Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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COVID-19 Genetics: Current Status: COVID-19 Genetics
No full textInterindividual clinical variability characterizes COVID-19 infection, ranging from no or mild symptoms in >95% of individuals to severe and life-threatening acute respiratory distress syndrome with bilateral pneumonia requiring intensive care unit monitoring in <0.5% of infected individuals. The host genetic background seems to determine the susceptibility and outcome in COVID-19 patients. Several relevant genetic variants and risk genes have been identified, relating to blood type, HLA system, angiotensin converting enzyme and other proteins, cytokines, and other host genetic signals and immune system’s specific response. On the other hand, emerging new variants of the COVID-19 virus with enhanced transmissibility/infectivity and immune escape ability pose new risks, especially if they are going to have an impact on the efficacy of currently available vaccines. All these issues relating to the impact of genetics on COVID-19 selectivity are herein reviewed. Rhythmos 2021;16(3): 48-56
False Negative Myocardial Perfusion Imaging: Regular Exercise Tolerance Test Coming to the Rescue: False Negative Myocardial Perfusion Imaging
No full textA case of a patient with critical coronary artery disease is presented where a regular exercise tolerance test was positive whereas myocardial perfusion imaging was (false) negative. Rhythmos 2021; 16(3):62-64
Transcatheter Aortic Valve Implantation (TAVI) and Mitral Valve Transcatheter Edge-To-Edge Repair (TEER): Current Frontiers and Horizons: TAVI and Mitral Valve Transcatheter Edge-To-Edge Repair
No full textDuring the last two decades transcatheter aortic valve implantation (TAVI) and mitral valve transcatheter edge-to-edge repair (TEER) have evolved in parallel to provide percutaneous interventional treatment solutions for patients with the two most common valvular heart diseases, aortic stenosis and mitral regurgitation, respectively. Having initially been conceived and used to treat patients considered inoperable, TAVI indications have been expanded to include high operative risk and more recently moderate or even low risk patients. The TAVI techniques have also improved to permit tackling challenging complex anatomies and bioprosthetic valve degeneration and structural failure. Similarly, TEER has been initially used to treat inoperable patients with severe symptomatic primary mitral regurgitation (MR), but recently published data have shown that it can provide benefit in carefully selected patients with refractory to optimal medical treatment (OMT) symptomatic severe secondary MR. Furthermore, apart from TEER with the traditional MitraClip system and its iterations, a second TEER system (Pascal) has provided promising results in initial clinical trials and can alternatively be used. We attempt herein a concise overview of the TAVI and mitral valve TEER current state of play. Rhythmos 2021;16(3): 57-6
Chronic Atrial Overdrive Pacing to Suppress Recurrences of Atrial Fibrillation: Atrial Overdrive Pacing
No full textA case of a patient with persistent atrial fibrillation is presented who was electrically cardioverted and was subsequently maintained on chronic overdrive atrial pacing and remained free of arrhythmia recurrences. Rhythmos 2021; 16(4):82-83
Cavotricuspid Isthmus Ablation Using a Novel High-Density Automated Electroanatomical Contact Mapping System: Atrial Flutter Ablation
No full textA case of atrial flutter ablation is presented with use of a novel high-density automated electroanatomic contact mapping system that was employed for guidance of the procedure. Rhythmos 2021; 16(2):39-40
Cardiology News / Recent Literature Review / First Quarter 2021: Cardiology Literature Review
No full textEHRA online Congress, 23-25/4/2021
ACC Meeting: Atlanta, 15-17/5/2021
EuroPCR online, 18-20/5/201
ESC Digital Congress 27-30/8/2021
TCT Meeting, San Francisco, 22-26/10/2021
EARLY-AF: Cryoballoon Ablation Lowers Rate of Atrial Fibrillation (AF) Recurrence Among Patients Receiving Initial Treatment for Symptomatic, Paroxysmal AF, Compared With Antiarrhythmic Drug (AAD) Therapy, as Assessed by Continuous Cardiac Rhythm Monitoring
Among 303 patients with symptomatic, paroxysmal, untreated AF randomized to catheter ablation with a cryothermy balloon or antiarrhythmic drug (AAD) therapy for initial rhythm control, at 1 year, 66 of 154 patients (42.9%) assigned to ablation had AF recurrence vs 101 of 149 patients (67.8%) assigned to AAD (hazard ratio-HR, 0.48; P<0.001). Symptomatic AF recurred in 11% vs 26.2% (HR, 0.39). The median percentage of time in AF was 0% with ablation and 0.13% with AAD. Serious adverse events occurred in 5 (3.2%) vs 6 patients (4%) (Andrade JG et al, N Engl J Med 2021; 384:305-315).
STOP AF First: Cryoballoon Ablation as Initial Therapy was Superior to Drug Therapy for Prevention of Recurrence in Patients With Paroxysmal Atrial Fibrillation (AF) with Uncommon Serious Procedure-Related Adverse Events
According to a multicenter trial which randomized 203 patients 18-80 years of age with paroxysmal AF to antiarrhythmic drugs (class I or III agents) (n=99) or pulmonary vein isolation with a cryoballoon (n=104), with initial success of the ablation procedure achieved in 97%, the Kaplan–Meier estimate of treatment success at 1 year was 74.6% in the ablation group and 45% in the drug-therapy group (P<0.001 by log-rank test). Two primary safety end-point events occurred in the ablation group (Kaplan–Meier estimate of the percentage of patients with an event within 12 months, 1.9%) (Wazni OM et al, N Engl J Med 2021; 384:316-324).
GALACTIC-HF: Among Patients with Heart Failure and a Reduced Ejection, Those on Omecamtic Mecarbil Had a Lower Incidence of a Composite of a HF Event or Death from Cardiovascular Causes on Placebo
Among 8256 patients (in- and out-patients) with symptomatic chronic HF and an ejection fraction of <35% assigned to omecamtiv mecarbil (25-50 mg bid) or placebo, in addition to standard HF therapy, over a median of 21.8 months, a primary-outcome event (composite of a first HF event, i.e. hospitalization or urgent visit for HF, or death from CV causes) occurred in 1523 of 4120 patients (37%) in the omecamtiv mecarbil group and in 1607 of 4112 patients (39.1%) in the placebo group (hazard ratio-HR, 0.92; P=0.03). A total of 808 patients (19.6%) and 798 patients (19.4%), respectively, died from CV causes (HR, 1.01). There was no significant difference between groups in the change from baseline on quality-of-life score. At week 24, the change from baseline for the median N-terminal pro–B-type natriuretic peptide level was 10% lower in the omecamtiv mecarbil group than in the placebo group; the median cardiac troponin I level was 4 ng/L higher. The frequency of cardiac ischemic and ventricular arrhythmia events was similar (Teerlink JR et al, N Engl J Med 2021; 384:105-116)... (excerpt
Cardiology News / Recent Literature Review / Second Quarter 2021: Cardiology News
No full textESC Digital Congress 27-30/8/2021
TCT Meeting, San Francisco, 22-26/10/2021
42nd Panhellenic Congress of Cardiology, Athens, 21-23/10/21
AHA Scientific Sessions 2021, Boston, MA, USA, 13-15/10/21
ACC.22, Washington, DC, USA, 2-4/4/22
EuroPCR, Paris, France, 17-20/5/22
Systemic Lupus Erythematosus (SLE) Patients Have a Higher Associated Risk of Heart Failure (HF) and Other Cardiovascular (CV) Outcomes Compared with Matched Control Subjects
Among 3,411 SLE patients (median age: 44.6 years; 86% women) who were matched with 13,644 controls, over a median of 8.5 years, absolute 10-year risks of outcomes were: HF, 3.71% vs 1.94%; atrial fibrillation, 4.35% vs 2.82%; ischemic stroke, 3.75% vs 1.92%; MI, 2.17% vs 1.49%; venous thromboembolism, 6.03% vs 1.68%; and the composite of ICD implantation/ventricular arrhythmias/cardiac arrest, 0.89% vs 0.30% (SLE patients, vs control subjects). SLE with subsequent HF was associated with higher mortality compared with HF without SLE (adjusted hazard ratio: 1.50) (Yafasova A et al, J Am Coll Cardiol 2021;77:1717-27).
Worse Long-Term Outcomes of Patients with Late Presentation of ST-Segment Elevation Myocardial Infarction (STEMI)
Of 13,707 patients (2011-2015), 5,826 consecutive patients diagnosed with STEMI within 48 h of symptom onset were categorized as late (12-48 h; n = 624) or early (<12 h; n = 5,202) presenters. Late presenters had worse clinical outcomes (180-day mortality: 10.7% vs. 6.8%; 3-year mortality: 16.2% vs. 10.6%; both log-rank p < 0.001), whereas presentation at ≥12 h of symptom onset was not independently associated with increased mortality after STEMI. The use of invasive interventional procedures decreased from the first (<12 h) to the second (12-24 h) 12-h interval of symptom-to-door time (“no primary PCI strategy” increased from 4.9% to 12.4%, and “no PCI” from 2.3% to 6.6%; both p < 0.001). Mortality rates increased from the first to the second 12-h interval of symptom-to-door time (from 6.8% to 11.2% for 180-day mortality; from 10.6% to 17.3% for 3-year mortality; all p < 0.05) (Cho KH et al, J Am Coll Cardiol 2021;77:1859-70).
High Dietary Sodium (HS) Intake Increases Plasma Volume, Lowers Standing Plasma Norepinephrine, and Decreases Δ Heart Rate in Patients With Postural Tachycardia Syndrome (POTS)
Among 14 POTS patients and 13 healthy control subjects (HC), age 23-49 years, enrolled in a crossover study with 6 days of low (LS) (10 mEq/d) or high sodium (HS) (300 mEq/d) diet, in POTS, the HS diet reduced upright heart rate and Δ heart rate compared with the LS diet. Total blood volume and plasma volume (PV) increased, and standing norepinephrine decreased with the HS compared with the LS diet. However, upright heart rate, Δ heart rate, and upright norepinephrine remained higher in POTS than in controls on the HS diet, despite no difference in the measured PV (Garland EM et al, J Am Coll Cardiol 2021; 77:2174-84)... (excerpt
Long QT Syndrome in Athletes: Challenges in the Diagnosis and Management: Long QT Syndrome in Athletes
No full textThe long QT syndrome (LQTS) is an inherited channelopathy characterized by a prolonged QT interval without structural heart disease posing a risk of sudden cardiac death. Especially in athletes, diagnosis is sometimes more difficult due to bradycardia and to the QT prolongation induced by the exercise. Based on limited clinical data which tend to demonstrate that exercise, especially swimming, is a trigger for cardiac events, participation in any competitive sports practice is not supported by 2020 European guidelines. However, based on retrospective studies and involving the patient-athlete in shared decision making, the 2015 US guidelines are more lenient. Rhythmos 2021;16(4): 79-81
COVID-19 Vaccines: Cardiovascular Perspectives: COVID-19 Vaccines
No full textThe accelerated development of COVID-19 vaccines has ushered in new hope for the beginning of the end of this unprecedented pandemic with the heaviest toll on global health and economy. The goal of vaccination is to achieve “herd immunity” which helps interrupt the chain of transmission with the threshold of such immunity estimated at 60-70%. There are four main types of COVID-19 vaccines: messenger RNA (mRNA); viral vector; protein-based; and whole virus. mRNA vaccines and most of the COVID-19 vaccines are using various versions of the spike (S) protein as their vaccine antigen component, while a few vaccines employ the whole virion. Local reactions and mild symptoms are the most common adverse reactions to vaccination; however, anaphylaxis is a potentially life-threatening adverse effect and needs to be monitored and promptly managed. Deaths with temporal association with vaccination have also been reported, but not causally linked to vaccination. Thrombotic events have also been reported, particularly with two brands, and have caused alarm but apparently remain extremely rare, nevertheless authorities remain watchful. One is considered fully vaccinated for COVID-19 ≥2 weeks after one has received the last dose. Unfortunately, new strains of COVID-19 are emerging fast, for which the current vaccines may be less effective. Thus, it is still crucial to continue wearing facemasks, apply hand washing, and social distancing in order to slow viral spread and to protect everybody from infection. Several unknowns still remain about COVID-19 vaccines that relate to the safety and efficacy of the vaccines in “special” populations, the degree and duration that these vaccines protect against infection and transmission. and possible long-term adverse effects of vaccination, not yet encountered in phase 3 trials. Rhythmos 2021;16(2): 22-33
Anticoagulation with Enoxaparin in Patients with Obesity: Anticoagulation in Patients with Obesity
No full textObesity is a relatively common characteristic in modern western world populations and has a significant impact on the person’s health status. Despite the fact that it constitutes a well-described risk factor for thromboembolic events, the optimal anticoagulation strategy in obese patients remains vague. The available data suggest that while standard fixed enoxaparin doses (for prophylactic purposes) can lead to subtherapeutic effect, the conventional weight-based dosing schemes may result in overtreatment. Although not particularly strong, contemporary evidence indicate that a dose reduction in morbidly obese patients will likely result in a therapeutic anti-Xa level without an increased probability for bleeding or VTE. Rhythmos 2021;16(2):34-38