% patients). Conclusions: BBs/ivabradine titration and routine ET during follow-ups in patients with fusion CRTP should be a standard approach to maximize resynchronization response. Fusion CRTP showed a positive outcome with important LV reverse remodeling and significant LVEF improvement in carefully selected patients.

Anatomical-MRI Correlations in Adults and Children with Hypertrophic Cardiomyopathy.

Hypertrophic Cardiomyopathy (HCM) is the most frequent hereditary cardiovascular disease and the leading cause of sudden cardiac death in young individuals. Advancements in CMR imaging have allowed for earlier identification and more accurate prognosis of HCM. Interventions aimed at slowing or stopping the disease's natural course may be developed in the future. CMR has been validated as a technique with high sensitivity and specificity, very few contraindications, a low risk of side effects, and is overall a good tool to be employed in the management of HCM patients. The goal of this review is to evaluate the magnetic resonance features of HCM, starting with distinct phenotypic variants of the disease and progressing to differential diagnoses of athlete's heart, hypertension, and infiltrative cardiomyopathies. HCM in children has its own section in this review, with possible risk factors that are distinct from those in adults; delayed enhancement in children may play a role in risk stratification in HCM. Finally, a number of teaching points for general cardiologists who recommend CMR for patients with HCM will be presented.

Saliva pH and Flow Rate in Patients with Periodontal Disease and Associated Cardiovascular Disease.

BACKGROUND Periodontal disease, a frequent oral health problem, is connected with cardiovascular morbidity and mortality. This study aimed to assess the unstimulated saliva flow rate and saliva pH as markers of the severity of periodontal disease in patients with cardiovascular disease. MATERIAL AND METHODS A cohort of 155 patients (78 men and 77 women, aged 30-92 years) was included, and a structured questionnaire obtained information about their health status, oral healthcare behaviors, and eating habits. An oral examination was performed to assess periodontal status and presence of dental calculus. The unstimulated whole salivary flow rate and salivary pH were measured. An oral hygienization was performed, and 3 months later, salivary flow rate and pH were reevaluated. RESULTS A severe form of periodontal disease was found in 22.4% of patients. Disease severity was strongly correlated with low pH values (6.25 in stage IV periodontal disease), lower salivary flow rate (0.28 mL/min), smoking, poor oral hygiene habits and obesity, with no significant differences by sex. We observed a significant increase of pH (up to 6.30±0.17) in patients with severe periodontal disease (P=0.001) and salivary flow rate values (0.29±0.07 mL/min; P=0.014) 3 months after oral hygienization. There was a strong association between the severity of periodontal disease and presence of cardiovascular disease (P=0.001). CONCLUSIONS Our study suggests that the decrease of salivary flow rate and pH level might be associated with the severity of periodontal disease.

Triglyceride-Glucose Index in Non-Diabetic, Non-Obese Patients with Obstructive Sleep Apnoea.

Obstructive sleep apnoea (OSA) is associated with increased insulin resistance. Triglyceride-glucose index (TyG) is a simple marker of insulin resistance; however, it has been investigated only by two studies in OSA. The aim of this study was to evaluate TyG in non-diabetic, non-obese patients with OSA. A total of 132 patients with OSA and 49 non-OSA control subjects were included. Following a diagnostic sleep test, fasting blood was taken for the analysis of the lipid profile and glucose concentrations. TyG was calculated as ln(triglyceride [mg/dL] × glucose [mg/dL]/2). Comparison analyses between OSA and control groups were adjusted for age, gender, body mass index (BMI) and smoking. TyG was higher in men (p < 0.01) and in ever-smokers (p = 0.02) and it was related to BMI (ρ = 0.33), cigarette pack-years (ρ = 0.17), apnoea-hypopnoea index (ρ = 0.38), oxygen desaturation index (ρ = 0.40), percentage of total sleep time spent with oxygen saturation below 90% (ρ = 0.34), and minimal oxygen saturation (ρ = -0.29; all p < 0.05). TyG values were significantly higher in OSA (p = 0.02) following adjustment for covariates. OSA is independently associated with higher TyG values which are related to disease severity in non-obese, non-diabetic subjects. However, the value of TyG in clinical practice should be evaluated in follow-up studies in patients with OSA.

ECG Markers of Cardiovascular Toxicity in Adult and Pediatric Cancer Treatment.

When a cardiologist is asked to evaluate the cardiac toxic effects of chemotherapy, he/she can use several tools: ECG, echocardiography, coronary angiography, ventriculography, and cardiac MRI. Of all these, the fastest and easiest to use is the ECG, which can provide information on the occurrence of cardiac toxic effects and can show early signs of subclinical cardiac damage. These warning signs are the most desired to be recognized by the cardiologist, because the dose of chemotherapeutics can be adjusted so that the clinical side effects do not occur, or the therapy can be stopped in time, before irreversible side effects. This review addresses the problem of early detection of cardiotoxicity in adult and pediatric cancer treatment, by using simple ECG recordings.

Vitamin D and Its Role in the Lipid Metabolism and the Development of Atherosclerosis.

Vitamin D, a crucial hormone in the homeostasis and metabolism of calcium bone, has lately been found to produce effects on other physiological and pathological processes genomically and non-genomically, including the cardiovascular system. While lower baseline vitamin D levels have been correlated with atherogenic blood lipid profiles, 25(OH)D supplementation influences the levels of serum lipids in that it lowers the levels of total cholesterol, triglycerides, and LDL-cholesterol and increases the levels of HDL-cholesterol, all of which are known risk factors for cardiovascular disease. Vitamin D is also involved in the development of atherosclerosis at the site of the blood vessels. Deficiency of this vitamin has been found to increase adhesion molecules or endothelial activation and, at the same time, supplementation is linked to the lowering presence of adhesion surrogates. Vitamin D can also influence the vascular tone by increasing endothelial nitric oxide production, as seen in supplementation studies. Deficiency can lead, at the same time, to oxidative stress and an increase in inflammation as well as the expression of particular immune cells that play a pivotal role in the development of atherosclerosis in the intima of the blood vessels, i.e., monocytes and macrophages. Vitamin D is also involved in atherogenesis through inhibition of vascular smooth muscle cell proliferation. Furthermore, vitamin D deficiency is consistently associated with cardiovascular events, such as myocardial infarction, STEMI, NSTEMI, unstable angina, ischemic stroke, cardiovascular death, and increased mortality after acute stroke. Conversely, vitamin D supplementation does not seem to produce beneficial effects in cohorts with intermediate baseline vitamin D levels.

Atherogenic Index of Plasma in Obstructive Sleep Apnoea.

BACKGROUND: Dyslipidaemia is well recognised in obstructive sleep apnoea (OSA) and could contribute to the development of cardiovascular disease (CVD). Atherogenic index of plasma (AIP) predicts cardiovascular morbidity and mortality better than the individual lipid levels. The aim of this study was to investigate the AIP in patients with OSA in relation with disease severity. METHODS: Four hundred sixty-one patients with OSA and 99 controls participated in this study. AIP was assessed in the morning following a diagnostic sleep study. The association between lipid values and OSA were adjusted for age, gender, and body mass index. RESULTS: Patients with OSA had higher AIP and triglyceride, and lower high-density lipoprotein cholesterol (HDL-C) levels (all p < 0.05). AIP significantly correlated with the Epworth Sleepiness Scale score (ρ = 0.19), the apnoea-hypopnoea index (ρ = 0.40) and oxygen desaturation index (ρ = 0.43, all p < 0.05). However, there was no relationship between the AIP and markers of sleep quality such as total sleep time, sleep period time, sleep efficiency, arousal index or percentage of REM sleep (all p > 0.05). AIP was not a better predictor for self-reported cardiovascular disease or diabetes than HDL-C. CONCLUSIONS: AIP is elevated in OSA and is related to disease severity. However, it does not seem to have an additional clinical value compared to HDL-C.

Neoplasia-Associated Pericarditis-Predictor of Cancer Progression?

Pericarditis may signal the presence of cancer, even in the absence of other clinical or paraclinical signs. Corollary, the following question arises: Could the discovery of a newly developed pericarditis be used in patients with known neoplasia as a marker of cancer progression? In an attempt to find an answer to this question, this two-centre study included 341 consecutive patients with a confirmed diagnosis of cancer and evidence of pericardial effusion at echocardiography and/or CT/MRI scan. The patients' data were collected retrospectively if they further fulfilled the following inclusion criteria: available medical data from confirmation of pericarditis until evidence of cancer progression or until at least 12 months without progression. The average age of the patients was 62.16 years (22-86 years), and the study comprised 44.28% males and 55.71% females. All types of the most common neoplasms were represented. The results showed that 85.33% of patients had cancer progression temporally linked to pericarditis. Of these, 41.64% had cancer progression within 18 months after the diagnosis of pericarditis with a median time to progression of 5.03 months, ranging from 0 to 17 months; 43.69% had progression within a maximum of 2 months before the diagnosis of pericarditis. Only 14.66% had no cancer progression during the observation period. We concluded that pericarditis could be a sensitive marker of cancer evolution that could be widely used as a follow-up investigation for cancer patients as a marker of progression or recidive.

Anthropometry in the immunotherapy of cutaneous and ocular melanomas.

The height of the adult individual is a balance of the expression of some genetic factors (especially the Y-M 170 haplotype of the Y chromosome) and the environment (nutrition and morbidity during childhood). Higher height is associated with a low risk of developing coronary heart disease, hypertension, gastroesophageal reflux, diaphragmatic hernia, but with a higher risk for atrial fibrillation, venous thromboembolism, intervertebral disc pathology, vasculitis and cancer. The research consisted of a retrospective observational study on patients who received immunotherapy (IT) with nivolumab for cutaneous and ocular melanoma neoplasms. We intended to highlight the associations between the duration of immunotherapy and sex profiles, age, anthropometric data (height, weight). Even though the number of available cases was relatively small (42), an inverse association between the body mass index of the subjects and the duration of immunotherapy could be proved, a more expressed association in case of male patients.

Significance of metastatic topography for the immunotherapy of cutaneous and ocular melanomas.

PD-1 is expressed on the surface of activated T lymphocytes and belongs to the category of negative immune stimuli. Its blocking stimulates the immune response to tumor antigens. Ocular melanomas represent 3-4% of the total melanomas and have metastatic potential, especially to the liver but also to the lungs, skin, and bones. In the case of metastatic melanoma, immunotherapy has a unique role due to the lower frequencies of BRAF mutation in choroidal melanomas and consecutive exclusion from treatment with specific BRAF tyrosine kinase inhibitors. A retrospective observational study was performed in 42 patients who received immunotherapy (IT) with nivolumab for cutaneous and ocular metastatic melanomas, aimed at highlighting the association between the topography of metastases and the duration of immunotherapy until progressive disease. The results indicated the presence of liver metastases as a negative predictive factor for IT duration in patients with melanoma and the presence of lymphatic metastases as a predictive factor for longer IT in patients with melanoma under 65 years old.