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.

Anaphylactic cardiovascular collapse manifesting as myocardial infarction following salad consumption. A case of Kounis variant type I syndrome.

Anaphylactic cardiovascular events constitute an underrated cause of medical emergencies in hospitalized patients. Coronary arteries and myocardium are targeted by anaphylactic mediators leading to acute coronary syndrome and imminent cardiovascular collapse. Early diagnosis and high clinical suspicion are required to secure prompt life-saving treatment in these cases. However, physicians of both Cardiology and Internal Medicine Departments are not familiar with this condition. Recently, we diagnosed and treated a case of anaphylactic cardiovascular collapse manifesting as acute myocardial infarction following salad consumption. Notably, Kounis anaphylaxis-associated acute coronary syndrome is a rare cause of ST segment elevation myocardial infarction with normal or diseased coronary arteries. We recommend that Kounis syndrome and its variants should be taken into consideration in the differential diagnosis of ischemic heart disease in patients with signs of allergic reaction and/or medical history of previous allergic reactions, who experience acute coronary syndrome after exposure to certain environmental stimuli.

Effect of Ticagrelor Versus Clopidogrel on Aortic Stiffness in Patients With Coronary Artery Disease.

Background We compared the acute and midterm effect of ticagrelor versus clopidogrel on aortic stiffness. Methods and Results We studied 117 patients in a randomized, assessor-blinded, parallel-group trial. The acute effect of ticagrelor was studied in 58 patients randomized (1:1) to receive a loading dose of clopidogrel (600 mg) or ticagrelor (180 mg). Carotid-femoral pulse wave velocity (cf PWV ) was measured before, 3, and 24 hours after the loading dose. The midterm effect (30-day treatment period) was studied in 59 subjects who underwent percutaneous coronary intervention and were randomized to either clopidogrel (75 mg, OD) or ticagrelor (90 mg BID). cf PWV was measured before and at 30 days of treatment. Circulating markers of inflammation and endothelial function were measured at all study points. Repeated-measures analysis showed a significant main effect for treatment ( P=0.03), with the ticagrelor showing a reduction in cf PWV after treatment. cf PWV at 24 hours was significantly lower in the ticagrelor group compared with the clopidogrel group ( P=0.017) (maximal response reduction by 0.42±0.26 m/s). At 30 days, cf PWV decreased in the ticagrelor group, whereas there was no change with clopidogrel (-0.43±0.57 versus 0.12±0.14 m/s, P=0.004). There were no significant changes in both the acute and midterm study period in the pro-inflammatory and endothelial function parameters. Conclusions URL : https://www.clinicaltrials.gov . Unique identifier: NCT02071212. Ticagrelor decreases cf PWV for 24 hours after the loading dose and at 1 month post-percutaneous coronary intervention compared with clopidogrel. Considering that aortic stiffness is an independent predictor of cardiovascular events, this finding may have clinical implications regarding the beneficial effect of ticagrelor. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT02071212.

Successful Stent Delivery Through a Slaloming Coronary Path.

A 66-year-old man with refractory angina was admitted for percutaneous coronary intervention (PCI) through a tortuous saphenous vein graft sequentially anastomosed with a diagonal and a first marginal branch. Our target was a critical stenosis at the retrograde limb of the first marginal proximal to saphenous vein graft anastomosis. Stent delivery to our target lesion mandated tracking through sequential angulations. In this case, we enhanced the support of the guide catheter and delivered a stent on the retrograde limb of the first marginal branch with very deep intubation of the guide catheter into the saphenous vein graft and use of a buddy wire, which is a cheaper and relatively safer maneuver than complex techniques such as the double guide-catheter extension technique. Proper selection of the type and size of the guide catheter and meticulous attention to the pressure waveform in order to avoid ischemia or dissection of the graft is mandatory during this technique.

Computational imaging of aortic vasa vasorum and neovascularization in rabbits using contrast-enhanced intravascular ultrasound: Association with histological analysis.

OBJECTIVE: Neoangiogenesis is pathophysiologically related to atherosclerotic plaque growth and vulnerability. We examined the in vivo performance of a computational method using contrast-enhanced intravascular ultrasound (CE-IVUS) to detect and quantify aortic wall neovascularization in rabbits. We also compared these findings with histological data. METHODS: Nine rabbits were fed with a hyperlipidemic diet. IVUS image sequences were continuously recorded before and after the injection of a contrast agent. Mean enhancement of intensity of a region of interest (MEIR) was calculated using differential imaging algorithm. The percent difference of MEIR before and after the injection of microbubbles (d_MEIR) was used as an index of the density of plaque or/and adventitial neovascularization. Aortic segments were excised for histological analysis. RESULTS: CE-IVUS and histological analysis were performed in 11 arterial segments. MEIR was significantly increased (~20%) after microbubble injection (from 8.1±0.9 to 9.7±1.8, p=0.016). Segments with increased VV/neovessels in the tunica adventitia (histological scores 2 and 3) had significantly higher d_MEIR compared with segments with low presence of VV/neovessels (score 1); 40.5±22.9 vs. 8±14.6, p=0.024, respectively. CONCLUSION: It is possible to detect VV or neovessels in vivo using computational analysis of CE-IVUS images, which is in agreement with histological data. These findings may have critical implications on vulnerable plaque assessment and risk stratification.

Correlation of CoreValve implantation 'true cover index' with short and mid-term aortic regurgitation: A novel index.

BACKGROUND: 'Cover index' has been proposed to appraise the congruence between the aortic annulus and the device, with the assumption of not taking into account the actual device implantation depth. The aim of this study was to investigate whether the annulus-prosthesis mismatch, as expressed with the new proposed 'true cover index' according to actual implantation depth, can predict aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). METHODS: Patients who had undergone TAVI with the self-expandable CoreValve device, were retrospectively studied. All available prosthesis sizes were ex-vivo scanned and the precise diameter at 0.3mm intervals along each device was measured. The 'true cover index' was evaluated, as a ratio of the following: 100×([prosthesis actual diameter at implantation depth-annulus diameter]/prosthesis actual diameter at implantation depth). AR was echocardiographically evaluated at discharge and 30days and classified as prominent if moderate, or trivial if none or mild. RESULTS: Overall, 120 patients who had undergone TAVI, were considered eligible for the study. 'True cover index' was statistically significantly lower among patients with prominent AR in comparison with trivial AR at discharge (5.7±4.8mm vs 9±5.1, p=0.025), as well as at one month post-TAVI (5.4±5.1mm vs 9.0±5.1, p=0.023), indicating increased AR for smaller index. After adjustment for severe annulus calcification, impaired baseline LVEF and previous valvuloplasty, it remained an independent predictor of one month prominent AR (OR: 0.854, CI: 0.730-0.999; p=0.048). 'True cover index' of <4.3 was shown to predict one-month prominent AR with sensitivity =75% and specificity =82.5%. CONCLUSIONS: 'True cover index' is strongly and independently correlated with the short and mid-term AR after CoreValve implantation.

First in Greece Transcatheter Aortic Valve Implantation using the CoreValve Evolut-R Retrievable and Repositionable Bioprosthesis with the InLine Sheath and the EnVeo Loading Guiding Catheter: A Major Advantage for SmallDiameter Access Vessels.

We report the first TAVI procedure in Greece to use the CoreValve Evolut-R (23 mm profile) bioprosthesis with the InLine sheath and the EnVeo loading guiding catheter in a patient with small anatomical characteristics (aortic annulus, access vessel) and severe comorbidities. The procedure was successfully conducted under general anesthesia through a surgically prepared, extensively calcified, left femoral artery.

Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm.

Pseudoaneurysm of the mitral aortic intervalvular fibrosa (MAIVF-P) usually ensues as a complication of endocarditis or aortic valve surgery. When large, symptomatic or related to complications (rupture, compression of adjacent structures, embolic events, mitral regurgitation or heart failure) it warrants surgical excision. The natural course of uncomplicated/asymptomatic MAIVF-Ps is largely unknown since most patients are offered surgery. Increased surgical risk imposed by repeat operations in the majority of these patients is an important consideration and conservative treatment should not be excluded in selected cases. Herein we present two illustrative cases of MAIVF-P manifesting with significant arrhythmogenesis and complex endocarditis respectively. Both patients were managed conservatively. By briefly reviewing the existing literature, we discuss important diagnostic and therapeutic issues for MAIVF-Ps. To our knowledge complex ventricular arrhythmia has not been previously described as a prominent manifestation of MAIVF-P.

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.

Inferior epigastric artery as a landmark for transfemoral TAVI. Optimizing vascular access?

OBJECTIVES: This study sought to investigate whether the site of common femoral artery (CFA) cannulation in regard to the inferior epigastric artery (IEA) is associated with the incidence of vascular complications in patients undergoing transfemoral aortic valve implantation (TAVI). BACKGROUND: Vascular access complications are a main issue during TAVI and have been associated with significant increase of morbidity and mortality. The need for establishment of reliable predictors for these serious events remains important. METHODS: A total of 90 patients, who had undergone TAVI, were retrospectively studied. Vascular complications were defined as major and minor according to the Valve Academic Research Consortium (VARC) criteria. Patients were divided into high cannulation site (CS) group and low CS group depending on the common femoral artery puncture site position, in regards to the most inferior border of the IEA. RESULTS: Vascular complications were significantly more frequent in the high CS group versus the low CS group (32.3% vs. 11.9%, P = 0.039). High cannulation remained an independent predictor of vascular complications after adjustment for known risk factors (OR: 4.827, CI: 1.441-16.168; P = 0.011). CONCLUSIONS: In patients undergoing transfemoral TAVI, arterial puncture above the most inferior border of the IEA is associated with vascular complications.

Effect of gender differences on early and mid-term clinical outcome after percutaneous or surgical coronary revascularisation in patients with multivessel coronary artery disease: insights from ARTS I and ARTS II.

AIMS: The aim of the current study was to compare the short and mid-term outcome between males and females treated with percutaneous coronary intervention (PCI) with bare metal stent implantation or coronary artery bypass graft (CABG) surgery and drug-eluting stent implantation in the Arterial Revascularisation Therapies Study I and II (ARTS I and II). METHODS AND RESULTS: The patients included in ARTS I were randomised to PCI with bare metal stents or to CABG. The patients enrolled in ARTS II were treated with Cypher stent implantation. All patients were scheduled for clinical follow-up at one, six and twelve months, and after three and five years. Major adverse cardiac and cerebrovascular events (MACCE) included death, cerebrovascular accident (CVA), myocardial infarction (MI), repeat target vessel PCI (RPCI) and CABG. At one and three-year follow-up in ARTS II, both the female and male patients had an incidence of MACCE similar to ARTS I-CABG. When comparing the female and male population of ARTS II, there were no differences between the two genders in terms of in-hospital outcome. At one year and three years there were no gender specific differences in the incidence of MACCE. CONCLUSIONS: Female and male patients in ARTS II had significantly lower MACCE rates compared with ARTS I-PCI, but similar to that of ARTS I-CABG. In ARTS II, MACCE free survival was similar for the two genders at three years follow-up.