Reduction in acute coronary syndromes during coronavirus disease 2019 global pandemic: data from the Marche region of Italy.

AIMS: During the novel severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019) pandemic, a worldwide reduction in total acute coronary syndrome (ACS) has been reported. In early 2020, Italy became the most affected country and national lockdown was declared early on in March. We described trends in ACS from all the Marche coronary catheterization laboratories (CCL) during the global pandemic. METHODS: Retrospective study of all consecutive patients admitted to the four regional CCL. The coronavirus disease 2019 period (20 February 2020 to 15 April 2020) was compared with the interyear control period (1 January 2020 to 19 February 2020) and to the intrayear control period (20 February 2019 to 15 April 2019). All patients with an initial diagnosis of ACS were included in the analysis, and further stratified into ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI)/unstable angina. RESULTS: A total of 1239 patients were enrolled. Daily incidence of ACS was 6.1, 6.3 and 4.5 for the interyear control period, the intrayear control period and the case period, respectively. There was no difference in overall STEMI daily incidence while NSTEMI/unstable angina fell from 3.6 and 3.3-1.8 during the case period (P = 0.01). Incidence rate ratios were significantly lower when the case period was compared with the intrayear control period (incidence rate ratios: 0.49, 95% confidence interval 0.41-0.59, P = 0.001) and the interyear control period (incidence rate ratios: 0.67, 95% confidence interval 0.50-0.90, P = 0.008). CONCLUSION: During the global pandemic there was a significant reduction in total ACS and NSTEMI in the Marche region. Unlike previous reports, there was no difference in overall access to CCL for STEMI during the same period.

Global Longitudinal Strain as a Predictor of First and Subsequent Arrhythmic Events in Remotely Monitored ICD Patients With Structural Heart Disease.

OBJECTIVES: This study sought to assess speckle-tracking-derived parameters as predictors of first and subsequent ventricular events in patients with structural heart disease and implantable cardioverter-defibrillators (ICD). BACKGROUND: Left ventricular ejection fraction (LVEF), the current primary parameter of risk stratification for ventricular arrhythmias (VAs) in structural heart diseases is burdened by many limitations. METHODS: In this retrospective, observational study, all consecutive patients with structural heart disease were admitted for ICD implantation. Patients not followed by a home-monitoring system were excluded. Two-dimensional (2D) speckle-tracking analysis was used to derive global longitudinal strain (GLS), mechanical dispersion (MD), and delta contraction duration (DCD) of all patients at enrollment. Home monitoring was checked weekly to detect all VAs and ICD therapies. A recurrent event statistical approach (Prentice, Williams, and Peterson model) was applied to evaluate subsequent events after the first ones. RESULTS: A total of 203 patients were consecutively enrolled and followed for a median of 2.2 years. Kaplan-Meier curves showed an increased risk of antitachycardia pacing or shock (log-rank p = 0.003) and VAs (log-rank p = 0.001) associated with lower quartiles of GLS. An impaired GLS was independently associated with an increased risk for the first ICD therapy (hazard ratio [HR]: 1.94; 95% confidence interval [CI]: 1.30 to 2.91; p = 0.001) and (HR: 1.42; 95% CI: 1.01 to 1.98; p = 0.04) for the first VA. GLS impairment was not significantly associated with an increased risk of recurrent ICD therapies or VAs. LVEF, MD, and DCD were not associated with an increased risk of first, second, and third ICD therapies or VA. CONCLUSIONS: Impaired GLS is associated with an increased risk of VAs and appropriate ICD therapies in a consecutive "real-world," unselected population of remotely monitored patients with structural heart disease, although it does not seem reliable in predicting further arrhythmic events after the first one. MD and DCD do not predict first or subsequent arrhythmic events in ICD patients with structural heart disease.

Prospective Study of Tricuspid Regurgitation Associated With Permanent Leads After Cardiac Rhythm Device Implantation.

BACKGROUND: Tricuspid regurgitation (TR) has been associated with cardiac rhythm device (CRD) implantation with intracardiac lead insertion. However, data on the incidence of postdevice TR are limited and largely from retrospective studies. We hypothesized that permanent lead implantation would be associated with an increase in TR. METHODS: We prospectively included consecutive patients with a clinical indication for CRD. Patients underwent transthoracic echocardiography 1 month before and 1 year after CRD implantation. RESULTS: A total of 328 patients were prospectively enrolled (69 ± 15 years, 38% female). Echocardiograms before and 1 year after CRD were available in 290 patients (15 died, 23 lost to follow-up). Compared with baseline, there was a significant change in TR grade 1 year after CRD insertion (no/trivial TR: 66% vs 29%; mild TR: 29% vs 61%; moderate TR: 3% vs 8%; severe TR 2% vs 2%; P < 0.001 for an increase in TR by at least 1 grade). Compared with baseline, there was a higher prevalence of moderate or severe TR in the 247 patients with CRD without cardiac resynchronization therapy (4% vs 10%, P = 0.004), but no progression in the 43 patients who received cardiac resynchronization therapy (14% vs 11%, P = 1). Multivariable analysis in the patients with less than moderate TR at baseline (n = 274) showed that only a history of atrial fibrillation was independently associated with progression to moderate or severe TR after correction for baseline TR grade (P = 0.013). CONCLUSIONS: One year after endocardial lead insertion, there was a 5% increase in the prevalence of moderate or severe TR, which may be clinically relevant.

Comparisons of microvascular and macrovascular changes in aldosteronism-related hypertension and essential hypertension.

Case-control observational study to evaluate the microvascular and macrovascular changes in patients with hypertension secondary to primary aldosteronism (PA), essential hypertension (EH) and healthy subjects. Measurements of arterial stiffness including augmentation index (AIx) and pulse wave velocity (PWV) were assessed using a TensioClinic arteriograph system. Retinal microcirculation was imaged by a Retinal Vessel Analyzer (RVA) and a non-midriatic camera (Topcon-TRC-NV2000). IMEDOS software analyzed the retinal artery diameter (RAD), retinal vein diameters (RVD) and arteriole-to-venule ratio (AVR) of the vessels coming off the optic disc. Thirty, 39 and 35 patients were included in the PA, EH and control group, respectively. The PA group showed higher PWV values compared only with the control group. The mean brachial and aortic AIx values did not show significant difference between groups. In the PA group, the mean RVD and AVR values were significantly lower than in the EH and control groups, whereas the parameters did not differ between the EH and control groups. In conclusion, AVR appears significantly modified in the PA group compared with the EH group and could represent an early and more reliable indicator of microvascular remodeling.

Prospective study of tricuspid valve regurgitation associated with permanent leads in patients undergoing cardiac rhythm device implantation: Background, rationale, and design.

Given the increasing numbers of cardiac device implantations worldwide, it is important to determine whether permanent endocardial leads across the tricuspid valve can promote tricuspid regurgitation (TR). Virtually all current data is retrospective, and indicates a signal of TR being increased after permanent lead implantation. However, the precise incidence of moderate or greater TR post-procedure, the exact mechanisms (mechanical, traumatic, functional), and the hemodynamic burden and clinical effects of this putative increase in TR, remain uncertain. We have therefore designed a multicenter, international, prospective study of 300 consecutive patients (recruitment completed, baseline data presented) who will undergo echocardiography and clinical assessment prior to, and at 1-year post device insertion. This prospective study will help determine whether cardiac device-associated TR is real, what are its potential mechanisms, and whether it has an important clinical impact on cardiac device patients.

Electrical and Myocardial Remodeling in Primary Aldosteronism.

OBJECTIVE AND DESIGN: Primary aldosteronism (PA) represents the most common cause of secondary hypertension. A higher risk of cardiovascular events has been reported in patients with PA than in otherwise similar patients with essential hypertension (EH). So far, only a few studies investigated the electrocardiographic changes in PA patients compared to EH patients. METHODS: To investigate the electrocardiographic changes and heart remodeling in PA, we enrolled 61 consecutive patients, 30 with PA [12 with aldosterone-producing adrenal cortical adenoma (APA) and 18 with bilateral adrenal hyperplasia-idiopathic adrenal hyperplasia] and 30 with EH. In all subjects, electrocardiographic parameters were evaluated from 12-lead electrocardiograms and heart remodeling with echocardiogram. RESULTS: No significant differences in age, sex, body mass index, and blood pressure were found in two groups. The P wave and PR interval duration were significantly prolonged in patients with PA respect to EH (p < 0.003 and <0.002, respectively). A first degree atrio-ventricular block was present in 16% of the patients with PA and only in 3.2% of those with EH. In PA patients, the interventricular septum thickness (IVST) correlated with PR duration (r = 0.51; p < 0.03). Left ventricular hypertrophy was present in 53% of the patients with PA and in 26% of the patients with EH (χ(2), p < 0.03). CONCLUSION: In this case-control study, patients with PA show more anatomic and electrical heart remodeling than those with EH. We hypothesize that in patients with PA these cardiac changes may play a role for the increased risk of future cardiovascular events.

Lack of the QTc physiologic decrease during cardiac stress test in patients with type 2 diabetes treated with secretagogues.

Patients with type 2 diabetes are at increased susceptibility to a prolonged QT interval. Furthermore, insulin secretagogues, drugs used to treat diabetes, may prolong QT interval and provoke arrhythmias. We evaluated whether secretagogues can affect QTc interval during cardiac stress test in 20 patients with type 2 diabetes treated with secretagogues. ECG stress test was performed in all patients. QTc interval was calculated both before cardiac stress test (BCST) and at acme of cardiac stress test (ACST). Diabetic patients treated with secretagogues showed longer QTc-ACST values than those treated with metformin only. QTc-ACST values resulted shorter than QTc-BCST values in control group. Diabetic patients treated with secretagogues showed QTc-ACST values significantly longer than QTc-BCST values. In our study, diabetic patients treated with secretagogues did not show the QTc physiologic decrease that is a protective against arrhythmias. These results suggest to evaluate, in these patients, QT length, even during routine cardiac stress test.