Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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Cardiology News / Recent Literature Review / Third Quarter 2021: Cardiology News
No full textTCT Meeting, San Francisco, 22-26/10/2021
42nd Panhellenic Congress of Cardiology, Athens, 21-23/10/21
AHA 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
Subanalysis of SYNTAXES: In Patients With 3-Vessel and/or Left Main Disease Having PCI or CABG, Those on Optimal Medical Therapy (OMT) at 5 Years Had a Survival Benefit at 10 Years
Among 1472 patients, patients on OMT at 5 years had a significantly lower mortality at 10 years compared with those on ≤2 types of medications (13.1% vs 19.9%; adjusted HR: 0.470; P=0.002) but had a mortality similar to those on 3 types of medications. Patients having CABG with antiplatelet drug and statin at 5 years had lower 10-year mortality than those without (Kawashima H et al, J Am Coll Cardiol 2021;78:27-38).
GALACTIC-HF: In Heart Failure (HF) Patients with Reduced Ejection Fraction (EF), Omecamtiv Mecardil Conferred Greater Benefit as Baseline EF Decreased
The risk of the primary composite endpoint (PCE) of time-to-first HF event or CV death in the placebo group was ~1.8-fold greater in the lowest EF (≤22%) vs the highest EF (≥33%) quartile. Amongst the pre-specified subgroups, EF was the strongest modifier of the treatment effect of omecamtiv mecarbil on the PCE (P=0.004). Patients receiving omecamtiv mecarbil had a progressively greater relative and absolute treatment effect as baseline EF decreased, with a 17% relative risk reduction for the PCE in patients with baseline EF≤22% (n=2,246; HR 0.83) vs patients with EF ≥33% (n=1,750; HR 0.99; P=0.013). The absolute reduction in the PCE increased with decreasing EF (EF≤22%; risk reduction, 7.4 events per 100 patient-years; number needed to treat for 3 years = 11.8), compared with no reduction in the highest EF quartile (Teerlink JR et al, J Am Coll Cardiol 2021;78:97-108).
Repurposing Metoprolol for COVID-19-Associated ARDS Appears a Safe and Inexpensive Strategy that Can Alleviate the Burden of the COVID-19 Pandemic
Among 20 COVID-19 patients with ARDS on invasive mechanical ventilation randomized to metoprolol (n=12, 15 mg daily for 3 days) or control (n=8, no treatment), patients randomized to metoprolol had significantly fewer neutrophils in bronchoalveolar lavage (BAL) on day 4 (P=0.016). Metoprolol also reduced neutrophil extracellular traps content and other markers of lung inflammation. Oxygenation (PaO2:FiO2) significantly improved after 3 days of metoprolol treatment (P=0.003), whereas it remained unchanged in control subjects. Metoprolol-treated patients spent fewer days on invasive mechanical ventilation than those in the control group (15.5±7.6 vs 21.9±12.6 days; P=0.17) (Clemente-Moragon A et al, J Am Coll Cardiol 2021;78:1001-11)... (excerpt
Cardiovascular Complications of COVID-19 Vaccination: COVID-19 Vaccines
No full textCurrently available COVID-19 vaccines may confer several side-effects, including cardiovascular (CV) adverse effects. Among them, perimyocarditis, acute myocardial infarction, arrhythmias and vaccine-induced immune thrombotic thrombocytopenia (VITT) with multiple vascular beds involved causing cerebral venous sinus thrombosis, splanchnic vein thrombosis, deep vein thrombosis and pulmonary embolism, as well as arterial thrombosis, constitute the most worrisome CV complications. Rhythmos 2021;16(4): 73-78
Asymptomatic Carriers/Patients with COVID-19 Infection: How is this Possible? Asymptomatic COVID-19
No full textA sizeable proportion of individuals contracting the corona virus disease 2019 (COVID-19) infection remains asymptomatic, while some patients develop mild symptoms and others exhibit severe symptomatology becoming critically ill necessitating admission to intensive care unit exposed to a high mortality risk. The pathophysiological mechanisms underlying this diversity in the clinical picture of COVID-19 are poorly understood. A variety of reasons have been postulated, among which, viral load, age, gender, immune response, blood type, genotypes, polymorphisms, comorbidities and pre-existing immunity are actively explored. Thus, there is a dire need to further elucidate this phenomenon and find ways to identify and discern susceptible from resistant individuals with the ultimate goal to find a cure for the disease. These issues are herein discussed and pertinent recent literature is reviewed. Rhythmos 2020;15(4):65-72
Post-PVI Left Atrial Flutter Managed with Pulmonary Vein Re-Isolation Using Cryoballoon Ablation
Get PDFA case of left atrial flutter occurring after pulmonary vein isolation effected via cryothermic balloon ablation for atrial fibrillation is presented, which was successfully managed with pulmonary vein re-isolation. Rhythmos 2020; 15(1):77-79
Transcatheter Bioprosthetic Aortic Valve Durability: Where do we Stand?
Get PDFTranscatheter aortic valve implantation (TAVI) was initially reserved for inoperable or high surgical risk patients with severe symptomatic aortic valve stenosis, but after the recent publication of randomized studies comparing TAVI to surgical aortic valve replacement (AVR) among intermediate risk (PARTNER 2 and SURTAVI) and low risk patients (PARTNER 3 and Evolut Low Risk), the momentum for further expansion of TAVI at the expense of AVR seems irreversible. The main obstacle before the wider application of TAVI for intermediate and lower risk patients is the uncertainty regarding bioprosthetic valve durability and the potential for structural deterioration and dysfunction over time. A concise overview regarding bioprosthetic valve durability issues, the relevant current scientific data and their importance for TAVI patient selection and management is herein presented. Rhythmos 2020;15(1):72-76
Use of Sodium–Glucose Cotransporter 2 (SGLT-2) Inhibitors Beyond Diabetes: On the Verge of a Paradigm Shift?
Get PDFThe sodium–glucose co-transporter 2 (SGLT2) inhibitors have proven effective in glycemia control in patients with type 2 diabetes (T2D) by increasing urinary glucose excretion. However, the beneficial effects of SGLT2 inhibition extend beyond glycemic control, with new studies demonstrating beneficial effects that lead to improved cardiovascular (CV) (cardioprotection) and renal outcomes (renoprotection) in patients with T2D. Pivotal CV outcomes trials have demonstrated a 27-35% reduction in heart failure (HF) hospitalizations in patients with T2D. Importantly, a variety of pleiotropic effects of these new agents have been identified that include, but are not limited to, anti-atherosclerotic, anti-inflammatory, and anti-oxidant effects, decreased vascular stiffness and improved endothelial function, weight loss, reduction in sympathetic activity and in cardiac arrhythmogenesis. Ongoing studies are investigating these actions in patients with and without diabetes. Such results, if positive, may lead to a paradigm shift in the management of CV, renal and even other diseases beyond diabetes. Rhythmos 2020;15(1):67-71
Atrial Fibrillation in Heart Failure With Preserved Ejection Fraction: Pathophysiology and the Role of Catheter Ablation: AF in HFpEF
Get PDFAtrial fibrillation (AF) and heart failure (HF) often coexist, and the prognosis of patients who have both these conditions is worse than those with either condition alone. Heart failure with preserved ejection fraction (HFpEF) is a clinical condition that was initially characterized as diastolic dysfunction HF, then as HF with normal ejection fraction, and more recently as HFpEF. About one-third of patients with HFpEF suffer from AF. Although, both clinical entities share common pathophysiologic mechanisms, current knowledge of the relationship between AF and HFpEF is limited. Catheter ablation, although data from randomized trials in this category of patients are limited, seems to have beneficial effects regarding maintenance of sinus rhythm and re-hospitalization rates. Rhythmos 2020;15(2):29-32
Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-Cov-2 Infection (PIMS-TS): Kawasaki-Like Multisystem Inflammatory Syndrome in Children (MIS-C) During the COVID-19 Pandemic with Predominant Myocarditis: Kawasaki-Like Multisystem Inflammatory Syndrome in Children (MIS-C) During the COVID-19 Pandemic
No full textDuring the COVID-19 pandemic, a Kawasaki-like multisystem inflammatory syndrome with predominant myocarditis associated with SARS-CoV-2 infection has recently been reported, now referred to as Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19, or Pediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 infection (PIMS-TS). These pediatric patients present with features that overlap features of Kawasaki Disease (KD) and toxic shock syndrome, albeit with distinct differences that relate to more common myocardial involvement requiring vasopressor support in PIMS-TS/MIS-C compared to KD (~50% vs ~5%), and less common coronary artery aneurysms (~9% vs ~25%). PIMS-TS/MIS-C seems to be largely immune-mediated, triggered by COVID-19, with the induced hyperinflammatory syndrome possibly due to post-infectious cytokine storm, rather than a result of direct cell injury caused by the virus. Treatment of this syndrome is similar to KD and includes intravenous immunoglobulin (IVIG), corticosteroids, and antiplatelet agents, while a few patients have also received interleukin-6 (IL-6) inhibitors. Rhythmos 2020;15(3):42-46
Cardiology News / Recent Literature Review / First Quarter 2020: Cardiology News
No full textRhythmos 2020;15(2):35-41.
Virtual HRS Meeting: (San Diego) 6-9/5/2020
Virtual EuroPCR: (Paris) 19-22/5/2020
?ESC Meeting: Amsterdam, 29/8-2/9/2020
?TCT: Miami Beach, FL, USA, 23-27/9/20
?HCS/Panhellenic (41st) Congress of Cardiology: Athens, 22-24/10/20
Persistent Proarrhythmic Neural Remodeling (Characterized by Extracardiac Sympathetic Hyperinnervation and Sympathetic Neural Hyper-activity) Despite Recovery from Premature Ventricular Contraction-Induced Cardiomyopathy (PVC-CM)
In 12 canines, with pacing-applied PVC-CM, after 12 weeks of PVCs, LVEF and dP/dT decreased significantly. Resting sympathetic nerve activity (SNA) and vagal nerve activity (VNA), exercise SNA, SNA response to evoked PVCs, heart rate (HR) at rest, and exercise increased, whereas HR variability (HRV) decreased. There was increased spontaneous atrial and ventricular arrhythmias in PVC-CM. Increased SNA preceded both atrial and ventricular arrhythmia onset. Clonidine suppressed SNA and abolished all arrhythmias. After stopping PVC for 4 weeks, LVEF, dP/dT, and resting VNA recovered to baseline levels. However, SNA, resting HR, HRV, and atrial and ventricular proarrhythmia persisted. Sympathetic hyperinnervation was found in stellate ganglia but not ventricles of PVC-CM and recovered animals versus sham controls. The authors concluded that neural remodeling in PVC-CM is characterized by extracardiac sympathetic hyperinnervation and sympathetic neural hyperactivity that persists despite normalization of LVEF, constituting an important trigger and substrate for atrial and ventricular proarrhythmia (Tan AY et al, J Am Coll Cardiol 2020; 75:1-13).
PARAGON-HF: The Benefits of Sacubitril/Valsartan in HFpEF are Present When Initiated in the High-Risk Window Within 180 Days of a Recent Hospitalization
Among 4,796 randomized patients in PARAGON-HF, over a median follow-up of 35 months, risk of total HF hospitalizations and cardiovascular death was inversely and nonlinearly associated with timing from prior HF hospitalization (p<0.001). Compared with valsartan, absolute risk reductions with sacubitril/valsartan were more prominent in patients enrolled early after hospitalization: 6.4% (≤1 month), 4.6% (1-3 months), and 3.4% (3-6 months), whereas no risk reduction was observed in patients screened >6 months or who were never hospitalized (trend in absolute risk reduction: pinteraction=0.050) (Vaduganathan M et al, J Am Coll Cardiol 2020; 75:245-54).
Oral Anticoagulation (OAC) for Patients With Atrial Fibrillation (AF) on Long-Term Dialysis: Not Associated With a Reduced Risk of Thromboembolism / Warfarin, Dabigatran, and Rivaroxaban Were Associated With Higher Bleeding Risk Compared With Apixaban and no Anticoagulant
Of 16 observational studies (N=71,877) regarding patients on long-term dialysis who had AF, only 2 studies investigated direct OACs. Outcomes for dabigatran and rivaroxaban were limited to major bleeding events. Compared with no anticoagulants, apixaban and warfarin were not associated with a significant decrease in stroke and/or systemic thromboembolism (apixaban 5 mg, hazard ratio -HR: 0.59; apixaban 2.5 mg, HR: 1.00; warfarin, HR: 0.91). Apixaban 5 mg was associated with a significantly lower risk of mortality (vs. warfarin, HR: 0.65; vs. apixaban 2.5 mg, HR: 0.62; vs. no anticoagulant, HR: 0.61). Warfarin was associated with a significantly higher risk of major bleeding than apixaban 5 mg/2.5 mg and no anticoagulant (vs. apixaban 5 mg, HR: 1.41; vs. apixaban 2.5 mg, HR: 1.40; vs. no anticoagulant, HR: 1.31). Dabigatran and rivaroxaban were also associated with significantly higher risk of major bleeding than apixaban and no anticoagulant (Kuno T et al, J Am Coll Cardiol 2019; 75:273-85)... (excerpt
Right Bundle Branch Block Pattern During Right Ventricular Pacing: Inadvertent Pacing Lead Placement or a False Alarm? / Just a Need for a Lower Relocation of V1/2 ECG Lead Placement! RBBB Pattern in RV Pacing
No full textA case of right bundle branch block pattern of right ventricular pacing is presented wherein a simple maneuver of precordial V1/2 ECG lead relocation clarified the problem. Rhythmos 2020; 15(2):33-34