bluuebunny/crossref_metadata_2025 huggingface dataset:
Staged hybrid ablation in left atrial appendage aneurysm a rare cause of refractory atrial tachyarrhythmia—a case report
Authors: Mittal Ashish , Navaratnarajah Manoraj , Harden Stephen , Velissaris Theodore , Roberts Paul R
Published: June 2024

Background

Left atrial appendage aneurysm (LAAA) is a rare cardiac anomaly, which can be congenital or acquired in origin. Because most cases are asymptomatic, it is typically diagnosed incidentally in the second to third decades of life. We present a case of a 28-year-old male with refractory atrial tachyarrhythmias and significantly reduced exercise tolerance. The informed consent was given by patient for this manuscript.

Case summary

We present a case of a 28-year-old male with refractory atrial tachyarrhythmias and significantly reduced exercise tolerance after an episode of COVID respiratory infection. He was referred by primary care physician for management of atrial fibrillation (AF) with CHA2DS2Vasc score zero. He had documented AF and atrial flutter (AFL) resistant to both chemical and electrical cardioversions. Initial portable focused transthoracic echocardiography documented borderline reduced left ventricular ejection fraction in context of AFL. Electrophysiological study confirmed the diagnosis of typical AFL. Successful radiofrequency ablation of cavo-tricuspid isthmus resulted in bidirectional isthmus conduction block. However, patient developed AF, which was electrically cardioverted at the end of procedure. Patient was discharged on bisoprolol, ramipril, and apixaban, and outpatient cardiac MRI was organized to look for post-COVID myocardial scarring. Patient had recurrence of symptoms, and this time it was due to AF. Multimodal imaging led to discovery of LAAA, in which after discussion in multidisciplinary meeting, he was accepted for and managed with surgical resection of LAAA with concomitant Cox-Maze IV procedure. On 9 months post-operative follow up, patient is maintaining sinus rhythm and has completely returned to baseline activities.

Discussion

A young patient with refractory atrial arrhythmia should be referred for multimodal cardiovascular imaging to rule out any structural heart disease. Left atrial appendage aneurysm is rare and can be managed conservatively, but surgical excision is most reported and appears to favour arrhythmia-free survival.
Ten things to remember about propensity scores
Authors: Groenwold Rolf H H , Dekkers Olaf M , le Cessie Saskia
Published: June 2024

Propensity score methods are popular to control for confounding in observational biomedical studies of risk factors or medical treatments. This paper focused on aspects of propensity score methods that often remain undiscussed, including unmeasured confounding, missing data, variable selection, statistical efficiency, estimands, the positivity assumption, and predictive performance of the propensity score model.
The risk of life-threatening arrhythmias and sudden death forecast scale
Authors: Vytrykhovskiy A , Nesterak R , Sovtus V
Published: June 2024

In order to develop and implement the concept of prevention and treatment of fatal complications in the population of people with a high and very high cardiovascular risk, a risk calculation scale of emergence and progression of life-threatening arrhythmias and sudden death was created. It was based on the assessment of the state of heart rate variability and heart rate turbulence, the value of the coefficient - deceleration capacity (DC), and the length of the QTc interval on ECG.

The creation of this scale was based on recommendations, protocols, and standards developed by the following: American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific Statement on noninvasive risk stratification techniques for identifying patients at risk for sudden cardiac death (2013); Task Force of European Society of Cardiology and The North American Society of Pacing and Electrophysiology (2009). Sudden Death Forecast scale (SDFS) values are expressed in points from 1 to 10. From indicators of heart rate variability, we selected: (Total Power, Low Frequency, High Frequency, Low Frequency/High Frequency) and the duration of the QTc interval – and valued each indicator with 1 point. The change of heart rate turbulence indicators - parameters of acceleration (То) and deceleration (Тs) of sinus rhythm, and the coefficient of deceleration capacity (DC) are estimated at 2 points each. The distribution of points was made according to the prognostic value of each of the indicators. Points are awarded when the indicator goes beyond physiologically acceptable norms. The value of the points indicates the degree of adaptation of the cardiovascular system, necessary to maintain the active balance of the body with the environment, as well as the risk of life-threatening arrhythmias and sudden cardiac death. 1-2 points are very low risk, and 3-4 points are low risk. SDFS = 5-6 points: indicates a state of pronounced tension of regulatory systems and mobilization of protective mechanisms, the risk of life-threatening arrhythmias is moderate. SDFS=7-8 points: a state of insufficiency of protective and adaptive mechanisms and excessive activation of regulatory systems which is no longer supported by appropriate functional reserves – the risk is high. 7 points - the body's hemostasis is preserved and works in a state of compensation, 8 points - the appearance of non-specific premorbid conditions. SDFS = 9-10 points: state of exhaustion, specific changes clearly prevail over non-specific ones, the risk of life-threatening arrhythmias and sudden death is very high. This scale is available in a specially created program for PC. Sudden Death Forecast scale (SDFS)
Klotho protein inhibits extracellular matrix degradation and apoptosis during heart ischemia/reperfusion injury via regulation of the NOS/MMP signalling axis
Authors: Olejnik A , Krzywonos-Zawadzka A , Bil-Lula I
Published: June 2024

Background

Ischemia/reperfusion injury (IRI) of the heart involves the activation of oxidative and apoptotic pathways [1]. It is known that nitric oxide synthase (NOS) and oxidative stress activate extracellular matrix degradation by matrix metalloproteinase (MMP). It results in apoptosis and damage to the heart tissue [1]. Klotho is a membrane-bound or soluble antiaging protein with potential protective activity, since it supports redox balance and metabolic functions of the cardiomyocytes [2].

Purpose

This study aimed to evaluate the influence of Klotho protein on the NOS/MMP signalling pathway and apoptosis that followed in the heart subjected to IRI.

Material and Methods

Isolated rat hearts perfused with the Langendorff method were subjected to ischemia, followed by reperfusion in the presence or absence of recombinant Klotho protein (0.5 ng/mL). Heart hemodynamic parameters, as well as factors related to oxidative stress (inducible NOS (iNOS), endogenous NOS (eNOS), asymmetric dimethylarginine (ADMA), nitrate/nitrite (NOx-), carbonyl content), extracellular matrix degradation (MMP-2, MMP-9, tissue inhibitor of metalloproteinase-4 (TIMP-4)) and apoptosis (caspase 3 and 8) were evaluated.

Results

Reduced left ventricle (LV) work in the IRI group (p=0.009) was observed, as compared to the aerobic control. There was a decreased level of iNOS protein (p=0.002) and slightly increased production of NOS inhibitor - ADMA (p>0.05) in the hearts after IRI. Reduced expression of the eNOS gene (p=0.006) and increased level of eNOS protein (p=0.009) in the IRI group were observed. Then, IRI resulted in a decrease in MMP-2 (p=0.019) and MMP-9 (p=0.039) gene expressions, and enhanced production of MMP-2 (p=0.042), MMP-9 (p=0.041) and TIMP-4 (p=0.043) proteins, as compared to aerobic conditions. Administration of Klotho protein during IRI significantly increased LV work (p=0.001) and recovery of heart mechanical function (p=0.0003). Then, Klotho regulated the production of iNOS protein (p=0.020), ADMA (p=0.007), eNOS mRNA (p=0.021) and eNOS protein (p=0.041) to the levels observed in aerobic control. It resulted in the inhibition of oxidative stresss, expressed as decreased (NOx)- level (p=0.022) and low carbonyl content (p=0.036) in the IRI+Klotho group. Then, Klotho significantly contributed to the reduction in MMP-2 (p=0.024) and MMP-9 (p<0.0001) protein levels and regulated MMP-9 gene expression (p=0.038) during IRI. Finally, there was restrained caspase 3 (p=0.043) and caspase 8 (p=0.040) release after supplementation of IRI hearts with Klotho.

Conclusion

Administration of Klotho protein resulted in full preservation of heart mechanical function, and suppression of extracellular matrix degradation and apoptosis in hearts subjected to IRI. Thus, Klotho can be recognized as a novel cardiopreventive agent in ischemic damage. Fig. 1.The level of eNOS protein  Fig. 2.The level of MMP-2 protein
Platelet-endothelial aggregation receptor 1 inhibits reendothelialization of injured arteries
Authors: Li T , Yuan J
Published: June 2024

Background

Platelet-endothelial aggregation receptor 1 (PEAR1) is primarily expressed in endothelial cells and platelets. Previous studies have revealed that PEAR1 inhibits neoangiogenesis and suppresses the proliferation of pulmonary microvascular endothelial cells.

Purpose

The study aims to explore the impact of PEAR1 on the reendothelialization of injured arteries.

Methods

The role of PEAR1 in injured endothelial cell proliferation and migration was determined in vitro with human coronary artery endothelial cells (HCAECs). All experiments were performed under IL-1α conditions to replicate an inflammatory environment following wire injury. We constructed three recombinant lentiviral vectors: short hairpin RNA against PEAR1 (sh-PEAR1), PEAR1 overexpression (OE-PEAR1), and non-targeting sh-PEAR1 (sh-PEAR1 NC) as control. The PEAR1-/-knockout mice and wild-type (WT) controls were studied for the response of femoral arteries to angioplasty wire injury. The study adhered to the "Principles of Laboratory Animal Care" and received approval from the Institutional Animal Care and Use Committee (IACUC) (Issue Number: 20230040).

Results

In comparison to the sh-PEAR1 NC group, PEAR1 knockdown significantly enhanced HCAEC proliferation and migration. Conversely, PEAR1 overexpression strongly inhibited HCAEC proliferation and migration (Figure 1). The reendothelialized area in PEAR1-/- arteries was significantly larger than in WT arteries on days 3 and 7 after injury. Moreover, on day 28, PEAR1-/- arteries halved neointima formation compared with WT arteries (Figure 2).

Conclusion

PEAR1 suppresses HCAEC proliferation and migration in the presence of IL-1α. PEAR1 delays reendothelialization and accelerates neointima formation of wire-injured arteries in mice. Figure 1  Figure 2
Is high intensity interval training superior to moderate intensity continuous training in older adults with cardiovascular disease? The Generation 100 study
Authors: Stensvold D S , Haavard Dalen H D , Elisabeth Kleivhaug Vesterbekkmo E K V , Jon Magne Letnes J M L , Ulrik Wisloeff U W
Published: June 2024

Background

Aerobic exercise is widely used as a secondary prevention strategy to improve health and prognosis in patients with various forms of cardiovascular disease (CVD). Although high-intensity interval training (HIIT) has been shown to induce superior health benefits compared to moderate-intensity continuous training (MICT) in the short term, the evidence from long-term randomized trials regarding the effects of different exercise intensities in older adults is lacking.

Purpose

The aim of this study was to compare the effects of five years of supervised HIIT and supervised MICT with a control group instructed to follow the physical activity recommendations, with respect to recurrent CVD events, peak oxygen uptake (VO2peak), and health related quality of life in patient with established CVD.

Methods

In total 274 patients with CVD (mean age 72.3±2.1) of our city, were included in the present study. The patients were randomized (1:1:2) to two weekly sessions of HIIT at about 90% of peak heart rate (n=60), MICT at about 70% of peak heart rate (n=78), or controls instructed to follow the national guidelines for physical activity (n=136), for five years. Clinical outcomes were identified by diagnoses in the community hospital medical records and reported according to International Classification of Diseases (ICD-9 and ICD-10). CVD events were defined as a valid diagnosis of CVD or death from CVD, whichever came first. In addition, cardiopulmonary testing was used to assess VO2peak, and The Short Form-8 (SF-8) was used to measure health related quality of life at baseline and at 5-year follow-up.

Results

The number of CVD events during the five-year follow-up was not significantly different between groups, with an incident rate of 28.3%, 27.3%, and 38.2% in HIIT, MICT, and controls, respectively. Atrial fibrillation was the most common CVD event during the intervention, with an incidence rate of 6.7%, 9.1% and 6.6% in HIIT, MICT and controls, respectively. Importantly, there were no acute adverse CVD events during testing or training during the five-year follow-up. After five years, HIIT showed a strong tendency towards a higher VO2peak compared to controls (1.49 mL/kg/min, 95% CI -0.10 to 3.09). No significant differences were observed in MICT compared to controls (0.32 mL/kg/min, 95% CI -1.12 to 1.77). There were no between-group differences in health-related quality of life after the intervention.

Conclusions

After 5 years, the recurrent CVD events was similar across groups randomized to HIIT, MICT and controls. This is the first study to show that HIIT is a feasible and safe exercise modality in older adults with established cardiovascular diseases.
Cardiac rehabilitation and long-term prognosis in cardiovascular disease patients with cancer history
Authors: Miki T , Kamiya K , Hamazaki N , Nozaki K , Uchida S , Noda T , Ueno K , Hotta K , Maekawa E , Sasaki J , Yamaoka-Tojo M , Matsunaga A , Ako J
Published: June 2024

Background

Cancer and CVD both tend to cause skeletal muscle mass loss, and their combined effects are associated with a poor prognosis. In response, studies have shown comprehensive cardiac rehabilitation (CR) to be associated with an improved prognosis, as well as reduced risk of rehospitalization, in CVD patients. However, the benefits of comprehensive CR for patients with CVD and cancer remain unclear.

Aim

The purpose of this study was to examine whether participation in outpatient CR is associated with a favorable long-term prognosis for CVD patients with a cancer history.

Methods

We retrospectively reviewed 1,502 CVD patients with a cancer history (median age: 76 [69–81] years, 968 males) who were hospitalized between 2007 and 2022. The primary and secondary outcomes were all-cause death and a composite of all-cause death and CVD-related rehospitalization, respectively. We performed propensity score matching, followed by Kaplan–Meier curves and Cox regression analysis to evaluate the association between CR and prognosis, with CR participation defined as partaking at least once within three months of discharge.

Results

Of the 1,502 patients in this study, 136 deaths and 133 CVD-related rehospitalizations occurred (median follow-up 1.6 [0.5–3.3] years). After propensity score matching, 1,036 patients (n = 518 pairs) were included, with standardized mean differences were <0.1 for all covariates. Further, CR hazard ratios for all-cause mortality and the composite outcome were 0.60 (95% CI: 0.43–0.84, P = 0.003) and 0.72 (95% CI: 0.55–0.94, P = 0.015), respectively.

Conclusions

Participation in outpatient CR was associated with a favorable prognosis in CVD patients with a cancer history.
Effects of urinary tract infection and stopping sodium-glucose cotranspoter-2 inhibitors in patients with type 2 diabetes mellitus: a population-based study
Authors: Wu M Z , Tung M O , Tsang T W , Guo R , Huang J Y , Ren Q W , Zhang J N , Gu W L , Yiu K H
Published: June 2024

Background

Sodium-glucose cotranspoter-2 (SGLT2) inhibitors are widely prescribed in patients with type 2 diabetes mellitus (T2DM). Yet these patients are susceptible to urinary tract infection (UTI).

Purpose

This study aims to investigate the efficacy of continuing SGLT2 inhibitors after an episode of UTI.

Methods

Patients with T2DM who were prescribed SGLT2 inhibitors from January 2015 to June 2022 were identified from Clinical Data Analysis and Reporting System (CDARS). The primary outcomes were major adverse cardiovascular events (MACE: a composite of heart failure hospitalization, stroke, myocardial infarction, and cardiovascular mortality), renal-specific composite outcomes (defined as 50% decline in eGFR, end-stage renal failure, and kidney mortality), cardiovascular mortality, and all-cause mortality. Multivariable Cox proportional hazards model was employed to estimate the hazard ratios (HRs), while Fine-Gray model was used to account for competing events. Incident UTI was treated as time-varying covariate in the model.

Results

A total of 61,661 patients (mean age 63 years, 64.1% male) with T2DM who were prescribed SGLT2 inhibitors were included in this study, of whom 3,976 (6.45%) patients had an episode of UTI in follow-up. Patients who had an incident UTI were associated with a higher risk of MACE (HR 1.98, 95% CI 1.78-2.21), renal-specific composite outcomes (HR 2.17, 95% CI 1.95-2.40), cardiovascular mortality (HR 4.60, 95% CI 3.86-5.48) and all-cause mortality (HR 4.25, 95% CI 3.89-4.65) compared to those without an incident UTI. Among patients who experienced a UTI, stopping SGLT2 inhibitors conferred a 76% reduction in the risk of long-term recurrent UTI (HR 0.24, 95% CI 0.14-0.40), but entailed a significantly higher risk of MACE (HR 1.29, 95% CI 1.05-1.57), renal-specific composite outcomes (HR 1.46, 95% CI 1.21-1.77), cardiovascular mortality (HR 1.69, 95% CI 1.27-2.24), and all-cause mortality (HR 2.77, 95% CI 2.37-3.23).

Conclusion

Using real-world data of patients with T2DM who were prescribed SGLT2 inhibitors, this study found that new-onset UTI increased the risk of MACE, renal-specific composite outcomes, cardiovascular mortality, and all-cause mortality. Moreover, stopping SGLT2 inhibitors after a UTI conferred a lower risk of long-term recurrent UTI, but a higher risk of MACE, renal-specific composite outcomes, cardiovascular mortality, and all-cause mortality.
Efficacy of early versus late b-blocker administration after primary PCI
Authors: Ntalianis A , Kondylis M , Makavos G , Chaldoupis A , Anninos E , Misegianidis A , Zografos N , Konstantinou G , Zenetos D , Repasos E , Mpalaska A , Papadopoulou E , Kanakakis J , Paraskevaidis I
Published: June 2024

Introduction/Purpose

Administration of B-Blockers (BB) in patients presenting with STEMI is strongly recommended during the first 24 hours after admission. Early initiation of BB might confer favorable effects via a significant reduction in myocardial energy consumption. The aim of this prospective single-centre randomized study was to investigate the safety and efficacy of early po BB administration in patients with STEMI submitted to primary PCI (pPCI).

Methods

60 consecutive patients referred for pPCI because of an acute STEMI were randomly assigned (3:1) into the following groups : a) Early initiation of BB (Group A) and b) Late initiation of BB (Group B). Patients with cardiogenic shock (CS), acute heart failure (AHF) with Killip class >2, bradycardia (<60 beats/min) and systolic blood pressure (SBP) less than 100 mmHg were excluded from the study. The Group A received 12,5mg of oral metoprolol tartrate within 3 hours after pPCI and two additional doses of 25 mg and 50 mg 6 and 12 hours after the intervention, provided that the heart rate (HR) was > 60 beats/min. The Group B received orally 12,5 mg of metoprolol tartrate 8 hours after pPCI and 25mg of the drug 24 hours after the procedure, as long as the HR was > 60 beats/min. The safety endpoints were as follows: a) severe bradycardia (defined as HR <50 beats/min), b) arterial hypotension (defined as SBP < 90mmHg), and c) the development of signs and symptoms of AHF/CS. The efficacy endpoints were the following: a) the infarct size as assessed by cardiac troponin levels (TnI) 24 hours after admission and b) left ventricular function at 6 months after STEMI as reflected by ejection fraction (EF) and global longitudinal strain (GLS), both measured with heart ultrasound.

Results

There was no statistically significant difference between Group A and B regarding the HR at baseline (BL) (78,4±4 vs 83,3±4bpm, p=ns), at 6 hours (73,8±4 vs 73,1±4bpm, p=ns) and 24 hours (71,2±4 vs 69,4±4bpm, p=ns) (Figure 1). SBP was slightly higher in Group A at BL (137,2±7 vs 119,9±6mmHg, p=0,02), but neither at 6 hours (127,2±7 vs 126,5±6mmHg, p=ns) nor at 24 hours (124±7 vs 121,5±6mmHg, p=ns). Interestingly, no episode of AHF/CS was noted. The infarct size was similar in both groups (TnI; 27009±3005 in Group A vs 27369±4765 ng/Dl in Group B, p=ns). Finally, no statistically significant difference was observed in the EF at BL between Group A and B (44,2±5 vs 45,3±4%, p=ns) and 6 months later (45,2±5 vs 46,2±4%, p=ns) nor in the GLS both at BL (-14,6±7 vs -16,2±6%, p=ns) and at 6 months (-15,3±7 vs -16,8±6%, p=ns) (Figure 2).

Conclusion

The strategy of an early administration of BB after pPCI in patients with STEMI is safe but not superior to a delayed administration strategy with regard to myocardial salvage and left ventricular function recovery.
Temporal trends in all-cause and cause-specific mortality following non-ST-elevation myocardial infarction in Israel, 2000-2013
Authors: Menipaz A , Gerber Y , Halabi M , Fluk-Gmach S , Halabi M , Beigel R , Orvin K , Iakobishvili Z
Published: June 2024

Background

International studies report a decline in 30-day and 180-day all-cause mortality after non-ST-elevation myocardial infarction (NSTEMI). However, studies on temporal trends of more extended follow-up periods after NSTEMI are lacking; similarly missing are studies on temporal trends of cause-specific mortality after NSTEMI.

Purpose

To assess temporal trends in the long-term (5-year follow up) all-cause and cause-specific mortality of patients admitted in the years 2000 to 2013 with NSTEMI.

Methods

We obtained baseline characteristics and admission data from the Acute Coronary Syndrome Israeli Surveys (ACSIS). ACSIS surveys have been conducted since 2000, once every 2 or 3 years, each year for eight consecutive weeks, among all patients admitted with acute myocardial infarction or unstable angina pectoris (ACS) in all public hospitals in Israel. Additionally, we obtained data on all-cause and cause-specific mortality (until 2017) from the Israel Centre for Disease Control. Cox regressions and competing risks models were employed to assess survival temporal trends.

Results

Among the 4,437 patients admitted with NSTEMI [mean age 65.9 (SD 13.1) years, 75.4% male], 1,127 deaths (25.4%) occurred during the 5-year follow-up. There were no changes over time in the percentage of male patients or the patients’ average age. However, the burden of comorbidities increased over time: the proportion of NSTEMI patients admitted with at least 2 comorbidities increased from 50.8% in 2000 to 64.4% in 2013 (Ptrend<0.001).

Compared to NSTEMI patients admitted during 2000-2004, and adjusted for age and sex, NSTEMI patients admitted during 2006-2008 and during 2010-2013 faced 14% and 19% lower risk (respectively) of all-cause mortality (HR=0.86, 95% CI: 0.75-0.98 and HR=0.81, 95% CI: 0.70-0.94, respectively; Ptrend <0.001). However, trends diverged between cardiovascular (CV) and non-CV deaths (see Figure). Whereas, adjusted for age and sex, patients admitted during 2010-2013 had 46% lower risk of CV deaths than patients admitted during 2000-2004 (HR=0.54, 95% CI: 0.42-0.68; Ptrend<0.001), the risk of non-CV deaths remained unchanged (HR=0.99, 95% CI: 0.80-1.22). As a result, the percentage of 5-year CV deaths among all fatalities consistently decreased (51.0% in 2000-2004, 44.4% in 2006-2008, and 39.0% in 2010-2013; Ptrend=0.002).

Conclusions

Substantial improvement in 5-year mortality was observed among patients admitted in Israel between 2000 and 2013 with NSTEMI. Given that the decline was mainly due to reduction in CV mortality, it is advisable to adopt a more comprehensive approach to NSTEMI patients and address comorbidities.
The frequency of coronary artery atherosclerotic plaques in patients with newly diagnosed type 2 diabetes mellitus
Authors: Hyseni V , Bakalli A , Gjikolli B , Elezi S , Olloni-Nikaj R , Vela-Gaxha Z
Published: June 2024

Introduction

Complications due to diabetes mellitus usually appear after long-standing disease. Furthermore, coronary artery disease (CAD) is the leading cause of morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). The calcium score in the coronary arteries is a reliable predictor of CAD. There are very scarce data in the literature regarding the frequency of CAD in newly diagnosed (ND) T2DM.

Purpose

The aim of this study was to assess the presence, extent and composition of subclinical atherosclerotic plaques in coronary arteries by means of Computed Tomography Calcium Score (CTCS) in asymptomatic patients with ND T2DM (<1 year duration).

Methods

In this prospective cross-sectional study 101 patients with ND T2DM according to the criteria of the American Diabetes Association were included. CTCS was performed on all patients by 64-slice cardiac CT, with a thickness of 2-5 mm. Calcification was identified as a structure >1 mm attached to or located within the lumen of a coronary vessel with intensity >130 HU. The Agatston method was used to determine the CTCS. Exclusion criteria were: stable angina pectoris, acute coronary disease, severe anemia, patients with history of stroke, moderate/severe renal insufficiency, liver insufficiency, claustrophobic patients, and pregnant women.

Results

Of the 101 asymptomatic patients with ND T2DM, 48 (47.5%) were females, with mean age of 54.4 ± 11.6 years. The risk factors were as follows: 61.4% with arterial hypertension, 37.6% smokers, 36.6% with dyslipidemia, 34.7% with positive family history for CAD, mean body mass index of 31.0 ± 5.6 kg/m2, while the duration of T2DM was 2.8 ± 5.3 months. Only 8 (7.9%) patients did not have atherosclerotic plaques or had a CTCS of 0; 7 (6.9%) patients had a CTCS of 1-10; 43 (42.6%) patients had a CTCS of 11-100; 23 (22.8%) patients had CTCS 101-400 and 20 (19.8%) patients had CTCS >400 (Figure). The mean total volume and mass of calcium in these patients was 210 and 180, respectively. The table displays CTCS parameters for specific coronary arteries.

Conclusions

Asymptomatic patients with ND T2DM in more than 85% of cases may present with atherosclerotic plaques, while the most loaded artery seems to be the LAD. Nearly half of these patients fall into the second category of calcium burden, characterized as a mild risk for CAD. Our study emphasizes the significance of comprehensive care for individuals with ND T2DM. In addition to maintaining glycemic control, there is a crucial need for early prevention of cardiovascular complications. CTCS of 7587 in a patient with NDT2DM  CT Calcium Score of the studied patients
Air pollution in relation to brain health indicators and global cognitive functioning in patients with cardiovascular disorders along the heart-brain axis
Authors: Timmermans E , Bron E , Bots M , Leeuwis A , Moonen J , Wolters F , Biessels G J , Vaartjes I
Published: June 2024

Background/Introduction

Exploring, understanding, and preventing the effects of exposure to air pollutants on the brain, and possible links to cognitive functioning, have been indicated as major global health challenges that urgently need to be addressed. Yet, relatively little work has been conducted to examine the associations of air pollution with indicators of brain health that are potentially related to cognitive functioning in patients who are at increased risk to develop cognitive impairments.

Purpose

This study aimed to examine cross-sectional and longitudinal associations of air pollution with global cognitive functioning, white matter hyperintensities (WMH), total brain volume (TBV), and cerebral blood flow (CBF) in individuals without or with heart failure, carotid occlusive disease, or vascular cognitive impairment. Additionally, this study examined whether the cross-sectional associations of air pollution with global cognitive functioning were mediated by WMH, TBV, and CBF.

Methods

For the cross-sectional and longitudinal analyses, we used data from 341 and 180 participants of the Dutch multi-center Heart-Brain Study, respectively. Cognitive functioning was measured using neuropsychological tests at baseline and two-year follow-up. Brain Magnetic Resonance Imaging provided WMH and TBV in mL, and CBF in mL/100g/min. WMH and TBV were divided by total intracranial volume. Annual average outdoor concentrations of particulate matter with diameters <2.5µm (PM2.5) and <10.0µm (PM10), and nitrogen dioxide (NO2) in µg/m3 in residential six-digit postal code areas were linked to participants at baseline. Adjusted multi-level regression analyses were applied to assess the associations of interest.

Results

No significant cross-sectional (βPM2.5=0.014, 95% CI=-0.076-0.104; βPM10=0.034, 95% CI=-0.043-0.111; βNO2=0.020, 95% CI=-0.004-0.045) and longitudinal associations (βPM2.5=0.041, 95% CI=-0.029-0.110; βPM10=0.016, 95% CI=-0.045-0.078; βNO2=-0.001, 95% CI=-0.022-0.022) of air pollution with global cognitive functioning were observed. No significant associations of air pollution with WMH, TBV, and CBF were found. The associations of PM2.5, PM10 and NO2 with global cognitive functioning were not significantly mediated by WMH, TBV, and CBF.

Conclusions

No supportive evidence was found for associations of air pollution with global cognitive functioning, WMH, TBV and CBF in healthy and vascularly compromised individuals.
Relationship between changes in cardiac function (HFrecEF, HFworEF) and physical function characteristics in heart failure patients
Authors: Fukuta Y , Tanaka S , Kawaguchi T , Arizono S , Sawai S , Yoshida A , Tsugita N , Fuseya T , Segawa T
Published: June 2024

Introduction

Recent research has categorised changes in LVEF in response to treatment into three distinct groups: improvement, worsening, and maintenance 1). Nevertheless, the relationship between the degree of EF change (ΔLVEF) and physical function remains unclear. Therefore, this study assessed the association between physical characteristics and Δleft ventricular ejection fraction(ΔLVEF) and physical function in two distinct categories: HF with recovered EF (HFrecEF) characterised by improved EF and HF with worsened EF (HFworEF) marked by worsened EF.

Methods

This retrospective cohort analysis included heart failure patients aged 65 years or older who underwent cardiopulmonary exercise testing between April 2016 and December 2022, called the pre-old age group starting at age 65, as the pre-older age group. LVEF (%) was measured using the modified Simpson method. Patients were assigned to two categories based (HFrecEF and HFworEF) on improvement (Δ) in LVEF. The relationship between ΔLVEF and physical function was analysed using the Spearman rank correlation. Multiple regression analysis was performed with ΔLVEF as the dependent variable for variables significantly related to ΔLVEF (P<0.05). The study subjects were classified into three groups based on LVEF, according to the JCS/JHFS 2021 guidelines 1). Among two, improvements and deteriorations were extracted.

Results

A total of 229 heart failure patients aged 65 years and older were included, with 40 patients who did not undergo follow-up echocardiography were excluded; HFuncEF excluded 144 patients, 45 patients, age 76.0 (67.5–79.5) years [HFrecEF 71.5(95% CI:66.0–78.5) vs HFworEF 78.0(72.5–81.5):P<0.01], were incorporated. Peak oxygen uptake (peak VO2) was significantly different between the two groups [HFrecEF 13.6(95% CI:11.9–15.4) vs HFworEF 10.1(7.8–11.8):P<0.01], and (peak ETCO2) was also significantly different, with lower values in HFworEF [HFrecEF 5. 36(5.02–5.96) vs HFworEF 4.7(4.5–5.2):P<0.05], (peak VE/CO2) was also significantly different and higher in HFworEF [HFrecEF 36.2(30.3–39.8) vs HFworEF 42.0(36.3–45.8):P<0.05] (minimum VE/CO2) was also significantly higher in HFworEF [HFrecEF 34.2(29.2–39.4) vs HFworEF 40.7(34.2–44.7):P<0.05].

Peak oxygen uptake/watt (peak VO2/w) was correlated with (ρ=0.547, P<0.01). In addition, peak oxygen uptake (peak VO2) (ρ=0.512, P<0.01) and peak carbon dioxide output (peak VCO2) (ρ=0.512, P<0.01) were also correlated. Peak VO2/w (β=0.492, P<0.01) was an independent predictor (R=0.492, F=13.72, P<0.01).

Conclusion

Patients with HF and recovered EF tended to be younger and more physically functional than those with worsened EF. In addition, peak VO2/w was an independent determinant of ΔLVEF.
Estrogen and the estrogen receptor in ZSF1 rats with heart failure with preserved ejection fraction
Authors: Buettner P , Werner S , Thiele H
Published: June 2024

Background

Heart failure with preserved ejection fraction (HFpEF) is more prevalent in women, so declining estrogen levels after menopause may be involved in genesis of the disease. Estrogen is cardio-protective, affecting blood pressure and vasodilatation and endothelial dysfunction is discussed as HFpEF pathomechanism. However, the potential connection between HFpEF and estrogen levels remains poorly understood. The well-established HFpEF ZSF1 rat model was used to analyze endothelial dysfunction, and a pronounced imbalance of the NO synthase substrates arginine and homoarginine was observed. Of note, estrogen levels in woman are directly and positively associated to homoarginine levels.

Purpose

We characterized serum estrogen levels and the expression of the estrogen receptor alpha (ERα) in the hearts of female ZSF1 HFpEF rats to investigate a possible contribution of estrogen signaling in HFpEF manifestation and to evaluate the suitability of this animal model in the context of estrogen and HFpEF.

Methods

In total, 12 obese ZSF1 rats with HFpEF (O-ZSF1) and 12 lean healthy ZSF1 rats (L-ZSF1) at 20 weeks of age and 5 animals of either phenotype aged 32 weeks were analyzed. Further, six O-ZSF1 rats were supplemented with homoarginine (hArg) when HFpEF was manifest and were observed up to 32 weeks of age. The manifestation of HFpEF was confirmed by echocardiography and determination of NT-proBNP by ELISA. Circulating estradiol (E2) in serum was determined using ELISA. Expression of the estrogen receptor alpha was determined by Western Blot analysis in the left ventricle (LV), septum and right ventricle (RV).

Results

Serum estradiol levels were similar in age-matched L-ZSF1 and O-ZSF1, but were ~2-fold increased at an age of 32 weeks compared to 20 weeks (p=0.002). The canonical ERα-66kDa was very weakly expressed in all tissues. ERα-45kDa expression in the LV was lower in O-ZSF1 at an age of 20 weeks (-46%, p=0.008) and at 32 weeks (-46%, p=0.002).

ERα-45kDa expression in LV was 2-fold higher than in septum and 5-fold higher than in RV in rats aged 20 weeks (p<0.001). In RV, no differences in ERα-45kDa expression were observed. Supplementation of O-ZSF1 with hArg reestablished the ERα-45kDa expression in the LV (p=0.005 vs. O-ZSF1 without supplementation).

Conclusion

The manifestation and progression of HFpEF in ZSF1 rats is accompanied by a decrease of the ERα-45kDa expression in the LV, whereas the RV is not affected. Supplementation with homoarginine normalizes ERα-45kDa expression. The ERα-45kDa isoform was found to suppress the transcriptional activity of the classical ERα-66kDa isoform and to be an acute regulator of endothelial NO synthase in response to estrogen. These results suggest that altered ERα expression in the LV may represent a novel pathomechanism in HFpEF. In combination with decreasing estrogen levels in woman, adverse consequences for NO production in the LV seem likely.
Early detection and management of heart failure and its associated risk factors: prospect for task shifting among healthcare workers
Authors: Sharma S K , Gautam U , Bhattarai U , Gautam A
Published: June 2024

Background

Cardiovascular diseases (CVDs) are a major cause of morbidity and mortality in low- and middle- income countries (LMICs) like Nepal. CVDs contribute to a major share, along with other NCDs, in causing poverty due to catastrophic health expenditures. There is a need for countries to identify context specific public health strategies and clinical interventions which are feasible, affordable and could act on the local disease burden.

Purpose

Heart failure remains a major cause of morbidity for CVDs. A community-based initiative was undertaken to identify undetected cases of heart failure and associated risk factors.

Methods

Purposively selected communities in Eastern Nepal for early detection of cardiovascular diseases. The initiative involved initial screening of the population for risk factors for CVDs like hypertension, diabetes and hyperlipidaemia by paramedical health workers at primary healthcare centres. Training was provided to identify complications and evaluate necessity of prompt referral based on clinical evaluation, blood glucose estimation (Fasting blood glucose, HbA1c), serum creatinine, lipid profile (HDL, LDL, TG, TC), and urine analysis (albumin, creatinine, ACR). The referrals to secondary or tertiary care centres were made considering need of immediate intervention or further diagnostic procedure like echocardiography. Echocardiography was performed as per the standard of care by a team of specialist physicians from a publicly funded tertiary level teaching institution at the primary health centres as a part of initiative. Patients requiring in-patient care were subsequently referred to higher institutions.

Results

Out of 4788 adult population screened, 240 (5%) individuals had clinical features suggestive of heart failure and were advised echocardiography. The mean age of heart failure cases was 62.1 years and almost half (49.2%) cases were male. Structural heart disease was detected among 151 cases of heart failure. The aetiology for heart failure comprised of dilated cardiomyopathy (16.3%), hypertensive heart disease (10.8%), ischaemic heart disease (7.5%), and valvular heart diseases (7.1%); while other factors included rheumatic heart disease (5%) and hypertrophic cardiomyopathy (2.9%). Diastolic dysfunction was noted among 43 (17.9%) cases of heart failure.

Conclusion

High burden of heart failure was identified in the screened communities. Early assessment of at-risk population can prevent progression, hospitalization, and death from heart failure. A protocol guided task shifting can be employed for timely detection of preventable aetiological factors and avoid late CVD complications.
Cardiovascular and haemodynamic changes in resistant hypertension: relation to blood pressure control in a longitudinal study
Authors: Alsharari R , Alsharari R , Thomas N , Lip G , Shantsila A
Published: June 2024

Introduction

Cardiovascular alterations and autonomic nervous abnormality exist in patients with resistant hypertension (RH) (1, 2). The effects of optimised antihypertensive treatment on cardiac, vascular and autonomic system are well-documented in essential hypertension. However, less is known about antihypertensive treatment optimisation on cardiovascular and autonomic function in the RH population.

Methods

Cardiac haemodynamics, strain function, vascular (brachial artery flow-mediated dilation, (FMD); pulse wave velocity, (PWV)) and autonomic functions (heart rate variability, (HRV)) were evaluated in patients with confirmed RH (n=17, mean age 58 years). The patients were followed up after eight weeks of optimised antihypertensive treatment to assess the changes in myocardial mechanics, vascular function and autonomic function.

Results

Following eight weeks of optimised antihypertensive treatment (Table 1), global longitudinal strain (GLS) and global circumferential strain (GCS) improved in RH group (GLS -17±1.5% vs. -19±2.8%, p=0.002; GCS -29.7±4.3% vs. -31.1±5.4%, p=0.04). FMD showed significant improvement (6.7±3 vs 5.3±3%, p=0.04). There were no significant changes in central systolic blood pressure (BP) (154 [139-193] mmHg vs. 177 [159-193] mmHg, p=0.11), central diastolic BP (82±20 mmHg vs 87±15 mmHg, p=0.28); PWV (9.3 [8-11] m/s vs. 9.8 [8-11] m/s, p=0.81); SDNN (p=0.16), rMSSD (p=0.28), pNN50 (p=0.42), and LF/HF (p=0.98), HRV (p=0.08), LF normalised (p=0.71), and log (LF/HF) (p=0.73).

Conclusion

After 8 weeks of antihypertensive treatment, cardiac strain function, endothelial function and 24h BP significantly improved compared with baseline in patients with true RH; however, arterial stiffness did not significantly change. Changes of cardiovascular and autonomic
Exercise cardiac magnetic resonance imaging across the lifespan
Authors: Hathorn B , Zamani S K , Zaha V G , Babb T , Hussain T , Haykowsky M J , Levine B D , Zia A , Grodin J L , Nelson M D
Published: June 2024

Introduction

Exercise cardiac magnetic resonance imaging (cMRI) offers several advantages over contemporary stress imaging approaches, including improved spatial resolution, free of ionizing radiation. With exercise cMRI becoming increasingly popular, more work is needed to better understand the hemodynamic response across the lifespan.

Purpose

To compare the cMRI response to exercise across the lifespan.

Methods

To accomplish this purpose, we leveraged data from several ongoing imaging studies in which healthy control participants completed exercise cMRI across at least two discrete workloads, ranging in intensity from mild to moderate. Imaging was performed using either a 1.5T or 3T Phillips MRI scanner. Exercise was performed using an MR compatible ergometer (Cardio Step, Ergospect GmbH, Innsbruck, Austria). Volumetric data were measured from a stack of short axis images spanning the length of the left ventricle from base to apex.

Results

Exercise cardiac magnetic resonance images were available from 48 participants, ranging in age from 10 to 81 years. On average, end-diastolic volume remained unchanged with exercise (73±14 vs. 75±15 vs. 74±14 mL, rest vs. mild vs moderate, p = 0.107), while end-systolic volume was reduced (27±7 vs. 25±7 vs. 23±6 mL, p = <.001), resulting in a modest increase in stroke volume (46±9 vs. 50±10 vs. 51±10 mL, p = <.001). To evaluate the influence of age, we compared the youngest participants (n = 13, 10-30 yrs) against the oldest participants (n = 18, 65-81yrs). As illustrated in Figure 1, while baseline volumes differed significantly with age, the relative response to exercise was similar between groups. Likewise, to evaluate the influence of sex, we compared male (n = 21) versus female (n = 27) participants. As illustrated in panels D-F, ventricular volumes were greater in men compared with women, but the exercise relative responses were similar.

Conclusions

Taken together, these data add to a growing body of literature highlighting the feasibility of exercise cardiac magnetic resonance imaging across the lifespan, and begin to define the normative response for future clinical comparison.
Feasibility of exercise cardiac magnetic resonance imaging for the concurrent assessment of oxygen uptake and its Fick determinants
Authors: Foulkes S , Thompson R B , Grenier J , Skow R , Sherrington R , Pituskin E , Nelson M D , La Gerche A , Haykowsky M J
Published: June 2024

Background

The concurrent assessment of oxygen uptake (VO2) and it’s Fick determinants (cardiac output x arterio-venous oxygen content difference [Qc x a-vO2diff]) provides key insights into the physiologic underpinnings of exercise intolerance across the spectrum of health and disease. However, the accurate assessment of the Fick-determinants is limited by the need for invasive measures of hemodynamics and arterial and venous O2 saturation and content (SaO2 and SvO2, and CaO2 and CvO2, respectively).

Purpose

To determine the feasibility of an exercise cardiac magnetic resonance imaging (ExCMR) approach that combines real-time free-breathing cardiac volumetric analysis with magnetic susceptometry-based oximetry to non-invasively quantify Qc, a-vO2diff, and VO2peak.

Methods

Bi-ventricular volumes and Qc were quantified from real-time, free-breathing steady-state free-precession imaging, whilst SvO2 in the inferior vena cava was quantified using magnetic susceptometry-based oximetry. These measures were combined with arterial oxygen saturation (from finger pulse oximetry) and haemoglobin concentration (from venous blood draw) to quantifyCaO2,and CvO2), a-vO2diff and VO2 in accordance with the Fick equation. Imaging was performed in 24 older women free of cardiovascular disease (68±4 yrs; VO2peak: 21.1±5.2 mL/kg/min) at rest, and during light- (Power output: 42±10W; 0-10 rating of perceived exertion [RPE]: 3.6±1.5) and moderate-intensity (Power output: 60±9W; RPE: 5.4±1.8) supine stepping exercise on an MRI compatible ergometer.

Results

Biventricular volumes and Qc were evaluable in all cases, whilst SVO2 could not be calculated in two participants (due to aliasing artefact or excessive motion during exercise). Consequently, VO2 and Fick determinants were assessed at rest and during exercise in 22 participants (92%). Resting VO2 was 223±77 mL/min (3.3±1.2 mL/kg/min) and increased linearly with increasing power output to 597±191 mL/min (8.9±2.5 mL/kg/min) at light-intensity and 819±225 mL/min (12.2±3.3 mL/kg/min) at moderate-intensity exercise (Fig 1A). The increase in VO2 from rest to exercise was the result of a progressive increase in Qc (Fig 1B), and a widening of a-vO2diff (Rest: 4.2±1.5vs Mod: 9.2±2.0 ml/dL) secondary to a decrease in CvO2 (Fig 1C; Rest: 13.4±1.5 mL/dL vs Mod: 8.3±2.0) and SvO2 (Rest: 73±7% vs Mod: 45±10%).

Conclusion

A combined non-invasive real-time cardiac and venous susceptometry ExCMR approach was feasible for measuring VO2 and its Fick determinants, and demonstrated normal physiologic responses to light and moderate intensity exercise. Further work is needed to determine the feasibility and utility of this approach during peak exercise in individuals with health and established disease.
Evolving information needs in cardiac rehabilitation 2.0
Authors: Tenbult - Van Limpt N C C W , Van Asten I , Brouwers R , Kemps H M C
Published: June 2024

Background

Despite individual preferences for the provision of health information, health education often follows a one-size-fits-all approach in cardiac rehabilitation (CR) programmes. This study evaluates changes in information needs of patients during the first twelve months after a cardiovascular event.

Methods

Quantitative data were collected from 259 patients who participated in CR because of symptomatic coronary artery disease. Information needs regarding nutrition, physical activity, smoking, psychosocial wellbeing and medication were assessed at baseline, three months, and twelve months using questionnaires. Furthermore, we conducted semi-structured interviews with 10 CR participants.

Results

Information needs were highest at baseline, decreased for all domains from baseline to three months of follow-up, and remained stable thereafter for most patients. No predictive factors were found for changes in information needs. After twelve months, 41% of patients still had a need for information regarding at least one of the 5 domains. Qualitative analyses supported these findings and highlighted individual preferences for health education, with timing of education as a critical element.

Conclusion

Baseline differences in information needs and their change over time indicate that there is a need for personalised provision of health information, as opposed to current one-size-fits-all health education programmes for patients with cardiovascular disease.