Eyes and the heart: what a clinician should know.

The eye is prone to various forms of afflictions, either as a manifestation of primary ocular disease or part of systemic disease, including the cardiovascular system. A thorough cardiovascular examination should include a brief ocular assessment. Hypertension and diabetes, for example, would present with retinopathy and dyslipidaemia would present with corneal arcus. Multisystem autoimmune diseases, such as Graves' disease, rheumatoid arthritis and sarcoidosis, would present with proptosis, episcleritis and scleritis, respectively. Myasthenia gravis, while primarily a neuromuscular disease, presents with fatigable ptosis and is associated with Takotsubo cardiomyopathy and giant cell myocarditis. Connective tissue diseases such as Marfan syndrome, which commonly presents with aortic root dilatation, would be associated with ectopia lentis and myopia. Wilson's disease, which is associated with arrhythmias and cardiomyopathies, would present usually with the characteristic Kayser-Fleischer rings. Rarer diseases, such as Fabry disease, would be accompanied by ocular signs such as cornea verticillata and such cardiac manifestations include cardiac hypertrophy as well as arrhythmias. This review examines the interplay between the eye and the cardiovascular system and emphasises the use of conventional and emerging tools to improve diagnosis, management and prognostication of patients.

Ramadan fasting: recommendations for patients with cardiovascular disease.

Ramadan fasting is observed by most of the 1.8 billion Muslims around the world. It lasts for 1 month per the lunar calendar year and is the abstention from any food and drink from dawn to sunset. While recommendations on 'safe' fasting exist for patients with some chronic conditions, such as diabetes mellitus, guidance for patients with cardiovascular disease is lacking. We reviewed the literature to help healthcare professionals educate, discuss and manage patients with cardiovascular conditions, who are considering fasting. Studies on the safety of Ramadan fasting in patients with cardiac disease are sparse, observational, of small sample size and have short follow-up. Using expert consensus and a recognised framework, we risk stratified patients into 'low or moderate risk', for example, stable angina or non-severe heart failure; 'high risk', for example, poorly controlled arrhythmias or recent myocardial infarction; and 'very high risk', for example, advanced heart failure. The 'low-moderate risk' group may fast, provided their medications and clinical conditions allow. The 'high' or 'very high risk' groups should not fast and may consider safe alternatives such as non-consecutive fasts or fasting shorter days, for example, during winter. All patients who are fasting should be educated before Ramadan on their risk and management (including the risk of dehydration, fluid overload and terminating the fast if they become unwell) and reviewed after Ramadan to reassess their risk status and condition. Further studies to clarify the benefits and risks of fasting on the cardiovascular system in patients with different cardiovascular conditions should help refine these recommendations.

Mitral regurgitation management: a systematic review of clinical practice guidelines and recommendations.

Multiple guidelines exist for the diagnosis and management of mitral regurgitation (MR), the second most common valvular heart disease in high-income countries, with recommendations that do not always match. We systematically reviewed guidelines on diagnosis and management of MR, highlighting similarities and differences to guide clinical decision-making. We searched national and international guidelines in MEDLINE and EMBASE (1 June 2010 to 1 September 2021), the Guidelines International Network, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations. Two reviewers independently screened the abstracts and identified articles of interest. Guidelines that were rigorously developed (as assessed with the Appraisal of Guidelines for Research and Evaluation II instrument) were retained for analysis. Five guidelines were retained. There was consensus on a multidisciplinary approach from the heart team and for the definition and grading of severe primary MR. There was general agreement on the thresholds for intervention in symptomatic and asymptomatic primary MR; however, discrepancies were present. There was agreement on optimization of medical therapy in severe secondary MR and intervention in patients symptomatic despite optimal medical therapy, but no consensus on the choice of intervention (surgical repair/replacement vs. transcatheter approach). Cut-offs for high-risk intervention in MR, risk stratification of progressive MR, and guidance on mixed valvular disease were sparse.

Post-Acute Sequelae of COVID-19 and Cardiovascular Autonomic Dysfunction: What Do We Know?

Post-acute sequelae of SARS-CoV-2 (PASC), or long COVID syndrome, is emerging as a major health issue in patients with previous SARS-CoV-2 infection. Symptoms commonly experienced by patients include fatigue, palpitations, chest pain, dyspnea, reduced exercise tolerance, and "brain fog". Additionally, symptoms of orthostatic intolerance and syncope suggest the involvement of the autonomic nervous system. Signs of cardiovascular autonomic dysfunction appear to be common in PASC and are similar to those observed in postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. In this review, we report on the epidemiology of PASC, discuss current evidence and possible mechanisms underpinning the dysregulation of the autonomic nervous system, and suggest nonpharmacological and pharmacological interventions to treat and relieve symptoms of PASC-associated dysautonomia.

A Systematic Quality Scoring Analysis to Assess Automated Cardiovascular Magnetic Resonance Segmentation Algorithms.

BACKGROUND: The quantitative measures used to assess the performance of automated methods often do not reflect the clinical acceptability of contouring. A quality-based assessment of automated cardiac magnetic resonance (CMR) segmentation more relevant to clinical practice is therefore needed. OBJECTIVE: We propose a new method for assessing the quality of machine learning (ML) outputs. We evaluate the clinical utility of the proposed method as it is employed to systematically analyse the quality of an automated contouring algorithm. METHODS: A dataset of short-axis (SAX) cine CMR images from a clinically heterogeneous population (n = 217) were manually contoured by a team of experienced investigators. On the same images we derived automated contours using a ML algorithm. A contour quality scoring application randomly presented manual and automated contours to four blinded clinicians, who were asked to assign a quality score from a predefined rubric. Firstly, we analyzed the distribution of quality scores between the two contouring methods across all clinicians. Secondly, we analyzed the interobserver reliability between the raters. Finally, we examined whether there was a variation in scores based on the type of contour, SAX slice level, and underlying disease. RESULTS: The overall distribution of scores between the two methods was significantly different, with automated contours scoring better than the manual (OR (95% CI) = 1.17 (1.07-1.28), p = 0.001; n = 9401). There was substantial scoring agreement between raters for each contouring method independently, albeit it was significantly better for automated segmentation (automated: AC2 = 0.940, 95% CI, 0.937-0.943 vs manual: AC2 = 0.934, 95% CI, 0.931-0.937; p = 0.006). Next, the analysis of quality scores based on different factors was performed. Our approach helped identify trends patterns of lower segmentation quality as observed for left ventricle epicardial and basal contours with both methods. Similarly, significant differences in quality between the two methods were also found in dilated cardiomyopathy and hypertension. CONCLUSIONS: Our results confirm the ability of our systematic scoring analysis to determine the clinical acceptability of automated contours. This approach focused on the contours' clinical utility could ultimately improve clinicians' confidence in artificial intelligence and its acceptability in the clinical workflow.

Hand-held Ultrasound Scanners in Medical Education: A Systematic Review.

BACKGROUND: Ultrasound imaging devices are becoming popular in clinical and teaching settings, but there is no systematic information on their use in medical education. We conducted a systematic review of hand-held ultrasound (HHU) devices in undergraduate medical education to delineate their role, significance, and limitations. METHODS: We searched Cochrane, PubMed, Embase, and Medline using the strategy: [(Hand-held OR Portable OR Pocket OR "Point of Care Systems") AND Ultrasound] AND (Education OR Training OR Undergraduate OR "Medical Students" OR "Medical School"). We retained 12 articles focusing on undergraduate medical education. We summarised the patterns of HHU use, pooled and estimated sensitivity, and specificity of HHU for detection of left ventricular dysfunction. RESULTS: Features reported were heterogeneous: training time (1-25 hours), number of students involved (1-an entire cohort), number of subjects scanned (27-211), and type of learning (self-directed vs. traditional lectures + hands-on sessions). Most studies reported cardiac HHU examinations, but other anatomical areas were examined, e.g. abdomen and thyroid. Pooled sensitivity 0.88 [95% confidence interval (CI) 0.83-0.92] and specificity 0.86 (95% CI 0.81-0.90) were high for the detection of left ventricular systolic dysfunction by students. CONCLUSION: Data on HHU devices in medical education are scarce and incomplete, but following training students can achieve high diagnostic accuracy, albeit in a limited number of (mainly cardiac) pathologies. There is no consensus on protocols best-suited to the educational needs of medical students, nor data on long-term impact, decay in proficiency or on the financial implications of deploying HHU in this setting.