Lipid-Lowering Therapy after Acute Coronary Syndrome in Outpatient Practice-How to Achieve Goal.

BACKGROUND: Secondary prevention of cardiovascular disease involves the use of optimal pharmacological treatment and modification of risk factors through lifestyle changes. Recent evidence demonstrates that the major initiating event in atherogenesis is the storage of low-density lipoproteins. OBJECTIVES: We aimed to compare the efficacy in achieving the therapeutic lipid target in relation to the frequency of follow-up at selected time points and to determine the safety and tolerability of cholesterol-lowering drugs (statins, ezetimibe). METHODS: This was a prospective analysis of 72 consecutive patients hospitalized for acute coronary syndrome: ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI). Patients were consecutively divided into two groups: first, with follow-up and laboratory tests at 1, 3, 6 and 12 months after hospital discharge, including 32 patients; second, including 40 patients with follow-up and laboratory tests 12 months after hospital discharge. RESULTS: A significant reduction in LDL-C level was observed at 12 months in both groups. LDL-C level was significantly lower in group 1 than in group 2 after 12 months (p = 0.02). Total cholesterol level was significantly lower in group 1 than in group 2 after 12 months. After 12 months of therapy, 21 (65.6%) patients in group 1 and 17 (42.5%) in group 2 had LDL-C < 1.4 mmol/L. In group 1, we observed a significant decrease in LDL-C, triglyceride, and total cholesterol levels at 1, 3, 6 and 12 months (p < 0.05). CONCLUSIONS: The group of patients with more frequent follow-up visits showed a greater reduction in LDL-C level than the group with only one visit after a 12-month hospital discharge.

Anatomic Variations of Renal Arteries as an Important Factor in the Effectiveness of Renal Denervation in Resistant Hypertension.

Hypertension remains the leading cause of death worldwide. Despite advances in drug-based treatment, many patients do not achieve target blood pressure. In recent years, there has been an increased interest in invasive hypertension treatment methods. Long-term effects and factors affecting renal denervation effectiveness are still under investigation. Some investigators found that the renal arteries' morphology is crucial in renal denervation effectiveness. Accessory renal arteries occur in 20-30% of the population and even more frequently in patients with resistant hypertension. Diversity in renal vascularization and innervation may complicate the renal denervation procedure and increase the number of people who will not benefit from treatment. Based on previous studies, it has been shown that the presence of accessory renal arteries, and in particular, the lack of their complete denervation, reduces the procedure's effectiveness. The following review presents the anatomical assessment of the renal arteries, emphasizing the importance of imaging tests. Examples of imaging and denervation methods to optimize the procedure are presented. The development of new-generation catheters and the advancement in knowledge of renal arteries anatomy may improve the effectiveness of treatment and reduce the number of patients who do not respond to treatment.

Mavacamten - a new disease-specific option for pharmacological treatment of symptomatic patients with hypertrophic cardiomyopathy.

Current pharmacotherapy for hypertrophic cardiomyopathy (HCM) is not disease-specific and has suboptimal efficacy, often necessitating interventional treatment. EXPLORER-HCM was a phase 3, randomized, double-blind, placebo-controlled, multicenter clinical trial investigating the effects of mavacamten, a first-in-class selective cardiac myosin inhibitor, in patients with HCM, left ventricular outflow tract obstruction (LVOTO) and New York Heart Association (NYHA) class II or III symptoms. The primary endpoint was defined as either a ≥1.5 ml/kg/min increase in peak oxygen consumption (pVO2) and ≥1 NYHA class reduction or a ≥3.0 ml/kg/min pVO2 increase without NYHA class worsening. Secondary endpoints evaluated changes in post-exercise LVOT gradient, pVO2, NYHA class, Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score (KCCQ-CSS), and Hypertrophic Cardiomyopa-thy Symptom Questionnaire Shortness-of-Breath subscore (HCMSQ-SoB). A total of 251 patients were randomized to receiving mavacamten or placebo. The primary endpoint and all secondary endpoints were met significantly more frequently in the mavacamten arm versus placebo. The safety profile of mavacamten was similar to that of placebo. In conclusion, disease-specific treatment with mavacamten in patients with obstructive HCM led to reduced LVOTO and improvement in both objective functional parameters and patient-related health status.

Serum N-terminal pro-B-type natriuretic peptide levels are associated with left atrial dilation, resting left ventricular outflow tract gradient, and pulmonary hypertension in patients with hypertrophic cardiomyopathy.

INTRODUCTION: N-terminal pro-B-type natriuretic peptide (NT-proBNP) can be a marker of left ventricle (LV) pressure overload in hypertrophic cardiomyopathy (HCM). The different clinical characteristics of HCM might correspond to the degree of NT-proBNP increase. AIM: This study aimed to establish whether the left atrium (LA) dimension, left ventricle outflow tract (LVOT) gradient, and pulmonary hypertension influence NT-proBNP serum levels in patients with HCM. MATERIAL AND METHODS: In 62 HCM patients (32 males and 30 females, mean age 31 ±11 years), echocardiography with LV outflow tract gradient provocation was performed using natural stimuli > 30 mm Hg (NOHCM - 36 patients, POHCM - 12 patients, HOCM - 14 patients). RESULTS: Smaller LAD was associated with a lower NT-proBNP/ULN level (p = 0.001). In contrast, smaller vs. larger LAD subgroups did not differ in NT-proBNP level (p = 0.42). Both NT-proBNP/ULN and NTproBNP were significantly elevated in the subgroup with lager LAA. The absolute value of NT-proBNP was significantly higher in the HOCM subgroup (NOHCM vs. POHCM vs. HOCM (p = 0.02). Similarly, NT-proBNP/ULN was significantly higher in the HOCM subgroup (NOHCM vs. POHCM vs. HOCM, p = 0.00047). This elevated value of biomarker is related to pulmonary hypertension. CONCLUSIONS: Increased NT-proBNP/ULN is positively associated with larger LAD and LAA, while elevated NTproBNP is only associated with larger LAA. The highest levels of both NT-proBNP and NTproBNP/ULN were associated with HOCM and pulmonary hypertension, whereas biomarker levels were comparably lower in both the POHCM and NOHCM.

Identification of a variant hotspot in MYBPC3 and of a novel CSRP3 autosomal recessive alteration in a cohort of Polish patients with hypertrophic cardiomyopathy.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) is a heart disorder caused by autosomal dominant alterations affecting both sarcomeric genes and other nonsarcomeric loci in a minority of cases. However, in some patients, the occurrence of the causal pathogenic variant or variants in homozygosity, compound heterozygosity, or double heterozygosity has also been described. Most of the HCM pathogenic variants are missense and unique, but truncating mutations of the MYBPC3 gene have been reported as founder pathogenic variants in populations from Finland, France, Japan, Iceland, Italy, and the Netherlands. OBJECTIVES: This study aimed to assess the genetic background of HCM in a cohort of Polish patients. PATIENTS AND METHODS: Twenty­nine Polish patients were analyzed by a next generation sequencing panel including 404 cardiovascular genes. RESULTS: Pathogenic variants were found in 41% of the patients, with ultra­ rare MYBPC3 c.2541C>G (p.Tyr847Ter) mutation standing for a variant hotspot and correlating with a lower age at HCM diagnosis. Among the nonsarcomeric genes, the CSRP3 mutation was found in a single case carrying the novel c.364C>T (p.Arg122Ter) variant in homozygosity. With this finding, the total number of known HCM cases with human CSRP3 knockout cases has reached 3. CONCLUSIONS: This report expands the mutational spectrum and the inheritance pattern of HCM.

Transcatheter aortic valve implantation improves carotid and vertebral arterial blood flow in patients with severe aortic stenosis: practical role of orthostatic stress test.

BACKGROUND: There are no data on the impact of transcatheter aortic valve implantation (TAVI) on carotid and vertebral arterial blood flow. Our aim was to assess the effects of the orthostatic stress test on carotid and vertebral artery blood flow in patients with severe aortic stenosis (AS) undergoing TAVI. HYPOTHESIS: TAVI may have beneficial effect on carotid and vertebral artery flow in patients with severe aortic stenosis. METHODS: Thirty carefully selected patients with severe AS undergoing TAVI were enrolled. Peak systolic blood-flow velocity and end-diastolic velocity in the common carotid artery, internal carotid artery, and vertebral artery, as well as spectral analysis of flow pattern with time-averaged maximum velocity (centimeters per second), time-averaged mean velocity (centimeters per second), and flow volume (milliliters per minute) on both sides were measured by duplex ultrasound. Measurements were performed in the supine position and at 1 to 2 minutes after the assumption of the standing position at baseline and 3 months after TAVI. RESULTS: All duplex ultrasound parameters assessed in the supine position have significantly improved in patients after TAVI as compared to baseline (P < 0.001 for all). The orthostatic stress test induced decrease of carotid and vertebral arterial flow velocities in AS patients before and after TAVI. However, the drop in velocities and flow volume was numerically lower after TAVI. CONCLUSIONS: TAVI may have some beneficial effect on extracranial artery blood flow by minimalization of its decrease as a response to orthostatic stress.

Decreased carotid and vertebral arterial blood-flow velocity in response to orthostatic unload in patients with severe aortic stenosis.

BACKGROUND: Responses of cerebral blood flow to the postural unloading maneuver in aortic stenosis (AS) have not been described so far. Our aim was to assess effects of orthostatic stress test on changes of carotid and vertebral artery blood flow and transaortic gradients. METHODS: From consecutive 101 AS patients we selected 50 patients with severe isolated AS. Maximal and mean transaortic pressure gradients, as well as peak systolic blood-flow velocity (PSV) and end-diastolic velocity (EDV) in the common carotid artery, internal carotid artery and vertebral artery on both sides were measured by duplex ultrasound in the supine position and at 1-2 min after the assumption of the sitting position in patients with AS, and in stand-ing position in healthy controls. RESULTS: The orthostatic stress test induced significant decrease of carotid and vertebral arterial flow velocities in AS patients. Transaortic pressure gradients also dropped while the patients were sitting (p < 0.001). A history of syncope/presyncope was not associated with a significantly lower PSV and EDV in carotid and vertebral arteries in the upright position. In healthy controls, the velocities in carotid and vertebral arterial flow have been unchanged after maneuver reducing preload. CONCLUSIONS: In AS patients, decrease of carotid and vertebral arterial flow velocities and transaortic gradients in the sitting position were observed. Orthostatic test position does not ap-pear to be associated with a history of syncope/presyncope in patients with severe isolated AS, de-spite a simultaneous drop of transvalvular pressure gradient.

Need for a standardized protocol for stress echocardiography in provoking subaortic and valvular gradient in various cardiac conditions.

(Semi) supine exercise testing has an established role in the evaluation of patients with valvular heart disease and can help clinical decision making. Stress echocardiography has the advantages of its wide availability, low cost, and versatility for the assessment of disease severity. However, exercise-induced changes in valve hemodynamics, left ventricular outflow obstruction and pulmonary artery pressure depended on load variation. Changing position from supine to upright rapidly decreases load conditions for the ventricles. Therefore several cardiac centers have proposed exercise stress echocardiography in the upright position with gradient monitoring sometimes also in post-exercise recovery. Doppler measurement of subaortic gradient has been a very helpful and informative examination in several heart diseases (especially in hypertrophic cardiomyopathy, valve heart diseases, prosthesis dysfunction).

Ecocardiografía de ejercicio en pacientes con miocardiopatía hipertrófica. ¿La evaluación ortostática es necesaria después de todo? / Exercise echocardiography in hypertrophic Ccrdiomyopathy: is upright evaluation needed after all?

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