Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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Midventricular Obstructive Hypertrophic Cardiomyopathy with Apical Aneurysm: Left Ventricular Hemodynamic and Angiographic Findings: Midventricular Obstructive Hypertrophic Cardiomyopathy
No full textA case of a 50-year-old patient with a midventricular obstructive hypertrophic cardiomyopathy is presented and the left ventricular hemodynamic and angiographic findings are depicted and discussed. Rhythmos 2022; 17(2):36-38
COVID-19 Re-Infections: More Common with the Omicron Variant / COVID-19 Pandemic: Is There Light at the End of the Tunnel? COVID-19 Re-Infections
No full textA recent surge of COVID-19 reinfections has been ascribed to new variants of concern (VOCs) with increased transmissibility, such as the Omicron variant, but also to laxity in compliance with measures of prophylaxis, incomplete or lack of vaccination, the Peltzman effect where people tend to increase their risky behavior when safety measures are mandated, weaker antibody responses after booster immunization in some individuals and/or immunocompromised patients, and increased antigen variability in VOCs. The latter impairs humoral and cellular immunity post-infection rendering COVID-19 convalescents more vulnerable and at risk of re-infection with VOCs. Unfortunately, COVID-19 disease is here to stay demanding observance of measures of prophylaxis, expansion of vaccination programs and continued vigilance; there is still a dire need for the development of durably effective vaccines against SARS-CoV-2 but also against its emerging variants. Rhythmos 2022;17(3): 46-52
Left Bundle Branch (LBB) Area Pacing for Cardiac Resynchronization Therapy (CRT): Most Promising Alternative CRT Pacing Modality: LBB Area Pacing for CRT
No full textCardiac resynchronization therapy (CRT) via biventricular pacing (BiVP) has benefitted a large group of heart failure (HF) patients with low (<35%) left ventricular (LV) ejection fraction (LVEF) and cardiac dyssynchrony, mostly in the form of left bundle branch (LBB) block, conferring amelioration of their HF symptoms and prolongation of their survival. However, it entails a tedious procedure to place and find a stable and functional position of the LV lead in a coronary sinus tributary, which may fail in a considerable percentage of patients, while up to one third of patients, even then, may turn out to be non-responders. Over the recent years, strong new data from observational studies and meta-analyses have shown the safety and feasibility of LBB area pacing (LBBAP) in patients with bradyarrhythmias and most importantly in HF patients in need for CRT. LBBAP yields satisfactory pacing threshold and R wave sensing and low complication rates. Particularly, in patients with CRT indication, LBBAP, as an alternative approach to CRT, has shown significant improvement of functional class and LVEF during short-and mid-term follow-up. Thus, LBBAP, as a relatively novel CRT modality, demonstrates a most promising potential (equivalent or even superior) role for effective CRT for HF patients in need of a viable alternative to BiVP, and also circumvents certain limitations of His bundle pacing, which is another, albeit potentially problematic, mode of CRT. Nevertheless, we are still in dire need for confirmatory data from properly designed randomized controlled trials to further establish the role and value of this alternative CRT pacing modality. Rhythmos 2022;17(4): 71-74
The Aftermath of a Negative Third FAME: Third FAME Trial
No full textThe current guideline recommendations regarding myocardial revascularization of patients with multivessel coronary artery disease (CAD) mostly advocate coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI), especially for patients with diabetes. However, in certain clinical cases, PCI can be considered. FAME and FAME 2 studies had demonstrated the superiority of fractional flow reserve (FFR)-guided PCI over angiography-guided PCI and over optimal medical therapy (OMT) alone respectively. FAME 3 study (Fractional Flow Reserve versus Angiography for Multivessel Evaluation), published early in 2022, was a study that investigated how PCI guided by FFR measurements can perform compared to CABG guided mostly by coronary angiography for the revascularization of patients with three-vessel CAD. Stable patients with an average SYNTAX score of 26 were randomized, while patients with left main disease, recent ST segment elevation myocardial infarction (STEMI), left ventricular ejection fraction <30% or cardiogenic shock were excluded. Regarding the composite primary endpoint of major adverse cardiovascular events (MACE), including death, non-fatal myocardial infarction, stroke or repeat revascularization, at 1 year follow-up, FFR-guided PCI failed to be proven as non-inferior compared to CABG. The findings of FAME 3 as added to those of FAME and FAME 2 should be considered in the context of current guidelines for myocardial revascularization and do not seem practice changing. Relevant limitations, possible implications and future perspectives are also briefly discussed herein. Rhythmos 2022;17(2): 32-35
Portable/Wearable ECG Recording Gadgets: ECG Recording Gadgets
No full textSeveral portable devices for ECG acquisition are already available in the market and have provided valuable information regarding various cardiac arrhythmias, most commonly atrial fibrillation (AF). Such gadgets are easy to use and can impact health care for both diagnosis and management in a variety of clinical settings, such as in patients complaining of palpitations, patients presenting with unexplained presyncope or syncope, patients with heart failure and suspected tachycardiomyopathy, those afflicted by cryptogenic stroke, and/or patient groups who are at high arrhythmic risk (e.g., older persons, individuals with obesity, sleep apnea, hypertension, diabetes or structural heart disease). Rhythmos 2022; 17(3):58-61
Cardiology News / Recent Literature Review / Third Quarter 2022: Cardiology News
No full textHCS, 43rd International Congress of Cardiology, Athens, 20-22/10/22
NY Cardiovascular Symposium 2022, New York, NY, USA, 9-11/12/22
AF Symposium, Boston, MA, USA, 2-4/2/2023
ACC Annual Meeting, New Orleans, LA, USA, 4-6/3/23
EHRA Annual Meeting, Barcelona, Spain, 16-18/4/23
Euro PCR 2023, Paris, 16-19/5/2023
HRS Annual Meeting, New Orleans, LA, USA, 19-21/5/23
EMPEROR-Preserved: Empagliflozin Reduced Cardiovascular Disease (CVD) and Heart Failure (HF) Hospitalizations (HFH) and Improved Symptoms Across a Wide Age Range / High age was not Associated with Decreased Efficacy or Intolerability
The relationship of age and empagliflozin effects was evaluated in the EMPEROR-Preserved trial. Patients (N=5,988) were grouped according to their baseline age (<65 years, n = 1,199; 65-74 years, n = 2,214; 75-79 years, n = 1,276; ≥80 years, n = 1,299). The incidence of primary outcomes (CVD or HFH) (P trend = 0.02) and CVD (P trend = 0.003) increased with age. Empagliflozin reduced primary outcomes (P trend = 0.33), first HFH (P trend = 0.22), and first and recurrent HFH (P trend = 0.11) across all age groups with an effect being similar at ≥75 years or >80 years. Empagliflozin improved Kansas City Cardiomyopathy Questionnaire–Clinical Summary Score at week 52 and attenuated the decline of estimated glomerular filtration rate without age interaction. There were no clinically relevant differences in adverse events between empagliflozin and placebo across the age groups. Thus, empagliflozin reduced primary outcomes and first and recurrent HFH and improved symptoms across a broad age spectrum. High age did not reduce efficacy or meaningful intolerability (Bohm M et al, J Am Coll Cardiol 2022;80:1-18).
ARIC Study: Adult Cancer Survivors Have Higher Risk of CVD, Especially HF, Independent of Traditional CV Risk Factors
A prospective community-based study including 12,414 ARIC (Atherosclerosis Risk In Communities) study participants (mean age 54 years, 55% female, 25% Black), of whom 3,250 (25%) had incident cancer over a median 13.6 years, indicated that age-adjusted incidence rates of CVD (per 1,000 person-years) were 23.1 (95% CI: 24.7-29.1) for cancer survivors and 12.0 (95% CI: 11.5-12.4) for subjects without cancer. After adjustment for CV risk factors, cancer survivors had significantly higher risks of CVD (HR: 1.37), HF (HR: 1.52), and stroke (HR: 1.22), but not CAD (HR: 1.11). Breast, lung, colorectal, and hematologic/lymphatic cancers, but not prostate cancer, were significantly associated with CVD risk (Florido R et al, J Am Coll Cardiol 2022;80:22–32).
VALOR-HCM Study: In Obstructive Hypertrophic Cardiomyopathy (OHCM) Patients With Intractable Symptoms, Mavacamten Reduced the Fraction of Patients Meeting Guideline Criteria for Septal Reduction Therapy (SRT) After 16 Weeks
Patients (N=112; age 60 ± 12 years, 51% men, 93% NYHA class III/IV) with left ventricular (LV) outflow tract (LVOT) gradient ≥50 mm Hg at rest/provocation who met guideline criteria for SRT were randomized, double blind, to mavacamten, 5 mg daily, or placebo, titrated up to 15 mg based on LVOT gradient and LV ejection fraction. After 16 weeks, 43 of 56 placebo patients (76.8%) and 10 of 56 mavacamten patients (17.9%) met guideline criteria or underwent SRT, difference (58.9%; P < 0.001). Hierarchical testing of secondary outcomes showed significant differences (P < 0.001) favoring mavacamten, mean differences in post-exercise peak LVOT gradient −37.2 mm Hg; ≥1 NYHA class improvement 41.1%; improvement in patient-reported outcome 9.4 points; and NT-proBNP and cardiac troponin I between-groups geometric mean ratio 0.33 and 0.53 (Desai MY et al, J Am Coll Cardiol 2022;80:95–108)... (excerpt
Hybrid Heart Failure Treatment
Get PDFA case of refractory heart failure (HF) is presented in a 64-year-old gentleman with ischemic cardiomyopathy and severe left ventricular dysfunction, who availed himself of currently available hybrid HF treatment, like optimal medical treatment, electrical and interventional therapies comprising drugs, an implantable cardiac resynchronization therapy defibrillator (CRT-D) effected via alternate route (middle cardiac vein) for left ventricular lead placement combined with percutaneous mitral valve therapy (MitraClip) that prolonged his life to ~10 years. Rhythmos 2021; 16(1):11-13
Cardiology News / Recent Literature Review / First Quarter 2022: Cardiology News
No full textACC.22, Washington, DC, USA, 2-4/4/22
EHRA 22, Copenhagen, Denmark, 3-5/4/22
HRS 22, San Francisco, CA, USA, 29/4-1/5/22
EuroPCR, Paris, France, 17-20/5/22
ESC Meeting, Barcelona, Spain, 26-29/8/2022
TCT 22, Boston, MA, USA, 16-20/9/22
PRAGUE-17: Left Atrial Appendage Closure (LAAC) Remains Noninferior to DOACs for Preventing Major CV, Neurological, or Bleeding Events / Nonprocedural Bleeding Was Significantly Reduced With LAAC
A total of 402 patients with AF (201 per group, age 73.3±7.0 years, 65.7% male, CHA2DS2-VASc 4.7±1.5, HASBLED 3.1±0.9) were randomized to percutaneous LAAC (Watchman or Amulet) with DOACs (95% apixaban). After a median of 3.5 years, LAAC was noninferior to DOACs for the primary endpoint (composite of cardioembolic events-i.e., stroke, TIA, or systemic embolism-, CV death, clinically relevant bleeding, or procedure-/device-related complications (LAAC group only)), by modified intention-to-treat (sub-distribution HR [sHR]: 0.81; P = 0.27; P for noninferiority = 0.006). For the components of the composite endpoint the corresponding sHRs were 0.68 (P= 0.19) for CV death, 1.14 (P=0.72) for all-stroke/TIA, 0.75 (P=0.28) for clinically relevant bleeding, and 0.55 (P=0.039) for nonprocedural clinically relevant bleeding. The primary endpoint outcomes were similar in the per-protocol (sHR: 0.80; P=0.25) and on-treatment (sHR: 0.82; P=0.30) analyses (Osmancik P et al, J Am Coll Cardiol 2022;79:1-14).
Higher Olive Oil Intake Conferred Lower Risk of Total and Cause-Specific Mortality / Replacing Margarine, Butter, Mayonnaise, and Dairy Fat with Olive Oil Lowered Mortality
Among 60,582 women (Nurses’ Health Study, 1990-2018) and 31,801 men (Health Professionals Follow-up Study, 1990-2018) who were free of cardiovascular (CV) disease or cancer, over 28 years, 36,856 deaths occurred. The multivariable-adjusted pooled HR for all-cause mortality among persons who had the highest consumption of olive oil (>0.5 tablespoon/day or >7 g/d) was 0.81 compared with those who never or rarely consumed olive oil. Higher olive oil intake conferred a 19% lower risk of CV mortality (HR: 0.81), 17% lower risk of cancer mortality (HR: 0.83), 29% lower risk of neurodegenerative disease mortality (HR: 0.71), and 18% lower risk of respiratory disease mortality (HR: 0.82). In substitution analyses, replacing 10 g/d of margarine, butter, mayonnaise, and dairy fat with the equivalent amount of olive oil conferred 8%-34% lower risk of total and cause-specific mortality. No significant associations were observed when olive oil was compared with other vegetable oils combined (Guasch-Ferré M et al, J Am Coll Cardiol 2022;79:101–112)... (excerpt
Pulsed Field Ablation (PFA) for Pulmonary Vein Isolation in τhe Treatment οf Atrial Fibrillation: Pulsed Field Ablation
No full textPulsed‐field ablation (PFA) is a promising new ablation modality for the treatment of atrial fibrillation (AF). Pulmonary vein isolation (PVI) remains the most frequently used treatment strategy of any AF ablation procedure. A major limitation of current catheter ablation procedures is PVI reconnection, reported to be about 20% of patients. Pulsed field ablation is a novel energy source by which high-voltage electric pulses are used to create pores in the cellular membrane (i.e., electroporation), leading to cellular death. The amount of energy required to produce irreversible electroporation is highly tissue dependent reducing the risk of damage to surrounding non-cardiac tissues. The tissue specificity of PFA may result in a wide therapeutic range and improved safety profile during atrial fibrillation ablation. There has been no evidence of incidental phrenic nerve injury, and finally, PFA has been shown not to injure esophageal tissue when directly applied to the esophagus or indirectly through ablation in the left atrium. Rhythmos 2022;17(4): 75-78
Cardiology News / Recent Literature Review / Second Quarter 2022: Cardiology News
No full textESC Meeting, Barcelona, Spain, 26-29/8/2022
TCT 22, Boston, MA, USA, 16-20/9/22
HCS, 43rd International Congress of Cardiology, Athens, 20-22/10/22
NY Cardiovascular Symposium 2022, New York, NY, USA, 9-11/12/22
AF Symposium, Boston, MA, USA, 2-4/2/2023
ACC Annual Meeting, New Orleans, LA, USA, 4-6/3/23
EHRA Annual Meeting, Barcelona, Spain, 16-18/4/23
Euro PCR 2023, Paris, 16-19/5/2023
HRS Annual Meeting, New Orleans, LA, USA, 19-21/5/23
Registry Study: In Patients With Multivessel Disease After Revascularization by PCI or CABG, Mildly Decreased Renal Function Did not Increase the Risk of the Primary Composite Outcome (Death, MI, or Stroke) and Mortality / Comparative Outcomes After PCI and CABG Were Similar in the Borderline-Risk Group
Among 10,354 eligible patients in a registry who underwent coronary revascularization, classified into 3 groups (stage I, n = 3,735, normal renal function; stage II, n = 5,122, mild dysfunction; and stage III, n = 1,497, moderate dysfunction), after propensity matching, the risk for primary composite outcome was not different between the stage I and the stage II group (HR: 1.12). However, the risk of the primary outcome was higher in the stage III group than in the stage I group (HR: 1.50). The relative effect of PCI vs CABG for the primary outcome was similar in the matched cohort of each renal function group of stages I, II, and III (Kim TO et al, J Am Coll Cardiol 2022;79:1270-84).
2-Cohort Studies: Long-Term Cumulative BP Was Associated With Subsequent Cognitive Decline, Dementia Risk, and All-Cause Mortality in Cognitively Healthy Adults Aged ≥50 Years / Efforts are Needed to Control Long-Term Systolic BP and Pulse Pressure and Maintain Adequate Diastolic BP
Data from the HRS (Health and Retirement Study, n=9,294, 45% men, median age 65 y) and ELSA (English Longitudinal Study of Ageing, n=7,566, 40% men, median age 62 y) indicated that over a median follow-up of 8 years each, elevated cumulative systolic BP and pulse pressure were independently associated with accelerated cognitive decline (P< 0.001 for both), elevated dementia risk (P< 0.001 for both), and all-cause mortality (P< 0.001 for both), while a significant inverse association was observed for diastolic BP. Strong dose-response relationships were identified, with similar results for the 2 cohorts. (Li C et al, J Am Coll Cardiol 2022;79:1321–35).
The BIOSIGNAL Study: MR-proANP is a Valid Biomarker to Determine Risk of Newly Diagnosed Atrial Fibrillation (NDAF) and MACE in Patients With Acute Ischemic Stroke (AIS) and Can Be Used as a Decision Tool to Identify Patients for Prolonged Cardiac Monitoring
Among 1,759 patients Log10MR-proANP levels were associated with cardioembolic (CE) stroke (OR: 7.96; risk ratio: 3.12), as well as NDAF (OR: 35.3; risk ratio: 11.47), and MACE (subdistributional HR: 2.02) during follow-up. The model to predict NDAF including only age and MR-proANP levels had a good discriminatory capacity with an area under the curve of 0.81, was well calibrated, and yielded higher net-benefit compared with validated scores to predict NDAF (AS5F score, CHA2DS2-VASc score) (Schweizer J et al, J Am Coll Cardiol 2022;79: 1369–81)... (excerpt