Cost-benefit of influenza vaccination in preventing sudden cardiac arrest amongst Australian adults.

OBJECTIVE: The objective of the study was to estimate the economic cost benefit of funding influenza vaccination to all Australian adults 50-64 years and predict its effect on sudden cardiac arrest (SCA) deaths and hospitalisation. METHODS: We combined SCA hospitalisation data from the Australian Institute of Health and Welfare (AIHW) with survival, vaccination, and cost parameters from published literature to create a model estimating the cost benefit of universally funded influenza vaccinations to prevent SCA deaths and hospitalisation. Costs were considered from a government perspective and included cost of vaccines and GP consultations, whilst averted deaths were estimated through the age-adjusted value of a statistical life. RESULTS: The target policy was estimated to prevent 278 SCA hospitalisations and 1269 SCA deaths. This would result in cost-savings of almost $4 billion annually, with an incremental benefit-cost ratio (BCR) of 59.94. The majority of savings were associate with averted deaths. When a sensitivity analysis was performed by altering statistical life year values and reducing life years left, the cost-saving remained significant with a minimum BCR of 29.97 derived. CONCLUSIONS: Reducing SCA through extended vaccination including adults 50-64 years is likely to be a cost beneficial policy from a governmental perspective. SCA deaths account for a significant economic loss due to the high mortality rate, which was far greater than the costs saved through averted hospitalisations. More accurate parameters are needed to improve the reliability of these estimate; however, this model can be used as a basis for further research into the economic impact of SCA.

Echocardiographic parameters of cardiac structure and function in the diagnosis of acute myocarditis in adult patients: A systematic review and meta-analysis.

BACKGROUND: Transthoracic echocardiography (TTE) plays a key role in the initial work-up of myocarditis where the identification of pathologic structural and functional changes may assist in its diagnosis and management. The aim of this systematic review was to appraise the evidence for the utility of echocardiographic parameters of cardiac structure and function in the diagnosis of myocarditis in adult populations. METHODS: A systematic literature search of medical databases was performed using PRISMA principles to identify all relevant studies assessing TTE parameters in adult patients with myocarditis (1995-2020; English only; PROSPERO registration CRD42021243598). Data for a range of structural and functional TTE parameters were individually extracted and those with low heterogeneity were then meta-analyzed using a random-effects model for effect size, and assessed through standardized mean difference (SMD). RESULTS: Available data from six studies (with a pooled total of 269 myocarditis patients and 240 controls) revealed that myocarditis can be reliably differentiated from healthy controls using echocardiographic measures of left ventricular (LV) size and systolic function, in particular LV end-diastolic diameter, LV ejection fraction (LVEF) and LV global longitudinal strain (LV-GLS) (p ≤ .01 for all). LV-GLS demonstrated the highest overall effect size, followed by LVEF and LVEDD (SMD: |0.46-1.98|). Two studies also demonstrated that impairment in LV-GLS was associated with adverse cardiovascular outcomes in this population, irrespective of LVEF. CONCLUSIONS: LV-GLS demonstrated the greatest overall effect size and therefore ability to differentiate myocarditis populations from healthy controls. GLS was also shown to be a predictor of adverse cardiovascular outcomes, in this population. HIGHTLIGHTS: What is already known on this subject? Myocarditis is a disease process that is often a diagnosis of exclusion, as it frequently mimics other acute cardiac pathologies. Transthoracic echocardiography is traditionally the initial imaging modality used for noninvasive structural assessment in populations with myocarditis. What might this study add? This study demonstrates that left ventricular (LV) global longitudinal strain, LV ejection fraction and LV end-diastolic diameter can differentiate between myocarditis patients and healthy controls. LV-GLS demonstrated the greatest overall effect size when comparing these two populations, in comparison to the other measures. How might this impact on clinical practice? This study demonstrates that assessment of myocardial deformation indices allows for sensitive discrimination between myocarditis patients from healthy controls. Routine assessment of LV-GLS may serve as an important diagnostic tool in the acute care setting.

The impact of body mass index on cardiac structure and function in a cohort of obese patients without traditional cardiovascular risk factors.

Background: Obesity has been linked with alterations in hemodynamic, autonomic, and hormonal pathways in the body, leading to a spectrum of cardiovascular changes. We sought to evaluate the effects of obesity on structural and functional changes of the heart in the absence of cardiac disease and associated risk factors. Methods: We identified healthy outpatients without any cardiovascular disease or risk factors from our institution's echocardiography database (2017-2020). Patients were stratified by body mass index (BMI; normal: 18.5-25 kg/m2; overweight: 25-30 kg/m2; class 1 obesity: 30-35 kg/m2; class 2 obesity: 35-40 kg/m2; class 3 obesity: >40 kg/m2). Traditional and advanced echocardiographic parameters of cardiac chamber size and function including left ventricular global longitudinal strain (LV-GLS), left atrial reservoir strain (LASr), and right ventricular free wall strain (RV-FWS) were examined. The optimal cut-off BMI for discriminating LV-GLS (>-17.5%), LASr (<23%), and RV-FWS (>-23%) impairment was calculated using ROC curves. Results: 307 patients were assessed (41.5 ± 13.3yrs; 36.5%male; LVEF 61.3 ± 4.8%). No significant differences in indexed chamber volumes or LVEF were appreciated across BMI groups (p > 0.05 for all). LV-GLS, LASr, and RV-FWS were all significant on one-way ANOVA for differences from the group mean (all p < 0.01). Jonckheere-Terpstra test confirmed a significant trend of lower absolute LV-GLS, LASr and RV-FWS values across the rising BMI groups. On ROC curve analysis, a BMI value of 29.9 kg/m2, 35.1 kg/m2, and 37.3 kg/m2 were associated with LASr (AUC: 0.75), RV-FWS (AUC: 0.72), and LV-GLS (AUC: 0.75) impairment respectively. Conclusion: Obesity is linked with subclinical reduction of cardiac function in otherwise healthy subjects without cardiovascular risk factors, with reduction of left atrial function occurring at lower BMI, followed by the right and left ventricular function.

Characterization of Subclinical Cardiac Dysfunction by Speckle Tracking Echocardiography in Patients With Non-severe Acute-Phase Myocarditis.

Subclinical changes in left ventricular (LV) function have been demonstrated in patients with acute-phase myocarditis (AM) despite normal LV ejection fraction. The impact of AM on right ventricular (RV) and left atrial (LA) function has not been well described. This study aimed to assess for subclinical chamber dysfunction by speckle tracking echocardiography and its clinical relevance in this population. Patients with a diagnosis of AM (as per the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases) admitted to our institution from 2013 to 2018 were assessed. Patients with elevated serum troponin, normal coronary assessment, and normal LV ejection fraction on transthoracic echocardiogram were included. Clinical and echocardiographic parameters were compared with healthy age-, gender- and risk-factor matched controls. Global longitudinal strain assessed through speckle tracking echocardiography was performed using vendor independent software (v4.6; TomTec Arena, Munich, Germany). The final cohort consisted of 80 patients (40 AM patients and 40 controls). No significant differences in baseline clinical characteristics were observed between groups. Of the echocardiographic parameters, AM patients had lower LV-global longitudinal strain (p <0.01), lower RV free-wall strain (p = 0.02) and lower peak LA strain (p <0.01). There were no differences in traditional echocardiographic measures of LV, RV, and LA function appreciated between groups. The presence of multichamber involvement was associated with peak Troponin levels (p <0.01). In conclusion, our study demonstrates the presence of global subclinical myocardial dysfunction in patients with AM. Additionally, the presence of multichamber involvement was significantly associated with degree of myocardial necrosis.

ObsErvatioNal prospective multicenter stuDy tO characterize the cLinical ANd DiagnoStiC feAtures of endocarditis in the contemPorary Era (ENDO-LANDSCAPE study): rationale and design.

BACKGROUND: Recent developments in the management of valvular heart disease and heart failure have resulted in a dramatic increase in percutaneous valve procedures and implanted devices. We hypothesize that this has impacted the epidemiology, diagnosis, and management of endocarditis. METHODS: The obsErvatioNal prospective multicenter stuDy tO characterize the cLinical ANd DiagnoStiC feAtures of endocarditis in the contemPorary Era (ENDO-LANDSCAPE study) is an observational, multicenter, and international study aimed to examine the epidemiology of endocarditis in the contemporary era. The study will constitute of a retrospective arm for the determination of the sample size of the prospective arm, where cases of endocarditis between 2016 to 2022 at three tertiary referral institutions will be analyzed. The prospective arm will examine all consecutive patients referred for an echocardiography with a suspected or confirmed diagnosis of endocarditis, and their clinical course followed up over 12 months for adverse outcomes. The primary aim of the study will be to characterize the epidemiology of endocarditis, focusing on patients with prosthetic or implanted devices. The secondary aims would be: the appropriateness of the requests for first-line echocardiographic imaging in exclusion of endocarditis; the role of other imaging modalities in the diagnosis of endocarditis; and the impact of a specialized endocarditis team on outcomes. IMPLICATIONS: The results of the ENDO-LANDSCAPE study will provide a contemporary update of the epidemiological trends in endocarditis. The data generated from this study would be useful in informing future clinical practice, potentially guiding future diagnostic and treatment algorithms in patients with endocarditis. CLINICALTRIALORG ID: NCT05547607.

The impact of COVID-19 and COVID vaccination on cardiovascular outcomes.

COVID-19 is an independent risk factor for cardiovascular disease. COVID-19 vaccination may prevent this, but in some cases, COVID-19 vaccination may cause myocarditis or pericarditis. Patients with COVID-19 may present with non-specific symptoms that have a cardiac origin. This review examines the cardiovascular complications of COVID-19 infection and the impact of COVID-19 vaccination. COVID-19 cardiovascular complications include myocardial injury, pericarditis, coagulopathy, myocardial infarction, heart failure, arrhythmias, and persistent post-acute risk of adverse cardiovascular outcomes. Diagnostic and referral pathways for non-specific symptoms, such as dyspnoea and fatigue, remain unclear. COVID-19 vaccination is cardioprotective overall but is associated with myopericarditis in young males, though at a lower rate than following SARS-CoV-2 infection. Increased awareness among primary care physicians of potential cardiovascular causes of non-specific post-COVID-19 symptoms, including in younger adults, such as fatigue, dyspnoea, and chest pain, is essential. We recommend full vaccination with scheduled booster doses, optimal management of cardiovascular risk factors, rapid treatment of COVID-19, and clear diagnostic, referral, and management pathways for patients presenting with non-specific symptoms to rule out cardiac complications.

Knowledge, attitudes and practices of health care workers in a cardiology department on influenza vaccination.

BACKGROUND: Evidence has accrued that influenza vaccination may be effective in preventing myocardial infarction (MI). However, vaccination rates in both adults and health care workers (HCW) are low, and hospitalisation is often a missed opportunity for vaccination. We hypothesised that knowledge, attitude and practices of health care workers regarding vaccination impacts vaccine uptake in hospitals. The cardiac ward admits high-risk patients, many of whom are indicated for influenza vaccine, especially those caring for patients with acute MI. AIM: To understand the knowledge, attitudes, and practices of HCW in cardiology ward within a tertiary institution, on influenza vaccination. METHODS: We used focus group discussions with HCW caring for AMI patients in an acute cardiology ward, to explore the knowledge, attitudes, and practices of HCW regarding influenza vaccination for patients under their care. Discussions were recorded, transcribed, and thematically analysed using NVivo software. In addition, participants completed a survey on their knowledge and attitudes towards the uptake of influenza vaccination. RESULTS: A lack of awareness regarding the associations between influenza, vaccination and cardiovascular health was identified amongst HCW. Participants did not routinely discuss the benefits of influenza vaccination or recommend influenza vaccinations to patients under their care; this may be due to a combination of a lack of awareness, not seeing it as part of their job and workload issues. We also highlighted difficulties in access to vaccination, and concerns of adverse reactions to the vaccine. CONCLUSION: There is limited awareness among HCW of the role of influenza on cardiovascular health and the benefits of influenza vaccine in the prevention of cardiovascular events. Improved vaccination of at-risk patients in hospital may need active engagement of HCW. Improving the health literacy of HCW regarding the benefits of vaccination as a preventative strategy may result in better health care outcomes for cardiac patients.

Barriers to Guideline-Directed Anticoagulation in Patients With Atrial Fibrillation: New Approaches to an Old Problem.

Optimising guideline-directed anticoagulation in atrial fibrillation remains a perennial problem despite strong evidence for improved health outcomes with guideline-directed use of anticoagulation. Efforts to improve uptake have been hampered by barriers found at the level of the physician, patient, disease, and choice of therapy. Clinician judgement is often clouded by factors such as therapeutic inertia, aversion to bleeding risk, and implicit bias. For patients, negative preconceptions of therapy, impact of therapy on day-to-day life, and the nocebo effect pose significant barriers. Both groups are affected by poor education. Utility of a single-pronged approach directed toward clinicians or patients have demonstrated variable success, with the highest impact appreciated in studies using shared-decision models. Further, there is emerging evidence for use of integrated models of care, which have shown efficacy in improving patient outcomes, as well as use of digital platforms such as mobile app-based interventions, which can be of aid to the clinician in improving patient adherence to anticoagulation, with translated improved outcomes in clinical trials. This narrative review aims to investigate the physician and health system, patient, and drug therapy and disease barriers to uptake of guideline-directed anticoagulation in the treatment of nonvalvular atrial fibrillation.

Serial Measurement of Global Longitudinal Strain Among Women With Breast Cancer Treated With Proton Radiation Therapy: A Prospective Trial for 70 Patients.

PURPOSE: Conventional photon radiation therapy (RT) for breast cancer is associated with a reduction in global longitudinal strain (GLS) and an increase in troponin, N-terminal pro hormone B-type natriuretic peptide (NT-proBNP), and incident heart failure. The cardiac radiation exposure with proton-RT is much reduced and thus may be associated with less cardiotoxicity. The objective was to test the effect of proton-RT on GLS, troponin, and NT-proBNP. METHODS AND MATERIALS: We conducted a prospective, observational, single-center study of 70 women being treated with proton-RT for breast cancer. Serial measurements of GLS, high-sensitivity troponin I, and NT-proBNP were performed at prespecified intervals (before proton-RT, 4 weeks after completion of proton-RT, and again at 2 months after proton-RT). RESULTS: The mean age of the patients was 46 ± 11 years, and the mean body mass index was 25.6 ± 5.2 kg/m2; 32% of patients had hypertension, and the mean radiation doses to the heart and the left ventricle (LV) were 0.44 Gy and 0.12 Gy, respectively. There was no change in left ventricular ejection fraction (65 ± 5 vs 66 ± 5 vs 64 ± 4%; P = .15), global GLS (-21.7 ± 2.7 vs -22.7 ± 2.3 vs -22.8 ± 2.1%; P = .24), or segmental GLS from before to after proton-RT. Similarly, there was no change in either high-sensitivity troponin or NT-proBNP with proton-RT. However, in a post hoc subset analysis, women with hypertension had a greater decrease in GLS after proton-RT compared with women without hypertension (-21.3 ± 3.5 vs -24.0 ± 2.4%; P = .006). CONCLUSIONS: Proton-RT did not affect LV function and was not associated with an increase in biomarkers. These data support the potential cardiac benefits of proton-RT compared with conventional RT.

High-Resolution Transthoracic Echocardiography Accurately Detects Pulmonary Arterial Pressure and Decreased Right Ventricular Contractility in a Mouse Model of Pulmonary Fibrosis and Secondary Pulmonary Hypertension.

Background To date, assessment of right ventricular (RV) function in mice has relied extensively on invasive measurements. Echocardiographic advances have allowed adaptation of measures used in humans for serial, noninvasive RV functional assessment in mice. We evaluated the diagnostic performance of tricuspid annular plane systolic excursion (TAPSE), RV peak systolic myocardial velocity (s'), RV myocardial performance index (MPI), and RV fractional area change (FAC) in a mouse model of pulmonary hypertension. Methods and Results Echocardiography was performed on mice at baseline and 3 weeks after induction of pulmonary hypertension using inhaled bleomycin or saline, including adapted measures of TAPSE, s', MPI, and FAC. RV systolic pressure was measured by invasive catheterization, and RV contractility was measured as the peak slope of the RV systolic pressure recording (maximum change pressure/change time). Postmortem morphological assessment of RV hypertrophy was performed. RV systolic pressure was elevated and maximum change pressure/change time was reduced in bleomycin versus control (n=8; P=0.002). Compared with controls, bleomycin mice had reduced TAPSE (0.79±0.05 versus 1.06±0.04 mm; P=0.003), s' (21.3±1.2 versus 29.2±1.3 mm/s; P<0.001), and FAC (20.3±0.7% versus 31.0±1.3%; P<0.001), whereas MPI was increased (0.51±0.03 versus 0.37±0.01; P=0.006). All measures correlated with RV systolic pressure and maximum change pressure/change time. Intraobserver and interobserver variability were minimal. Receiver operating characteristic curves demonstrated that TAPSE (<0.84 mm), s'(<23.3 mm/s), MPI (0.42), and FAC (<23.3%) identified maximum change pressure/change time ≤2100 mm Hg/s with high accuracy. Conclusions TAPSE, s', MPI, and FAC are measurable consistently using high-resolution echocardiography in mice, and are sensitive and specific measures of pulmonary pressure and RV function. This validation opens the opportunity for serial noninvasive measures in mouse models of pulmonary hypertension, enhancing the statistical power of preclinical studies of novel therapeutics.

Incidence of immune checkpoint inhibitor mediated cardiovascular toxicity: A systematic review and meta-analysis.

BACKGROUND: Immune checkpoint inhibitors (ICI) are a novel class of anti-cancer therapy becoming increasingly associated with fatal cardiovascular toxicities (CVTs). The aim is to determine the incidence of CVTs in cohorts treated with ICIs as sole anti-cancer therapy. METHODS: A systematic literature search of scientific and medical databases was performed using PRISMA principles to identify relevant cohorts (PROSPERO registration CRD42021272470). Data for specific CVTs (pericardial disease, myocarditis, heart failure, arrhythmia, myocardial infarction/ischaemia and angina), CVT-related death and CV risk factors were extracted. Presence of CVTs in ICI-monotherapy versus combination-ICI therapy, and programmed death 1/programmed death ligand 1- (PD1/PDL1-) versus cytotoxic T-lymphocyte-associated protein 4- (CTLA4-) inhibitor groups were dichotomised and meta-analysed using random-effect models. RESULTS: Forty-eight studies (11,207 patients) were identified, from which 146 CVTs were observed (incidence 1.30%). ICI-monotherapy led to more CVTs than combination therapy (119/9009; 1.32% vs. 18/2086; 0.86%). Across monotherapies, PD1/PDL1-inhibitors had lower incidence of CVTs compared to CTLA4-inhibitors (62/6950; 0.89% vs. 57/2059; 2.77%). Based on eight studies that were meta-analysed, no significant difference was observed comparing monotherapy versus combination-ICI therapy (RR-0.69, 95% CI -1.47 to 0.09) for all CVTs, or PD1/PDL1- to CTLA4-inhibitors (RR-0.27, 95% CI -2.06 to 1.53), for all CVTs including CVT-death. CV risk factors could not be attributed to an ICI group as data was population based rather than individual based. CONCLUSION: ICI-mediated CVTs are rare and potentially fatal. The role of CV risk factors in their development remains unclear.

The Volume-Time Curve by Three-Dimensional Echocardiography in Chagas Cardiomyopathy: Insights into the Mechanism of Hemodynamic Adaptations. / A Curva Volume-Tempo Obtida pela Ecocardiografia Tridimensional na Cardiomiopatia Chagásica: Análise do Mecanismo das Adaptações Hemodinâmicas.

BACKGROUND: Three-dimensional echocardiography (3D ECHO) allows the generation of a volume-time curve representative of changes in the left ventricular (LV) volume throughout the entire cardiac cycle. OBJECTIVE: This study aims to demonstrate the hemodynamic adaptations present in Chagas cardiomyopathy (CC) by means of the volume and flow measurements obtained by the volume-time curve by 3D ECHO. METHODS: Twenty patients with CC and 15 healthy subjects were prospectively enrolled in a cross-sectional design study. 3D ECHO was performed in all subjects and the volume over time curves of the LV was generated. The flow was obtained by the first derivative of the volume-time curve using the software MATLAB. Statistical significance was set at p<0.05. RESULTS: Although CC patients had lower LV ejection fraction compared to the control group (29.8±7.5 vs. 57.7±6.1, p<0.001), stroke volume (61.5±25.2 vs. 53.8±21.0, p=0.364) and maximum ejection flow during systole (-360.3±147.5 vs. -305.6±126.0, p=0.231) were similar between the groups. Likewise, the maximum flow in the early diastolic filling phase and during atrial contraction was similar between groups. An increase in preload expressed by LV end diastolic volume (204.8±79.4 vs. 93.0±32.6), p<0.001) may maintain the flow and stroke volumes similar to the controls. CONCLUSION: Using a non-invasive tool, we demonstrated that an increase in LV end-diastolic volume may be the main adaptation mechanism that maintains the flow and stroke volumes in the setting of severe LV systolic dysfunction.

FUNDAMENTO: A ecocardiografia tridimensional (ECO 3D) permite a geração de uma curva volume-tempo representativa das alterações no volume ventricular esquerdo (VE) ao longo de todo o ciclo cardíaco. OBJETIVO: O presente estudo tem como objetivo demonstrar as adaptações hemodinâmicas presentes na cardiomiopatia chagásica (CC) por meio das medidas de volume e fluxo obtidas pela curva volume-tempo por ECO 3D. MÉTODOS: Vinte pacientes com CC e 15 indivíduos saudáveis foram incluídos prospectivamente em um estudo de desenho transversal. Realizou-se ECO 3D em todos os indivíduos e as curvas volume-tempo do VE foram geradas. O fluxo foi obtido pela primeira derivada da curva volume-tempo por meio do software MATLAB. A significância estatística foi definida com p<0,05. RESULTADOS: Embora os pacientes com CC tivessem menor fração de ejeção do VE em comparação com o grupo controle (29,8±7,5 vs. 57,7±6,1, p<0,001), o volume (61,5±25,2 vs. 53,8±21,0, p=0,364) e o fluxo de ejeção máximo durante a sístole (-360,3±147,5 vs. -305,6±126,0, p = 0,231) mostraram-se semelhantes entre os grupos. Da mesma forma, o fluxo máximo na fase de enchimento inicial e durante a contração atrial mostrou-se semelhante entre os grupos. Um aumento na pré-carga expressa pelo volume diastólico final do VE (204,8±79,4 vs. 93,0±32,6), p<0,001) pode manter o fluxo e o volume ejetado semelhantes aos dos controles. CONCLUSÃO: Com uma ferramenta não invasiva, demonstramos que o aumento no volume diastólico final do VE pode ser o principal mecanismo de adaptação que mantém o fluxo e o volume ejetado no cenário de disfunção sistólica ventricular esquerda severa.

Diagnostic and Prognostic Value of Left Atrial Function in Identification of Cardioembolism and Prediction of Outcomes in Patients with Cryptogenic Stroke.

BACKGROUND: Stroke of undetermined source, commonly termed cryptogenic stroke (CS), accounts for a significant proportion of ischemic stroke etiology and have high rates of stroke recurrence. The heterogeneous etiology of CS makes decisions regarding treatment for such patients challenging. The aim of this study was to evaluate the diagnostic and prognostic value of left atrial (LA) function in the identification of cardioembolism and prediction of outcomes in patients with CS. METHODS: Consecutive patients admitted to a tertiary institution with ischemic stroke or transient ischemic attack (TIA) who underwent transthoracic echocardiography were recruited, with comprehensive evaluation of LA metrics including LA strain. Ischemic strokes and TIAs were classified as noncardioembolic, cryptogenic, or cardioembolic. A total of 709 patients (mean age, 66.0 ± 15.1 years; 55% men) were recruited. Two hundred ninety-one patients had CS, 189 had noncardioembolic stroke, and 229 had cardioembolic stroke. Patients with CS were followed for 20.0 ± 13.8 months for recurrent ischemic stroke or TIA. RESULTS: Receiver operating characteristic curves showed LA reservoir and contractile strain to be strong discriminators of cardioembolic strokes, and log-rank tests showed both measures to be significantly associated with the distribution of time to recurrent ischemic stroke or TIA in patients with CS. Multivariable hazard models showed LA reservoir and contractile strain to be independent predictors of recurrent ischemic stroke or TIA in patients with CS, in addition to estimated glomerular filtration rate and active smoking. CONCLUSIONS: LA reservoir and contractile strain were strong discriminators of cardioembolic stroke and independently predicted recurrent ischemic stroke or TIA in patients with CS. Use of LA strain may improve risk stratification and decision-making in patients with CS, with particular regard to prolonged ambulatory heart rhythm monitoring and/or empiric anticoagulation.

The utility of cardiac magnetic resonance imaging in the diagnosis of adult patients with acute myocarditis: a systematic review and meta-analysis.

BACKGROUND: The presence of myocardial late gadolinium enhancement (LGE) indicates myocyte necrosis, and assists with the diagnosis of acute myocarditis (AM). Cardiac magnetic resonance (CMR) measures other than LGE i.e. tissue characterization and myocardial structural and functional parameters, play an important diagnostic role in assessment for inflammation, as seen in AM. The aim of this systematic review was to appraise the evidence for the use of quantitative CMR measures to identify myocardial inflammation in order to diagnose AM in adult patients. METHODS: A systematic literature search of medical databases was performed using PRISMA principles to identify relevant CMR studies on AM in adults (2005-2020; English; PROSPERO registration CRD42020180605). Data for a range of quantitative CMR measures were extracted. Continuous variables with low heterogeneity were meta-analyzed using a random-effects model for overall effect size measured as the standard mean difference (SMD). RESULTS: Available data from 25 studies reporting continuous quantitative 1.5-T CMR measures revealed that AM is most reliably differentiated from healthy controls using T1 mapping (SMD 1.80, p<0.01) and T2 mapping (SMD 1.63, p<0.01), respectively. All other measures examined including T2-weighted ratio, extracellular volume, early gadolinium enhancement ratio, right ventricular ejection fraction, and LV end-diastolic volume, mass, ejection fraction, longitudinal strain, circumferential strain, and radial strain also had discriminatory ability although with smaller standard mean difference values (|SMD| 0.32-0.96, p < 0.01 for all). CONCLUSIONS: Meta-analysis shows that myocardial tissue characterization (T1 mapping>T2 mapping) followed by measures of left ventricular structure and function demonstrate diagnostic discriminatory ability in AM.

A Curva Volume-Tempo Obtida pela Ecocardiografia Tridimensional na Cardiomiopatia Chagásica: Análise do Mecanismo das Adaptações Hemodinâmicas / The Volume-Time Curve by Three-Dimensional Echocardiography in Chagas Cardiomyopathy: Insights into the Mechanism of Hemodynamic Adaptations

Resumo Fundamento A ecocardiografia tridimensional (ECO 3D) permite a geração de uma curva volume-tempo representativa das alterações no volume ventricular esquerdo (VE) ao longo de todo o ciclo cardíaco. Objetivo O presente estudo tem como objetivo demonstrar as adaptações hemodinâmicas presentes na cardiomiopatia chagásica (CC) por meio das medidas de volume e fluxo obtidas pela curva volume-tempo por ECO 3D. Métodos Vinte pacientes com CC e 15 indivíduos saudáveis foram incluídos prospectivamente em um estudo de desenho transversal. Realizou-se ECO 3D em todos os indivíduos e as curvas volume-tempo do VE foram geradas. O fluxo foi obtido pela primeira derivada da curva volume-tempo por meio do software MATLAB. A significância estatística foi definida com p<0,05. Resultados Embora os pacientes com CC tivessem menor fração de ejeção do VE em comparação com o grupo controle (29,8±7,5 vs. 57,7±6,1, p<0,001), o volume (61,5±25,2 vs. 53,8±21,0, p=0,364) e o fluxo de ejeção máximo durante a sístole (-360,3±147,5 vs. -305,6±126,0, p = 0,231) mostraram-se semelhantes entre os grupos. Da mesma forma, o fluxo máximo na fase de enchimento inicial e durante a contração atrial mostrou-se semelhante entre os grupos. Um aumento na pré-carga expressa pelo volume diastólico final do VE (204,8±79,4 vs. 93,0±32,6), p<0,001) pode manter o fluxo e o volume ejetado semelhantes aos dos controles. Conclusão Com uma ferramenta não invasiva, demonstramos que o aumento no volume diastólico final do VE pode ser o principal mecanismo de adaptação que mantém o fluxo e o volume ejetado no cenário de disfunção sistólica ventricular esquerda severa.

Abstract Background Three-dimensional echocardiography (3D ECHO) allows the generation of a volume-time curve representative of changes in the left ventricular (LV) volume throughout the entire cardiac cycle. Objective This study aims to demonstrate the hemodynamic adaptations present in Chagas cardiomyopathy (CC) by means of the volume and flow measurements obtained by the volume-time curve by 3D ECHO. Methods Twenty patients with CC and 15 healthy subjects were prospectively enrolled in a cross-sectional design study. 3D ECHO was performed in all subjects and the volume over time curves of the LV was generated. The flow was obtained by the first derivative of the volume-time curve using the software MATLAB. Statistical significance was set at p<0.05. Results Although CC patients had lower LV ejection fraction compared to the control group (29.8±7.5 vs. 57.7±6.1, p<0.001), stroke volume (61.5±25.2 vs. 53.8±21.0, p=0.364) and maximum ejection flow during systole (-360.3±147.5 vs. -305.6±126.0, p=0.231) were similar between the groups. Likewise, the maximum flow in the early diastolic filling phase and during atrial contraction was similar between groups. An increase in preload expressed by LV end diastolic volume (204.8±79.4 vs. 93.0±32.6), p<0.001) may maintain the flow and stroke volumes similar to the controls. Conclusion Using a non-invasive tool, we demonstrated that an increase in LV end-diastolic volume may be the main adaptation mechanism that maintains the flow and stroke volumes in the setting of severe LV systolic dysfunction.

Prognostic implications of traditional and non-traditional cardiovascular risk factor profiles in patients with non-valvular atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is a prevalent disease with associated mortality risk, mediated in large part through its associated cardiovascular risk factors. Standard modifiable cardiovascular risk factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes and smoking) are established drivers of cardiovascular disease; however, the importance of non-traditional mediators of cardiovascular risk (NTRFs) such as chronic renal impairment, obstructive sleep apnoea and obesity is emerging. The differential impact of these risk factors on outcomes in patients with AF is not well studied. METHODS: Consecutive patients admitted to our service between January 2013 and January 2018 with a primary diagnosis of non-valvular AF were assessed. Assessment of demographic, anthropometric, risk factor profile and pharmacotherapeutics was performed. The clinical course of these patients was followed for up to five years for the composite outcome of all-cause death and major adverse cardiovascular events. RESULTS: Of the 1010 patients (62.29 ± 16.81 years, 51% men) included, 154 (15%) had no risk factors, 478 (47%) had only SMuRFs, 59 (6%) had only NTRFs and 319 (32%) had both SMuRFs and NTRFs. Over a mean follow-up period of 33.18 ± 21.27 months, a total of 288 patients met the composite outcome. On Cox regression, the coexistence of SMuRFs and NTRFs was an independent predictor of the composite outcome (HR 1.40; 95%CI 1.09-1.82, p = .01). Other independent predictors included age, heart failure, CHA2 DS2 VASc score, persistent AF and anaemia. CONCLUSIONS: The presence of both SMuRFs and NTRFs has prognostic implications in patients with non-valvular AF.

Coordinating Health Care With Artificial Intelligence-Supported Technology for Patients With Atrial Fibrillation: Protocol for a Randomized Controlled Trial.

BACKGROUND: Atrial fibrillation (AF) is an increasingly common chronic health condition for which integrated care that is multidisciplinary and patient-centric is recommended yet challenging to implement. OBJECTIVE: The aim of Coordinating Health Care With Artificial Intelligence-Supported Technology in AF is to evaluate the feasibility and potential efficacy of a digital intervention (AF-Support) comprising preprogrammed automated telephone calls (artificial intelligence conversational technology), SMS text messages, and emails, as well as an educational website, to support patients with AF in self-managing their condition and coordinate primary and secondary care follow-up. METHODS: Coordinating Health Care With Artificial Intelligence-Supported Technology in AF is a 6-month randomized controlled trial of adult patients with AF (n=385), who will be allocated in a ratio of 4:1 to AF-Support or usual care, with postintervention semistructured interviews. The primary outcome is AF-related quality of life, and the secondary outcomes include cardiovascular risk factors, outcomes, and health care use. The 4:1 allocation design enables a detailed examination of the feasibility, uptake, and process of the implementation of AF-Support. Participants with new or ongoing AF will be recruited from hospitals and specialist-led clinics in Sydney, New South Wales, Australia. AF-Support has been co-designed with clinicians, researchers, information technologists, and patients. Automated telephone calls will occur 7 times, with the first call triggered to commence 24 to 48 hours after enrollment. Calls follow a standard flow but are customized to vary depending on patients' responses. Calls assess AF symptoms, and participants' responses will trigger different system responses based on prespecified protocols, including the identification of red flags requiring escalation. Randomization will be performed electronically, and allocation concealment will be ensured. Because of the nature of this trial, only outcome assessors and data analysts will be blinded. For the primary outcome, groups will be compared using an analysis of covariance adjusted for corresponding baseline values. Randomized trial data analysis will be performed according to the intention-to-treat principle, and qualitative data will be thematically analyzed. RESULTS: Ethics approval was granted by the Western Sydney Local Health District Human Ethics Research Committee, and recruitment started in December 2020. As of December 2021, a total of 103 patients had been recruited. CONCLUSIONS: This study will address the gap in knowledge with respect to the role of postdischarge digital care models for supporting patients with AF. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621000174886; https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12621000174886. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34470.