Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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Takotsubo Syndrome: A Brief Review in Light of New Evidence
Get PDF“Takotsubo Syndrome” (TTS) is now recognized as a distinct entity within the spectrum of stress-induced cardiomyopathies. It is believed that enhanced sympathetic stimulation induces transient myocardial stunning through a variety of mechanisms that include epicardial spasm, ischemia due to microvascular dysfunction, and direct cardiomyocyte toxicity from catecholamine-mediated calcium overload. Once associated with emotional or significant physical stress, it is now clear that even minor stressors can trigger the syndrome and that roughly 30% of patients with TTS have no identifiable trigger at all. Traditionally regarded benign, TTS is now recognized as a potentially fatal condition with serious complications and considerable short-term mortality, similar to that of acute coronary syndromes. The major features of the TTS regarding clinical characteristics, pathogenesis and treatment options are herein briefly reviewed. Rhythmos 2016;11(4):90-95
Predictive Factors for Positive Coronary Angiography and the Role of Early Intervention After Out-of-Hospital Cardiac Arrest
Get PDFBackground: In recent years, there has been considerable research in the field of post-resuscitation care. Recent guidelines recommend early coronary angiography and percutaneous coronary intervention (PCI) as the best strategy in survivors of out-of-hospital cardiac arrest (OOHCA) with ST elevation myocardial infarction (STEMI). However, there are no decisive data for patients who do not exhibit clinical and ECG criteria suggestive of STEMI. We sought to review current evidence regarding the predictive factors of positive coronary angiography and the role of early PCI in an OOHCA setting.Methods & Results: Between 1995 & 2014, we identified 35 studies reporting on adult survivors of OOHCA who underwent coronary angiography and PCI. In total, there are over 16,000 patients included in reported series of resuscitated OOHCA victims who have undergone coronary angiography and PCI when indicated. PCI was successful in 92% (51-100%) of the attempted cases. The survival rate was 64% (22% - 88%) with a satisfactory neurological outcome at follow-up that varied from 47-96%. As the survival benefit seems to be time dependent, the selection of which patients are candidates for early PCI is under considerable research. Predictive factors for positive coronary angiography and outcome were ventricular fibrillation, history of coronary heart disease and diabetes, ST elevation on ECG, male gender, and intact brain stem functions. Negative predictive factors were normal ECG on admission or plain repolarization abnormalities, and loss of brain stem functions.Conclusions: Early coronary angiography and PCI is a promising management strategy in the OOHCA setting. As there is evidence that the survival benefit from PCI is time dependent, the research is still ongoing in identifying which patients would benefit most from an aggressive revascularization approach
Insights into Catheter Ablation of Ventricular Tachycardias in Arrhythmogenic Right Ventricular Cardiomyopathy / Dysplasia
Get PDFArrhythmogenic right ventricular cardiomyopathy/ dysplasia (ARVC/D), mostly affecting young/middle-aged individuals, poses a significant risk of malignant ventricular arrhythmias (VAs) and subsequent sudden cardiac death (SCD). Antiarrhythmic agents (AAA) provide insufficient arrhythmia suppression and prevention and can be proarrhythmic. Thus, the implantable cardioverter-defibrillator (ICD) is considered the first-line treatment, especially in patients with secondary prevention indication. Nevertheless, catheter ablation is an additional therapy to the ICD which has proved its efficacy in primary and secondary prevention of fatal arrhythmias and sudden cardiac death. The superiority of the combined endo- and epicardial VT ablation in this population is clear since ARVC/D substrate has been shown to be mostly epicardial. Due to progressive nature of ARVC/D, ablation seems to be a useful tool for the patients who experience recurrent VT episodes or electrical storms
Management of Major Bleeding with the Non-Vitamin K Oral Anticoagulants: the Role of Antidotes
Get PDFOver the recent years, new oral anticoagulant agents have been developed and entered the clinical arena, the direct or non-vitamin K oral anticoagulants (NOACs). Although more expensive, these agents have been proven as equivalent or superior to vitamin K antagonists in the treatment of non-valvular atrial fibrillation (AF) and venous thrombo-embolism with a lower incidence of intracerebral hemorrhage. Nevertheless, occurrence of major or life-threatening bleeding events is still quite possible. Thus, there is a major concern regarding the lack of a specific antidote and rapid reversal agent in such disastrous situations. Fortunately, the development of effective specific NOAC antidotes has recently made great advances, which are herein briefly reviewed
Adverse Cardiovascular Events with Nonsteroidal Anti-inflammatory Agents
Get PDFThe extensive use of nonsteroidal anti-inflammatory drugs (NSAIDs), both nonselective and cyclooxygenase- 2–specific inhibitors, for the relief of acute and chronic musculoskeletal pain, in addition to gastrointestinal toxicity, confers serious cardiovascular toxicity that affects the overall risk/benefit ratio of this commonly employed therapy. A plethora of studies have provided convincing evidence for a high risk of adverse cardiovascular events associated with NSAIDs related to a number of risk factors, which are herein briefly reviewed and an algorithm is suggested for their safer use
You Are What You Eat, Hence Curtail Saturated and Trans Fats, Free Sugars and Salt
Get PDFThe new Dietary Guidelines for Americans 2015-2020 focus on healthy eating patterns and exercise. They recommend 3 different healthy eating patterns: the Healthy US Style, the Healthy Mediterranean Style, and the Healthy Vegetarian Style eating pattern, accommodating a variety of cultural and individual preferences, but sharing many common food based features. A healthy eating pattern includes a variety of vegetables, fruits, grains, low-fat dairy products, protein foods, and oils. Specific recommendations have been made for particular dietary components to reduce: saturated fat (< 10% of calories); sodium (< 2.3 g/day); and added sugars (< 10% of calories). Interestingly, these guidelines do not make a recommendation for a quantitative limit for dietary cholesterol indicating the lack of adequate evidence for such recommendation. However, they state that there is evidence showing that eating patterns that include lower intake of dietary cholesterol (~100 - 300 mg/d) are associated with reduced risk of cardiovascular disease, and risk of obesity. Finally the new guidelines emphasize the importance of physical activity and exercise to promote health
Cardiology News / Recent Literature Review / Second Quarter 2016
Get PDFESC Meeting: Rome, 27-31/8/2016HCS Panhellenic Congress: Athens, 20-22/10/2016TCT Conference: Washington, DC, 29/10-2/11/2016AHA Scientific Sessions: New Orleans, 12-16/11/2016 AF Symposium: Orlando, 12-14/1/2017ACC.17: Washington, DC, 17-19/3/2017HONEST Study: Morning Home Blood Pressure (BP) May be Superior to Clinic BP as a Predictor of Coronary Events and Stroke in Patients With HypertensionIn 21,591 hypertensive patients (mean age ~65 years), having 127 stroke and 121 CAD events over a mean follow-up of 2 years, the incidence of stroke events was significantly higher in patients with morning home systolic blood pressure (HSBP) ≥145 mmHg compared with <125 mmHg (hazard ratio -HR ~6.0), and in patients with clinic systolic blood pressure (CSBP) ≥150 mmHg compared with <130 mmHg (HR 5.82); morning HSBP predicted stroke events similarly to CSBP. Incidence of CAD events was significantly higher in patients with morning HSBP ≥145 mmHg compared with <125 mmHg (HR 6.24) and in patients with CSBP ≥160 mmHg compared with <130 mmHg (HR 3.51). Thus, compared with morning HSBP predicted CAD events more strongly than CSBP (Kario K et al, J Am Coll Cardiol 2016;67:1519-1527).A 1-h Combination Algorithm Allows Fast Rule-Out/ Rule-In of Major Adverse Cardiac Events (MACE): In Patients with Chest Pain Presenting to Emergency Department (ED), Combining hs-cTnT Levels on Arrival and 1 h Later With the Patient History and ECG More Effectively Identified MACE Within 30 Days Than Screening Based on hs-cTnT AloneIn a prospective observational study enrolling 1,038 patients presenting to the emergency department (ED) with chest pain, an extended algorithm comprising hs-cTnT results at 1 h combined with history and ECG, identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm alone (97.5% vs 87.6%; p< 0.001). The negative predictive value was 99.5% and the likelihood ratio was 0.04 with the extended algorithm vs 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled-in 14% of patients with a higher sensitivity (75.2% vs 56.2%; p< 0.001) but a slightly lower specificity (94.0% vs 96.4%; p< 0.001) than the troponin algorithm. The rule-in arms of both algorithms had a likelihood ratio >10 (Mokhtari A et al, J Am Coll Cardiol 2016;67:1531-1540)... (excerpt
Cardiology News / Recent Literature Review / Third Quarter 2016
Get PDFHCS Panhellenic Congress: Athens, 20-22/10/2016TCT Conference: Washington, DC, 29/10-2/11/2016AHA Scientific Sessions: New Orleans, 12-16/11/2016AF Symposium: Orlando, 12-14/1/2017ACC.17: Washington, DC, 17-19/3/2017HRS Scientific sessions: Chicago, 10-13/5/2017EHRA Europace-Cardiostim: Vienna, 18-21/6/2017ESC Congress: Barcelona, 26-30/8/2017POST 2 Study: Patients with Vasovagal Syncope Improved Modestly with Fludrocortisone 0.2 mg daily with Insignificant 31% Reduction in the Hazard of Fainting in the Intent-to-Treat Analysis Among 210 patients (71% female, median age 30 years) with recurrent vasovagal syncope randomized to fludrocortisone or placebo at highest tolerated doses from 0.05 mg to 0.2 mg daily, there was a marginally nonsignificant reduction in syncope in the fludrocortisone group (hazard ratio - HR: 0.69; p = 0.069). In a multivariable model, fludrocortisone significantly reduced the likelihood of syncope (HR: 0.63; p = 0.024). When the analysis was restricted to outcomes after 2 weeks of dose stabilization, there was a significant benefit due to fludrocortisone (HR: 0.51; p = 0.019) (Sheldon R et al, J Am Coll Cardiol 2016;68:1-9).Patients With Variant Angina Presenting With Aborted Sudden Arrhythmic Death (SCD) Face a Worse Prognosis Than Those Without SCD, While Therapy With Vasodilator Drugs is not Sufficiently Protective/ Additional ICD Implantation Might be Necessary as a Secondary Prevention Treatment Among 188 patients with variant angina with atherosclerosis (ASCD) and 1,844 patients with variant angina without ASCD (predictors of ASCD: age, hypertension, hyperlipidemia, family history of sudden cardiac death, multivessel spasm, and left anterior descending artery spasm), over a median of 7.5 years, the incidence of cardiac death was higher in ASCD patients (24.1 vs 2.7 per 1,000 patient-years; hazard ratio - HR: 7.26; p< 0.001). Death from any cause also occurred more frequently in ASCD patients (27.5 vs 9.6 per 1,000 patient-years; HR: 3; p< 0.001). The incidence rate of recurrent ventricular tachyarrhythmia in ASCD patients was 32.4 per 1,000 patient-years, and the composite of cardiac death and ventricular tachyarrhythmia was 44.9 per 1,000 patient-years. A total of 24 ASCD patients received ICDs (Ahn JM et al, J Am Coll Cardiol 2016; 68:137-145)... (excerpt
Right Ventricular Septal Pacing: In Lieu of Biventricular Pacing for Cardiac Resynchronization in a Patient With Right Bundle Branch Block?
Get PDFA 71-year-old male with ischemic cardiomyopathy, severe systolic left ventricular dysfunction and symptomatic heart failure was not considered a good candidate for implantation of a biventricular pacing system to effect cardiac resynchronization due to underlying right bundle branch block (RBBB). He received instead a dual-chamber implantable cardioverter defibrillation with the ventricular lead placed at an alternate site position at the high right ventricular septum. This resulted in significant narrowing of the QRS duration (resynchronization) with a good clinical response over short-term. The case illustrates a possible alternative approach to biventricular pacing for cardiac resynchronization in patients with RBBB
Cardiology News / Recent Literature Review / Second Quarter 2015
Get PDFESC Congress: London, 29/8-2/9/2015TCT Meeting 2015: San Francisco, 11-15/10/2015HCS Congress: Thessaloniki, 29-31/10/2015AHA Scientific Sessions: Orlando, 7-11/11/2015DAPT Study: Continuation of Dual Antiplatelet Therapy After PCI in Patients With and Without Acute Myocardial Infarction (MI) Beyond 1 Year Reduced Ischemic Events, but Increased Bleeding Compared With Treatment With Aspirin AloneAmong 11,648 randomized patients (9,961 treated with DES, 1,687 with BMS), 30.7% presenting with MI, between 12 and 30 months, continued thienopyridine reduced stent thrombosis compared with placebo in patients with and without MI at presentation (MI group, 0.5% vs 1.9%, p< 0.001; no MI group, 0.4% vs. 1.1%, p< 0.001). The reduction in major adverse cardiovascular and cerebrovascular events (MACCE) for continued thienopyridine was greater for patients with MI (3.9% vs 6.8%; p< 0.001 for MI; 4.4% vs 5.3%; p= 0.08 for no MI). In both groups, continued thienopyridine reduced MI (2.2% vs 5.2%, p< 0.001 for MI; 2.1% vs 3.5%, p< 0.001 for no MI) but increased bleeding (1.9% vs 0.8%, p= 0.005 for MI; 2.6% vs 1.7%, p= 0.007 for no MI). The authors concluded that extended dual antiplatelet therapy reduced the risk of stent thrombosis and MI in patients with and without MI, but increased bleeding (Yeh RW et al, J Am Coll Cardiol 2015;65:2211-2221).Metaanalysis: Dual Antiplatelet Therapy (DAPT) is Associated With Protection Against Stent Thrombosis but Increases Risk of Bleeding in Patients With Drug Eluting Stents (DES) / Benefit of Extended DAPT for Patients With First-Generation DES, but not for Second-Generation DESMetaanalysis of 10 randomized controlled trials (N = 32,135) indicated that compared to longer duration DAPT (L-DAPT; mean exposure time 20.3 months for second-generation DES and 28 months for first-generation DES), shorter duration DAPT (S-DAPT; mean exposure time 7.8 months for second-generation DES and 10.9 months for first-generation DES) had an overall higher rate of stent thrombosis (odds ratio - OR: 1.71; p = 0.001). The effect of S-DAPT on stent thrombosis was attenuated with the use of second-generation DES (OR: 1.54) compared with first-generation DES (OR: 3.94; p for interaction = 0.008). S-DAPT had an overall significantly lower risk of bleeding (OR: 0.63; p < 0.001). Finally, a numerically lower all-cause mortality rate was observed with S-DAPT (OR: 0.87; p = 0.073). The authors conclu-ded that S-DAPT had overall lower rates of bleeding, yet higher rates of stent thrombosis compared with L-DAPT; the latter effect was significantly attenuated with the use of second-generation DES. All-cause mortality was higher (not statistically) with L-DAPT (Giustino G et al, J Am Coll Cardiol 2015;65: 1298-1310)... (excerpt