bluuebunny/crossref_metadata_2025 huggingface dataset:
Incident cardiovascular disease in women with type 1 or type 2 diabetes by history of hypertensive disorders of pregnancy
Authors: Timpka S , Pihlsgard M , Enhorning S , Mattsson K
Published: November 2023

Background

Whereas a history of a hypertensive disorder of pregnancy is associated with incident cardiovascular disease, the extent to which this is relevant for women with diagnosed diabetes is unknown.

Purpose

To analyse the risk of incident cardiovascular disease by a history of hypertensive disorders of pregnancy in women with diagnosed type 1 or type 2 diabetes and to examine the extent to which any associated risk was contingent on the level of clinical risk factor control.

Methods

By using nationwide register data (The Swedish Medical Birth Registry and The Swedish Diabetes Registry) between 1998 to 2021, we retrieved information on pregnancy history and cardiovascular disease (myocardial infarction, stroke, and heart failure), in all women with diabetes aged 18 to 69 years who had their first delivery registered. Risk of incident cardiovascular disease was estimated using Cox regression models. In further analyses, we categorized patients by number of risk factors (glycated hemoglobin and low-density lipoprotein cholesterol levels, albuminuria, smoking, and blood pressure) within target ranges.

Results

In total, 1804 (19.7%) of 9179 women with type 1 diabetes, and 5311 (10.6%) of 50,244 of women with type 2 diabetes, had their first delivery complicated by a hypertensive disorder of pregnancy. The risk for any cardiovascular disease event was higher in women with a previous hypertensive disorder of pregnancy in both diabetes groups: for type 1 diabetes the adjusted hazard ratio was 1.25 (95% confidence interval [CI]: 1.03 – 1.52) and for type 2 diabetes 1.20 (95% CI: 1.07 – 1.35). The risk decreased stepwise by improved risk factor profile: from a 7-fold and 4-fold higher risk in type 1 and type 2 diabetes patients, respectively, compared to women with diabetes but without a hypertensive disorder of pregnancy, to negligible risk differences (both groups) with adequate risk factor control.

Conclusions

A history of hypertensive disorder of pregnancy was associated with increased risk of incident cardiovascular disease in women with diabetes, but not in those with adequate risk factor control. Our findings emphasise the importance of preventive care in these patients, as well as a health care provider with access to information about reproductive history.
Change in hbA1c following treatment with and the short-term risk of major adverse cardiovascular outcomes
Authors: Zareini B , Soerensen K K S , Pedersen-Bjergaard U P B , Torp-Pedersen C T P
Published: November 2023

Background

Post-hoc analyses from glucagon-like peptide-1 receptor agonist (GLP1-RA) trial populations have shown a benefit on cardiovascular outcomes from reduction in glycated hemoglobin (HbA1c). It is of interest to see if this finding translates into a cohort of real-world GLP1-RA users.

Purpose

To study among new GLP1-RA users, how reaching a Hba1c below 53 mmol/mol six months after initiation affects the risk of major adverse cardiovascular outcomes (MACE), compared with a HbA1c above 53 mmol/mol.

Methods

We included new GLP1-RA users six months after initiation of treatment, with an available HbA1c value 0-6 months before and 0-6 months after GLP1-RA initiation, from the Danish registries between 2010-2022. HbA1c levels pre- and post-treatment were categorized as above 53 mmol/mol or below 53mmol/mol. The primary outcome was defined as a composite of myocardial infarction, stroke, and all-cause death. Patients were followed from index (6 months after GLP1-RA initiation) until the outcome, a total of 1 years, or end-of-study (31.12.21), whichever comes first. Crude 1-year risks were compared using the Kaplan Meier estimator, or the Aalen Johansen estimator if competing risk was present. The effect of HbA1c below 53 mmol/mol versus a HbA1c above 53 mmol/mol on MACE was estimated using a Cox regression model adjusted for age, sex, educational level, baseline comorbidities, type 2 diabetes duration, and baseline cardiovascular disease including heart failure. Hospitalization for hyperglycemia was also evaluated using a Cox regression.

Results

A total of 4,081 new GLP1-RA users (median age: 58y [IQR:50;66], 52% males) were included, 3,090 had a post-treatment HbA1c below 53 mmol/mol and 991 had a post-treatment Hba1c above 53 mmol/mol. During a median follow-up of 1 year (IQR:1.0,1.0), the crude 1-year risk of MACE in persons with a HbA1c below 53 mmol/mol was 6.4% (95% confidence interval [CI]: 5.5;7.2) and 9.5% (7.7;11.3) in persons with HbA1c above 53 mmol/mol, yielding a hazard rate of 0.69 (0.54;0.88). No interaction between pre-and post HbA1c was found (p=0.59). The hazard rate of hospitalization for hypoglycemia was 0.76 (0.45:1.23) for persons reaching HbA1c level below 53 mmol/mol compared to patients with a HbA1c above 53 mmol/mol, with no interaction between pre- and post HbA1c observed (p =0.052).

Conclusion

A HbA1c level below 53 mmol/mol, among GLP1-RA users reduced the 1-year rate of MACE and did not significantly increase the 1-year rate of hospitalization for hypoglycemia.
Impact of the coronary artery calcium score on the cardiovascular preventive management of asymptomatic patients with diabetes
Authors: Boukhris M , Macia A , Sow M A , Boulogne C , Salle L , Aboyans V
Published: November 2023

Background

Coronary artery calcium (CAC) scoring with non-contrast computed tomography is increasingly used for cardiovascular risk stratification and provides a measure of coronary atherosclerotic burden of particular interest for risk stratification in patients with diabetes. We aimed to assess the impact of CAC on the management of asymptomatic patients with diabetes.

Methods

We studied consecutive asymptomatic patients who underwent CAC for cardiovascular risk stratification for diabetes, from 01/2014 to 12/2020. The study population was subdivided according to the CAC score into 4 subgroups: CAC=0, CAC 1-99, CAC 100-399 and CAC ≥400. We focused on the prescription of aspirin, lipid-lowering therapy (LLT) and glucagon-like peptide-1 receptor agonists (GLP1-RA) before and within 6 months after CAC estimation.

Results

We studied 371 patients (mean age 59.9 ± 10.6 years, 49.3% males). The study population was subdivided according to CAC as follows: CAC = 0 (N=90, 24.3%); CAC 1-99 (N=111, 29.9%); CAC 100-399 (N=70, 18.9%); CAC ≥400 (N=100, 26.9%). Patients with higher CAC (100-399 and CAC ≥400) were older, more often males and had higher prevalence of hypertension and dyslipidaemia. At baseline, the prescription of aspirin and lipid-lowering drugs was statistically higher in presence of CAC>100 (all p<0.001) while no difference was found regarding GLP1-RA prescription among the 4 subgroups (Figure). After CAC estimation, we found no modification in prescription of aspirin in patients with CAC=0 and CAC 1-99. Conversely, aspirin prescription significantly increased from 27.1% to 41.4% and from 40 to 56% in CAC 100-399 and CAC≥400 (p=0.002 and p<0.001), respectively. Similarly, significant changes (initiation or intensification) of LLT were only observed in presence of CAC 100-399 and CAC≥400 ([8.6% and 7.1%; p=0.031] and [19% and 20%; p<0.001], respectively) (Figure). No significant change was found regarding GLP1-RA prescription before and after CAC estimation in the 4 subgroups.

Conclusion

CAC represents an interesting tool to stratify asymptomatic patients with diabetes but there is room for improvement in preventive management of those stratified at the highest risk levels. Important efforts should be made to introduce the use of GLP1-RAs among cardiologists.Figure
Metabolic syndrome and long-term heart rate variability: a systematic review and meta-analysis
Authors: Ortiz-Guzman J E , Molla-Casanova S , Arias-Mutis O J , Calvo C , Bizy A , Such-Miquel L , Genoves P , Serra P , Chorro F J , Zarzoso M
Published: November 2023

Introduction

Metabolic syndrome (MS) is defined as the convergence over time of a group of non-communicable chronic diseases (hypertension, diabetes, dyslipidemia, obesity). There is agreement that MS is related to pathological changes in the behavior of the autonomic nervous system (ANS). Heart rate variability (HRV) is a very useful tool for assessing autonomous behavior, widely used and that could be useful for the diagnosis and monitoring of MS. However, to date, there are no quantitative analyses using meta-analysis (MA) that have addressed the changes that MS causes on the ANS. Therefore, the objective of this systematic review and MA is to evaluate changes in long-term HRV in patients with MS, in order to characterize the cardiac autonomic dysfunction induced by this pathological condition and the most frequently reported explanatory variables.

Methods

We searched PubMed, Web of Science and Scopus electronic databases for original works with long-term HRV recordings (24-h holter) that compared people with MS (MS+) versus healthy people as a control group (MS-). The search was carried out between June 25th, 2022 and September 1st, 2022. In the databases selected, the terms used were "metabolic syndrome" linked to "heart rate variability" (HRV), "cardiac autonomic control", "cardiac autonomic function", or "cardiac autonomic modulation". This systematic review and MA was performed according with PRISMA guidelines and registered at the International Prospective Register of Systematic Reviews (CRD42022358975). Results are reported as standard mean difference [95% CI].

Results

Thirteen articles were included in the qualitative synthesis and seven of them met required criteria to be included in the MA. MS decreased SDNN (-0.33 [-0.57, -0.09], p=0.008), LF (-0.40 [-0.51, -0.28], p<0.0001), VLF (-0.35 [-0.50, -0.21], p p<0.0001)) and TP (-0.24 [-0.43, -0.05], p=0.01). The MA did not find significant differences in rMSSD (-0.09 [-0.31, 0.13], p=0.41), HF (-0.29 [-0.61, 0.03], p=0.07) and LF/HF (-0.04 [-0.45, 0.36], p=0.84). No article reported information by gender. In the case of the non-linear variables, the information reported was not enough to carry out the MA, but the qualitative analyses showed no change in SD1 of the Poincare plot and a decrease in the multiscale entropy. For the SD2 of the Poincare plot and alfa-1 of the detrended fluctuation analyses, the results are not conclusive.

Conclusions

The analysis of HRV (time-domain) in long recording periods showed that patients with MS have lower values in the SDNN and no significant changes in rMSSD. Regarding the frequency domain analysis, we found that MS induced a significant decrease in LF, VLF and TP. The MA did not show changes in HF and LF/HF, and quantitative analyses of non-linear parameters could not be performed.
Outcomes of diabetic patients with acute coronary syndromes treated with aspirin in primary prevention
Authors: Costa H , Espirito Santo M , Fernandes R , Carvalho D , Bispo J , Guedes J , Azevedo P , Vinhas H , Mimoso J , Jesus I
Published: November 2023

Introduction

The use of aspirin in primary prevention (PP) remains a matter of international debate. In type 2 diabetes mellitus (DM2) patients with high/very high cardiovascular (CV) risk, low dose aspirin may be considered for PP (class IIb, evidence level A) in european guidelines in the absence of hemorrhagic contraindication.

Objectives

Our aim was to analyze in-hospital and one year follow-up (FU) outcomes of acute coronary syndrome (ACS) DM2 patients without previous atherosclerotic CV disease (ASCVD) treated with vs without aspirin in primary prevention.

Methods

A retrospective analysis was carried out of DM2 patients without established ASCVD admitted with ACS included in the Portuguese Registry of ACS between 2010-2021. Patients were divided in two groups regarding the use of aspirin in primary prevention (with-AG and without-NAG). Composite primary outcome (re-infarction, heart failure, shock, death – in-hospital) and secondary outcomes (one-year all-cause mortality and mortality/rehospitalization) were compared in both groups. Independent predictors of primary outcome were assessed by multivariate logistic regression. Survival analysis and cox regression were used to compare and identify predictors of secondary outcomes. P value < 0.05 indicates statistical significance.

Results

A total of 4517 patients were analyzed, mean age 68±12 years, 64.8% male. AG showed higher rates of hypertension (89.9%, p<0.001), dyslipidemia (74.1%, p<0.001), history of heart failure (9.2%, p<0.001), valvular disease (3.9%, p=0.002) and chronic renal disease (12.3%, p<0.001). STEMI presentation was more frequent in NAG (48%, p<0.001). Multivessel disease (mainly three vessels disease) was more frequent in AG (32.7%, p<0.001), but anterior descendent (AD) as culprit artery was more common in NAG (40.3%, p=0.013). Both groups had no difference in major hemorrhage occurrence. Primary outcome was more frequent in AG (18.6%, p=0.034). One-year all-cause mortality and mortality/rehospitalization were higher in AG (9.90%, p=0.004 and 32.9%, p=0.017, survival analysis). Independent predictors of primary outcome were aspirin in primary prevention (OR 1.38, p=0.026), age (OR 1.59, p<0.001), valvular disease (OR 4.46, p<0.001), STEMI at presentation (OR 2.20, p<0.001), LVEF <40% (OR 4.40, p<0.001) and Killip-Kimball class > I (OR 12.9, p<0.001). Aspirin in primary prevention (HR 1.84, p=0.004), chronic lung disease (HR 5.68, p<0.001), and Killip-Kimball class > I (HR 3.27, p<0.001) were predictors of one-year all-cause mortality.

Conclusion

DM2 patients with ACS treated with aspirin in primary prevention had worst in-hospital and one-year FU outcomes. Although with higher rates of three vessels disease, PP with aspirin showed less AD disease and STEMI presentation, with similar major clinical hemorrhage.
Effect of sodium-glucose co-transporter inhibitors on arterial stiffness in patients with type 2 diabetes mellitus
Authors: Szigeti J , Bukva M , Gaszner B
Published: November 2023

Introduction

Selective sodium-glucose co-transporter 2 inhibitors (SGLT2i) reduce cardiovascular morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). In addition to glucose homeostasis the impaired arterial stiffness may participate in this morbidity and mortality.

Purpose

The aim of this study was to investigate the effect of administration of SGLT2i therapy on arterial stiffness parameters, including aortic pulse wave velocity (PWV) and central systolic blood pressure (SBPao), which have significant prognostic value for predicting cardiovascular events.

Methods

Our prospective, observational study included 40 patients with T2DM (mean age: 60.3±9.9 years, 24 males). Biochemical and arterial stiffness parameters were analysed before starting SGLT2i therapy (14 patients on dapagliflozin, 25 patients on empagliflozin, 1 patient on ertugliflozin), at 3, 6 months and an average of 3.3±1.3 years follow-up period. Arterial stiffness parameters were determined using an invasively validated oscillometric based Arteriograph (AG) method. Changes in the variables and their interrelation was analysed by repeated data ANOVA and multivariate linear regression.

Results

Significant decrease in PWV and HgbA1c were observed 3 months after the initiation of SGLT2i therapy (PWV: 10.68±1.35 m/s vs. 10.05±1.40 m/s and HgbA1c: 7.86±0.55 vs. 6.83±0.66 %, p<0,05) and this long-term effect continued during the 3.3-years follow-up period (PWV: 9.96±1.25 m/s and HgbA1c: 7.19±0.81 %, p<0,005, Figure 1). Pearson's correlation analysis and multivariate linear regression analysis showed no association between decreased PWV and BMI, brachial diastolic blood pressure (DBPb) while significant, but weak correlation was observed with HgbA1c and brachial systolic blood pressure (SBPb) (r=0.22-0.26, p<0.05, Figure 2). SBPao results showed non-significant decrease and a subsequent non-significant long-term increase comparing to baseline during the 3.3 years follow-up.

Conclusion

Short and long-term SGLT2i therapy in T2DM significantly improved PWV values and this effect is independent of changes in SBPao. All these findings emphasize the clinical relevance of arterial stiffness as a biomarker in the SGLT2i induced beneficial effect on the vasculature, however further clarification, long-term evaluation needed to define the role of PWV in the prediction of cardiovascular events.Figure 1Figure 2
Exercise capacity of the patients after cardiac surgery with special reference to left atrium incision
Authors: Kanazawa M , Miura M , Sawada S , Funaki T , Anzai J , Uchimura K , Komaru K , Kagaya Y , Saito H , Sato K , Kondo M , Kawatsu S , Endo H , Oda K , Nakamura A
Published: November 2023

Background

Chronotropic incompetence (CI) is sometimes observed during exercise in patients who underwent cardiac surgery, however, little is known which factors affect to the incidence of CI and exercise capacity of those patients.

Purpose

We hypothesized that the incidence of CI is higher in patients with left atrium incision (LAI) as compared with those without LAI, which is caused by impairment of cardiac sympathetic nerves by LAI. The purpose of this study is to elucidate whether LAI causes CI, and if so, to analyze which factor determine the exercise capacity of the patients with LAI.

Methods

We performed cardiopulmonary exercise testing in total 157 patients who had undergone elective cardiac operation (46 patients with LAI, 111 patients without LAI). We analyzed chronotropic response index (CRI), parameters of exercise capacity, echocardiography, and blood hemoglobin concentration (Hb).

Results

The value of CRI was significantly reduced in the patients with LAI as compared with those without LAI (0.24±0.22 vs. 0.45±0.17, respectively, p<0.001). Exercise capacity such as peak oxygen uptake (peak VO2), anaerobic threshold showed no significant difference between two groups. In patients with LAI, peak VO2 showed significant correlations between peak oxygen pulse (peak VO2/HR; r=0.34, p<0.05), Hb (r=0.43, p<0.005) and left atrium dimension (LAD) measured by echocardiography (r=-0.56, p<0.001).

Conclusions

The present study demonstrated that higher incidence of CI was observed in patients with LAI as compared with those without LAI. Moreover, peak VO2 of patients with LAI showed significant correlations with peak VO2/HR, Hb and LAD. These results suggest that 1) LAI may impairs cardiac sympathetic nerves and causes CI, 2) peak VO2/HR and its component Hb are important factors which determine exercise capacity of patients with CI, 3) LAD which indicates left atrial function may also affect exercise capacity of patients with CI.
Layer-specific circumferential strain using fast strain-encoded cardiac magnetic resonance imaging in acute myocardial injury - a prospective study of diagnostic and prognostic accuracy
Authors: Weberling L D , Albert D , Ochs A , Ochs M , Siry D , Salatzki J , Giannitsis E , Frey N , Riffel J , Andre F
Published: November 2023

Background

In patients presenting acutely with chest pain or shortness of breath, an acute myocardial injury diagnosed through modern troponin assays is common. Yet, a differential diagnosis is often demanding and must weigh the timely treatment of an ischemic cause against the risk of an invasive procedure without intervention. Modern cardiac magnetic resonance (CMR) strain sequences such as fast-SENC (fSENC) might support clinical decision-making in identifying predictors of myocardial dysfunction (1). Furthermore, their resolution should be able to differentiate epicardial from endocardial function impairment. This study sought to assess a layer-specific strain approach's diagnostic and prognostic accuracy using circumferential strain.

Methods

In this board-approved prospective observational study, patients from the emergency department fulfilling rule-in criteria for NSTEMI according to current guidelines received an ultra-fast fSENC CMR independently of standard care (2,3). fSENC was acquired in a single heartbeat acquisition, and global/segmental circumferential strain (GCS) as well as dysfunctional segments were measured. GCS was measured in two layers (epicardial/endocardial = GCSepi/GCSendo). Patients were followed up for two years for the occurrence of cardiovascular death and divided into groups according to their final diagnosis upon discharge.

Results

64 patients (51 male) were included, consisting of 25 with NSTEMI, 16 with myocarditis and 23 with other causes of myocardial injury (OMI). GCS was reduced in all patients but with no significant difference between groups (NSTEMI: -14.3±3.8; myocarditis: 15.9±4.6; OMI: 13.9±3.8; p>0.05). GCSendo (-16.3±4.0) was generally lower than GCSepi (-12.5±3.1) in all groups (p < 0.001), but did not differ between groups (p>0.05). Overall, 2-year mortality was low (4.7%). Nevertheless, GCSendo predicted outcome (p = 0.03), unlike GCS. 2-year survival in patients with normal GCS (>-17%) and ≤5 dysfunctional segments was 100.0%.

Conclusions

Layer-specific circumferential strain is a significant predictor of prognosis. Endo- and epicardial strain is reduced in all types of myocardial injury. For the identification of underlying pathology however, layer-specific circumferential strain did not add incremental value.
Echocardiographic deformation imaging as a substitute for cardiac magnetic resonance imaging in arrhythmogenic right ventricular cardiomyopathy risk prediction
Authors: Kirkels F P , Rootwelt-Norberg C , Bosman L P , Aabel E W , Muller S , Taha K , Van Osta N , Lie Ø H , Asselbergs F W , Lumens J , Te Riele A S J M , Hasselberg N E , Cramer M J , Haugaa K H , Teske A J
Published: November 2023

Background & aims

Echocardiography has a central role in diagnosis and follow-up of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). It is however not included in the risk calculator for ventricular arrhythmia (VA) which was recently developed and validate, since traditional echo parameters were outperformed by RV ejection fraction (RVEF) measured by CMR. CMR is however not as widely available as echocardiography. We aimed to investigate whether echocardiographic RV deformation imaging could be used as a substitute for RVEF by CMR in arrhythmic risk prediction in ARVC.

Methods & results

From two referral centres, 150 consecutive patients with a definite ARVC diagnosis, no prior sustained VA and an echocardiogram suitable for deformation analysis were included (aged 41 ± 17 years, 50% female). During a median follow-up of 6.3 (IQR 3.1-9.8) years, 37 (25%) experienced a first-time sustained VA. The current ARVC risk calculator, including RVEF by CMR performed well in this cohort, with an optimism corrected C-statistic of 0.77 (95% CI 0.71 – 0.84). When RVEF was replaced by RV free wall longitudinal strain, the latter was an independent predictor (p = 0.005) and C-statistic changed to 0.80 (95% CI 0.74 – 0.86). The model including RV deformation imaging reduced the Akaike information criterion by >2.

Conclusions

This study showed that echocardiographic RV deformation imaging is able to replace RVEF by CMR in ARVC risk prediction without losing discriminative power. In clinical use, repeated yearly risk assessment using echocardiography could be alternated with a CMR every few years.
Post-coronavirus disease-19: the impact of cardiopulmonary rehabilitation on arterial stiffness, left ventricular deformation, and ventricular-arterial coupling
Authors: Gounaridi M , Vontetsianos A , Oikonomou E , Theofilis P , Chynkiamis N , Lampsas S , Anastasiou A , Papamikroulis G A , Kalogeras K , Pesiridis T , Vavuranakis M , Bakakos P , Koulouris N , Siasos G
Published: November 2023

Introduction

Although coronavirus disease-19 (COVID-19) is a primarily a respiratory disease, impairment of cardiovascular function has been documented, even in the post-acute phase. Cardiopulmonary rehabilitation could represent an appealing approach in the management of cardiovascular sequelae of post-COVID-19, which may affect arterial and left ventricular function, ultimately influencing ventricular-arterial coupling (VAC).

Purpose

In this study, we assess the impact of a post-acute COVID-19 rehabilitation program on arterial stiffness, left ventricular deformation, and VAC.

Methods

We enrolled 60 convalescent patients from COVID-19 and one-month post-acute disease were randomized at 1:1 ratio in a 3-month cardiopulmonary rehabilitation program (study group) or not (control group). The levels of pro-inflammatory interleukin-1β (IL-1β) were determined. Arterial stiffness was evaluated by carotid-femoral Pulse wave velocity (cf-PWV) at 1 month and at 4 months post-acute disease. Transthoracic echocardiography was performed, and left ventricular global longitudinal strain (LV-GLS) was estimated. Finally, the ratio of cf-PWV/LV-GLS was calculated as an index of VAC.

Results

There were no significant differences in major risk factors across the studied groups (age, sex, body mass index, smoking, hypertension, diabetes mellitus, dyslipidemia). Moreover, patients across the study groups did not differ regarding the levels of IL-1β. Although cf-PWV was similar in the study and the control group at baseline, it was improved only in the study group (8.2±1.3m/sec vs. 6.6±1.0m/sec, p<0.001) but not in the control group (8.9±1.8m/sec vs. 8.8±1.9m/sec, p=0.74). Similarly, for GLS, no differences were noted at baseline. However, the study group exhibited a significant improvement during the study (-19.6±2.0% vs. -21.3±1.9%, p<0.001), while no changes were observed in the control group (-18.7±2.9% vs. -18.3±2.1%, p=0.15). Finally, VAC was significantly ameliorated only in patients receiving cardiopulmonary rehabilitation (-0.43±0.11m/s% vs. -0.31±0.06m/s%, p<0.001). When individuals undergoing cardiopulmonary rehabilitation were stratified according to median baseline IL-1β levels, those presenting with lower concentrations experienced a significant benefit in ΔVAC (IL-1β<8.4pg/ml: 0.14±0.08m/s% vs. IL-1β≥8.4pg/ml: 0.09±0.05m/s%, p=0.04).

Conclusion

A 3-month cardiopulmonary rehabilitation program following the acute phase of COVID-19 accelerates the recovering of arterial and ventricular function, especially in individuals with a lower baseline inflammatory burden.
Cardiac remodelling in male and female athletes: An MRI assessment of cardiac size and its impact on cardiorespiratory fitness
Authors: Rowe S , Janssens K , Mitchell A , D'ambrosio P , Fahy L , Spencer L , Heidbuchel H , Claessen G , La Gerche A
Published: November 2023

Background

Cardiac remodelling occurs in response to endurance training in elite athletes. Previous small studies have shown relationships between cardiac size and cardiorespiratory fitness (CRF) using echocardiography, but few studies have assessed the relationship on a larger scale with female athletes and cardiac MRI.

Aim

To examine the relationship between CRF and MRI measures of cardiac size and function in male and female endurance athletes.

Methods

183 male and 64 female elite endurance athletes aged > 16 years underwent assessment of biventricular size and function using cardiac MRI and CRF (as measured by VO2peak). The association between biventricular size, function and VO2peak was assessed using univariate linear regression and multivariate regression adjusting for age, BMI and systolic blood pressure.

Results

There was a strong correlation between VO2peak and LVEDV and RVEDV in both male and female athletes (females r = 0.81 and r = 0.82 respectively, males r = 0.76 and 0.67, p < 0.001). There was no significant correlation between VO2peak and LV or RV EF in female athletes, and there was a weak association in males (LVEF r= 0.15, p=0.04, RVEF r = 0.27, p< 0.001). On multivariate analysis, LVEDV and LV mass were independent predictors in males and explained 78% of the variance in VO2peak (b = 0.41 and 0.18 respectively, p= < 0.001) and only LVEDV was an independent predictor in females explaining 64% of VO2peak variance (b =0.67, p < 0.001).

Conclusion

CRF as measured by VO2peak is determined by cardiac size as opposed to function in both male and female elite endurance athletes. This study is the largest assessment of endurance athletes with cardiac MRI and emphasises the role of cardiac volumes in predicting exercise capacity in the population.
Advanced echocardiographic assessment in wild-type and hereditary transthyretin cardiac amyloidosis: the role of myocardial work and left atrial strain
Authors: Trimarchi G , Teresi L , Perna A , Zito C , De Gregorio C , Carerj S , Di Bella G
Published: November 2023

Introduction

Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive infiltrative cardiomyopathy caused by extracellular deposition of insoluble transthyretin (TTR) amyloid fibrils in the myocardium.

ATTR-CA can be classified as wild type ATTR-CA (ATTRwt-CA), caused by age-related misfolding of TTR, and hereditary ATTR-CA (ATTRv-CA), an autosomal dominant disease in which gene mutations lead to changes in TTR protein. Speckle tracking echocardiography and myocardial work (MW) analysis can better characterize left ventricular and left atrial (LA) function in ATTRwt-CA and in ATTRv-CA.

Aims

to investigate differences in myocardial work and left atrial strain parameters between patients affected by ATTRwt-CA and patients affected by ATTRv-CA.

Material and methods

40 male patients affected by ATTR-CA were prospectively enrolled, distinguishing between 20 patients with ATTRwt-CA (76 ± 7 yrs) and 20 patients with ATTRv-CA (74 ± 6 yrs) (1 pts with Val30Met mutation, 6 pts with Val122Ile mutation; 8 pts with Glu89Gln mutation; 5 pts with Phe64Leu mutation). All underwent a transthoracic echcoardiogram to calculate global longitudinal strain (GLS), MW parameters and LA strain.

Results

No difference was found between the two groups (ATTRwt-CA vs ATTRv-CA) for what regards age (76 ± 7 vs 74 ± 6 yrs, p = 0,06), BMI (27,2 ± 2,2 vs 26,6 kg/mq; p = 0,3), BSA (1,8 ± 0,2 vs 1,7 ± 0,1 mq; p = 0,1) and left ventricle mass index (LVMi) (183,41 ± 45,2 vs 148,5 ± 47,3 g/mq; p = 0,07). In ATTRwt-CA patients, ejection fraction (EF) is lower, but without any statistical significance (50 ± 6,9 vs 54 ± 6,4 %, p = 0,06). On the other hand, in ATTRwt-CA patients GLS is significantly higher than in ATTRv-CA patients (-9,8 ± 3,2 vs -15,0 ± 2,5 %; p < 0,0001). Global work index (GWI) (853,6 ± 367,6 vs 1431,6 ± 318,3 mmHg%; p < 0,0001), global constructive work (GCW) (1169 ± 303 vs 1726,5 ± 310,3 mmHg %; p < 0,0001) and global work efficiency (GWE) (83,2 ± 9,4 vs 89 ± 5,3 %; p = 0,04) are significantly reduced in ATTRwt-CA in comparison with ATTRv-CA. For what regards atrial function, in ATTwt-CA patients LA reservoir (9,7 ± 3,7 vs 17,6 ± 7,5 %; p = 0,004) and LA ejection fraction (LAFE) (28,9 ± 13,6 vs 46,2 ± 8,9; p = 0,02) are reduced, while LA booster is higher (-2,5 ± 3,1 vs -10 ± 4,7 %; p < 0, 0001).

Conclusion

In patients with ATTR-CA advanced echocardiographic assessment can better differentiate left atrial and left ventricular involvement in ATTRwt-CA versus ATTRv-CA.TablesGraphs
Inferior T wave inversion in young individuals: should we be worried
Authors: Abela M , Yamagata K , Fleri Soler J , Camilleri W , Felice T , Sammut M A , Grech V
Published: November 2023

Introduction

Cardiac screening in young individuals may identify individuals at risk of sudden cardiac death (SCD). The ECG is crucial to identify individuals who harbour pre-clinical/clinical phenotypes. T wave inversion (TWI) are often found at screening. Outcomes and clinical implications of individuals with TWI are dependent on demographic variables and territory involved. However, the implications of inferior TWI in young individuals are poorly understood.

Aim

This study was carried out to ascertain prevalence and outcomes of adolescent individuals with inferior TWI.

Methodology

Cardiac screening (questionnaire/ECG) was carried out in 2672 students (14-17 years) attending year 11 classes during the 2017/2018 scholastic year (3991 eligible citizens) as part of a national cardiac screening program (BEAT-IT). Cases with contiguous TWI in ≥2 leads in the inferior (II/III/aVF) leads were included (isolated and those extending into the lateral leads). ECGs with inferior TWI were repeated (in shallow breathing) to ensure appropriate lead placement. An athlete was defined as an individual who participated in organized sport and/or engaged in >4 hours of physical activity weekly.

Results

2672 adolescents gave consent (mean, 50.4% were female). 1042 (39.0%) were athletes. Most were of Caucasian ethnicity (95.8%). Inferior TWI were present in 15 (0.6%), all were Caucasian and 9 of these were non-athletic individuals. 4 had symptoms (26.7%) and 1 (6.7%) had a positive family history [HCM].

Inferior TWI (n=15) was more frequent in females (n=13 [1.0%] vs n=2 [0.2%] vs 0.2%, p=0.037). The prevalence was similar in athletes and non-athletes (n=6 [0.6%] vs n=9 [0.6%], p=0.858). 11 (0.4%) had isolated inferior TWI. Only 1 (9.1%) had TWI involving all three inferior leads. Another 4 (0.1%) had inferior TWI extending into the lateral leads. Borderline/other pathological ECG patterns were as likely in both groups (p=0.770). Two participants with inferior TWI (22.2%) had other abnormal ECG patterns (P mitrale [n=1] and ST segment depression [n=2]). One participant (24.0%) from the inferolateral TWI group had ST segment depression.

Two patients (13.3% of all participants with inferior TWI) were given a clinical diagnosis (one HCM [inferolateral TWI] and one MVP [inferior TWI]). Both were asymptomatic. The yield was similar for inferolateral (25.0%) and isolated inferior (11.1%) TWI [2 leads] (p=0.523).

Most participants with isolated inferior TWI (n=5, 55.6%) were discharged after referral vs 0% in those with inferolateral TWI. Some (n=6) are under surveillance (mean±SD 1897±9 days). Two refused further evaluation.

Conclusion

Inferior TWI is an infrequent finding in young individuals and may be a marker of pathology in a small group of subjects. The number of leads with TWI (inferior [2 leads], inferior [3 leads] and inferolateral TWI) did not influence the diagnostic yield. Further evaluation is warranted in such cases.
Fragmented QRS complexes in veteran athletes
Authors: Fyyaz S , Ujeyl A , Al-Turaihi S , Papatheodorou E , Merghani A , Chatrath N , Parry-Williams G , Bhatia R , Bulleros P , Fanton Z , Tome-Esteban M , Papadakis M , Alfakih K , Moon J C , Sharma S
Published: November 2023

Background

QRS fragmentation (fQRS), characterized by multiple peaks within the QRS, is considered an adverse risk marker that may indicate underlying myocardial fibrosis and has been implicated in cardiomyopathies. The presence of fQRS is often noted in pre-participation screening of athletes. In this study, we aimed to investigate the prevalence and clinical significance of fQRS in a cohort of ostensibly fit veteran athletes (VA).

Methods

We recruited 314 predominantly Caucasian VA's with a history of endurance exercise and no traditional risk factors for coronary artery disease. Participants underwent a 12-lead electrocardiogram, cardiopulmonary exercise testing (CPET), 24-hour Holter monitoring, and cardiac magnetic resonance imaging (CMR). fQRS was categorized as >2 consecutive leads using established criteria (1).

Results

fQRS in 2 or more contiguous leads was identified in 12% of VA's. The presence of fQRS was more prevalent in males and increased with age (p < 0.05). There were no significant differences in ECG conduction indices. When CMR parameters were considered, the presence of fQRS was associated with increased left ventricular (LV) mass index and increased right ventricular (RV) function. There was no relationship with the presence of late gadolinium enhancement. Athletes with fQRS achieved a significantly lower predicted peak VO2 and trended towards lower peak resistance on CPET. No relationship was observed with total ventricular premature beat count or the presence of complex ectopy on 24-hour Holter monitoring.

Conclusions

fQRS in 2 or more contiguous leads is commonly present amongst male Caucasian VA’s, and its prevalance increases with age. It is associated with greater LV mass and increased RV ejection fraction. Athletes with fQRS may achieve a lower percentage predicted VO2 max compared to those without. Furthermore, FQRS did not predict late gadolinium enhancement, increased VPB count or complex ectopy.Comparing VAs with FQRSQRS-fragmentation patterns (Das et al)
A change in risk assessment for treatment with statins in patients with familial hypercholesteremia and Gilbert's syndrome
Authors: Brown D
Published: November 2023

Background

Gilbert’s Syndrome (GS) is a heredity disease that mildly increases serum unconjugated bilirubin. GS is usually asymptomatic and considered to be benign. It is postulated to be present in 10-16% of the population but the exact incidence is unknown since it is usually an incidental finding that goes under diagnosed and under-reported. Conversely, heterozygous familial (FH) hypercholesteremia, estimated to be present in 1 in 250, is responsible for significant morbidity and mortality and never ignored. Patients with FH are especially at risk for atherosclerotic cardiovascular disease (ASCVD) due to the cumulative effect of high cholesterol starting at a young age. Recent studies report that mildly elevated serum bilirubin (especially the UGT1A1*28 allele), in patients with concurrent GS and FH, is protective against ASCVD. The deleterious effect of one liver mutation may be offset by the beneficial effect of the second mutation resulting in an inverse relationship between the two diseases. Due to that association, statins may be contraindicated in patients with concurrent FH and GH because they are more susceptible to toxicity and adverse events.

Purpose

Patients with coexisting FH and GS are postulated to have innate cardioprotection and therefore, treatment with statins may be unnecessary and should be avoided due to an increased risk for drug toxicity and intolerable adverse events.

Methods

This was a systematic review of 31 peer-reviewed publications identified by using databases: EBSCO Discovery, World Cat, PubMed, OVID, Google Scholar, Springer, Theime, Elsevier, Science Direct, and Cochrane Collaboration. Publications ranged from 2006-2021 and included subjects ages 18-80 and bench studies using Gunn rats. The quality of evidence was analyzed and evaluated.

Results

Recent retrospective and prospective studies indicate that mildly elevated serum bilirubin, in patients with concurrent GS and FH, is protective against ASCVD. Consequently, this population may not need statin therapy and may be more susceptible to statin toxicity and intolerable adverse events.

Conclusion

GS is postulated be innately cardioprotective for ASCVD. The identification of patients with concurrent FH and GS is not mainstream and is overdue. These are not uncommon diseases and their co-existence has been underestimated because GS is considered benign and underreported. The potential exists for patients with FH and silent Gilbert’s Syndrome to be overtreated or unnecessarily treated with statins. Medications that inhibit UDP-glucuronosyltranferase-enzyme activity and UG1A1 mediated glucuronidation may lead to toxicity and intolerable adverse events. Studies have shown an adverse relationship between statins and increased bilirubin. It is recommended that both FH and Gilbert’s Syndrome be routinely screened for in pediatric and adult populations, especially prior to statin prescribing.
Cardiovascular disease screening in homeless individuals-a feasibility study
Authors: Banerjee A , Surey J , Veitch M , Rogers S , Al-Shakarchi N , Burridge S , Leonard M , Munday S , Story A
Published: November 2023

Background

The risk and burden of cardiovascular disease (CVD) are higher in homeless than in housed individuals, yet population-level CVD screening largely excludes homeless individuals.

Purpose

(i)To investigate feasibility of dedicated mobile CVD screening for homeless individuals; and (ii)To estimate prevalence of risk factors and burden of CVD

Methods

With patients, health professionals and researchers, we co-developed and implemented a 15-minute CVD assessment for homeless individuals as an add-on service to the Find&Treat service (a peer-led, multi-disciplinary outreach team across London) during scheduled, routine visits to homeless hostels. We included a questionnaire (demographic, past medical history and symptom data) as well as clinical assessment (blood pressure, ABPI, cholesterol, HDL, HDL ratio, glucose, HbA1c and mobile ECG to detect atrial fibrillation, AF).

Results

Among 656 individuals screened in 75 routine visits between May 2019 and January 2023, we recruited 524 (79.9%) individuals. Mean age was 47 (SD 13.1) years (range 18-87). Male gender (79%) and white ethnicity (55%) were more common. Current or previous smoking (79%), previous CVD (stroke, myocardial infarction, or peripheral arterial disease) (15%) and family history of heart attack in a 1st degree relative<60 years (27%) were common.

Although only 2% reported previously diagnosed hypercholesterolaemia, 24% of screened individuals had total cholesterol>5.0 mmol/L. Prevalence of AF was high, particularly among those aged 18-30 (7/57, 12.3%). Asian and British Asian individuals had highest prevalence of raised HbA1C levels (>6%) (8/33, 24.2%), compared to black and black British (22/120, 18.3%) and white (15/283, 5.3%) individuals. Among individuals aged 25 – 84 with no previous CVD, one third had a 10-year QRISK score of ≥10% (120/362, 33.1%), consistent across different ethnic groups: white (75/233, 32.2%), black (24/77, 31.2%) and Asian (6/17, 35.3%).

Conclusions

A simple, pragmatic CVD assessment for homeless individuals was feasible and acceptable, and identified gaps in diagnosis and prevention. There is a high burden of CVD risk factors and CVD amongst homeless individuals, which could be addressed by integration of CVD screening into existing inclusion health outreach frameworks.
Novel SPECT/CT biomarker in transthyretin cardiac amyloidosis: correlation with myocardial amyloid load and cardiac structure and function
Authors: Rettl R , Calabretta R , Duca F , Binder C , Kronberger C , Willixhofer R , Poledniczek M , Dona C , Beitzke C , Loewe C , Hengstenberg C , Badr Eslam C , Bergler-Klein J , Hacker M , Kammerlander A A
Published: November 2023

Background

Single photon emission computed tomography/computed tomography (SPECT/CT) with determination of standardized uptake value (SUV) allows quantification of cardiac amyloid deposition.

Purpose

We aimed to investigate the relationship between quantitative cardiac tracer uptake determined by SPECT/CT and myocardial amyloid load, as well as cardiac structure and function in patients with transthyretin amyloid cardiomyopathy (ATTR-CM), and to identify nuclear imaging biomarkers for monitoring disease progression.

Methods

ATTR-CM patients underwent [99mTc]-radiolabeled diphosphono-1,2-propanodicarboxylic acid ([99mTc]-DPD) scintigraphy and SPECT/CT imaging (n=40) with determination of SUV, as well as cardiac magnetic resonance imaging (CMR, n=25) and transthoracic echocardiography (TTE, n=40).

Results

We observed significant correlations (r, Pearson's correlation coefficient) between SUV retention index and myocardial amyloid load [CMR extracellular volume (ECV): r=0.565, p=0.004, Figure 1A], cardiac structure [CMR interventricular septum: r=0.409, p=0.042, Figure 1B; CMR left ventricular mass index: r=0.508, p=0.010, Figure 1C], longitudinal cardiac function [TTE left ventricular global longitudinal strain (LV GLS): r=0.531, p=0.003, Figure 1D; TTE right ventricular free wall longitudinal strain: r=0.470, p=0.024, Figure 1E; TTE left atrial reservoir strain (LASr): r=-0.434, p=0.038, Figure 1F] and cardiac biomarkers [N-terminal prohormone of brain natriuretic peptide (NT-proBNP): r=0.475, p=0.004; high-sensitive troponin T (hs-TnT): r=0.358, p=0.027]. ATTR-CM patients were divided into two cohorts based on the median (4.32 mg/dL) of SUV retention index (low SUV uptake cohort: ≤4.32 mg/dL, n=20; high SUV uptake cohort: >4.32 mg/dL, n=20). We observed significant between-cohort differences with respect to LV ejection fraction (low SUV uptake: 51.8% vs. high SUV uptake: 46.2%, p=0.045), LV GLS (-14.5% vs. -11.1%, p=0.001), LASr (11.6% vs. 7.1%, p=0.023), NT-proBNP (1300 pg/mL vs. 2786 pg/mL, p<0.001), hs-TnT (42.9 ng/L vs. 62.2 ng/L, p=0.016) and 6-min walk distance (440.1 m vs. 330.1 m, p=0.022).

Conclusions

Using quantitative SPECT/CT imaging, we demonstrated that SUV retention index correlates with myocardial amyloid load, cardiac structure and function, and cardiac biomarkers. Our data suggest that quantitative SPECT/CT imaging with determination of SUV retention index may be a valid tool to monitor disease progression in ATTR-CM patients.Figure 1
Meta-analysis: increased risk of subclinical atherosclerosis in young women after preeclampsia
Authors: Jansen G , De Rooy A , Dinh T , Altintas S , Van 'T Hof A , Kietselaer B , Spaanderman M , Ghossein-Doha C
Published: November 2023

Background

Preeclampsia leads to a two-to-eight fold increased risk of developing future cardiovascular disease (CVD). It is vital to identify the subgroup of high-risk women who will ultimately develop CVD. Preeclampsia is characterized by systemic endothelial dysfunction with a hyper inflammatory state. In combination with the pregnancy specific hypercholesteraemic state, this may trigger early onset atherosclerosis which could underlie future development of CVD.

Purpose

This meta-analysis aims to determine the prevalence of subclinical atherosclerosis at different age intervals, in young women after preeclamptic pregnancies compared to non-preeclamptic pregnancies.

Methods

A systematic search identified studies reporting prevalence of atherosclerosis. Only studies including a preeclamptic and non-preeclamptic group using CT or ultrasound scan were included. There was no restriction on follow up duration. All subtypes of atherosclerotic plaque in any maternal vessel were included. Quality of articles was assessed by the Newcastle-Ottawa scale. Odds ratios (OR) were calculated with logistic regression as a measure of effect size for the prevalence of any atherosclerotic plaque. The Random effects model pooled odds ratios to produce an overall odds ratio and also stratified data using maternal age and imaged artery.

Results

Nine studies included 4148 women in total: 1444 (35%) with preeclampsia and 2704 (65%) without preeclampsia. Prevalence of atherosclerosis was higher in women with previous preeclampsia. The overall OR of having atherosclerosis after preeclampsia was 1.67 (95% CI 1.38-2.02) with an I2 of 62%. The odds of atherosclerosis after preeclampsia <40 years of age was 0.64 (0.10-4.32), 40-49 was 1.59 (1.30-1.93) and >50 was 2.67 (1.84-3.89).

Conclusion

Women with preeclampsia have a significantly increased risk of early-onset atherosclerosis compared to women with healthy pregnancies. This elevated risk starts from 40 years onwards suggestive of accelerated atherosclerosis. Early lifestyle or pharmacological preventive measures should be considered and investigated to reduce CVD burden after preeclamptic pregnancies.Overall resultsTable of odds ratios