bluuebunny/crossref_metadata_2025_split huggingface dataset:
CAROTID PLAQUES TREATED WITH BEMBEDOIC ACID: A 7% OF REDUCTION IN 6 MONTHS
Authors: Fazio G 
Published: May 2024

Abstract

Bempedoic acid were indicated to be able to reduce the hypercholesterolemia add on to statin and ezetimibe therapy. We investigated the effect of the same treatment in carotid atherosclerosis after a follow up of 6 months.

Methods
A continuous series of 22 patients were enrolled in a prospective analysis. All patients started a therapy with bempedoic acid for hypercholesterolemia add on to rosuvastatin or atorvastatin plus ezetimibe therapy for an insufficient reduction of cholesterol. The mean of LDL dosage was 101 mg/dl. All patients were high or very high–risk patient. In all patients the bempedoic acid was added to optimal medical therapy without new symptoms in ambulatory. The recruitment period was long 1 month. After the recruitment the patient was follow for other 6 month. At the start and at the end of the follow–up we evaluated. The atherosclerosis was evaluated in an ultrasound doppler of carotids The data was collect in excel and analysed by the Q–R–Calc program.

Results
The mean age of patients was 68 age, 44% female. 33% was diabetic patients. Hypertension was present in 73%, hypercholesterolemia in 100%. 11% was smokers. 94% were Caucasian patients. The mean of Weight was 75 kg at the first control. The mean height 174 cm. All patients performed a cardiological control in which the medical doctor prescribed bempedoic acid. 100% of patients assumed a statin, 100% ezetimibe. After 6 month the mean LDL was 78 mg/dl. The doppler showed plaques in 89% of patients. The mean plaques occluded the lumen for 37% before the bempedoic acid and 30% after with a reduction of 7% (p:0,03%) In 50% of patients, we revel a reduction of atherosclerosis (in this subgroup the reduction was 11%).

Conclusion
The bempedoic acid add on to statin therapy reduced the carotid. atherosclerosis for 7% in a continuous series of 23 patients.
FRUCTOSE EXACERBATES ANTHRACYCLINE AND HER–2 BLOCKING AGENT MEDIATED CARDIOTOXICITY THROUGH NLRP3 AND MYD88 MEDIATED PATHWAYS: NEW ROLES OF SWEETENERS IN CARDIO–ONCOLOGY
Authors: Quagliariello V , Iovine M , Giacobbe I , Giordano V , Arianna R , Barbato M , Izzo F , Maurea F , Bisceglia I , Inno A , Canale M , Maurea N 
Published: May 2024

Abstract

Background
Combinatorial therapy based on anthracyclines and HER–2 blocking agents increases the risk of cardiomyopathy in women with breast cancer. Fructose is a monosaccharide associated with high risk of diabetes, non–alcoholic fatty liver disease, atherosclerosis and visceral obesity. A high fructose diet is a potential cardiometabolic risk factor and may increase cardiac risk in women with breast cancer treated with cardiotoxic drugs.

Purpose
In this study, we highlighted the role of sweeteners fructose in the worsening of cardiotoxicity induced by combinatorial therapy anthracycline–HER2–blocking agents.

Methods
Human cardiomyocytes were pre–exposed with doxorubicin combined to trastuzumab (at 300 and 1000 nM) for 48 and 72h alone or combined to fructose at 0.25, 1 and 2.5 mM. After the incubation period, we performed the following tests: determination of cell viability, through mitochondrial dehydrogenase activity, study of lipid peroxidation (quantifying cellular Malondialdehyde and 4–hydroxynonenal), intracellular Ca2+ homeostasis. Moreover, pro–inflammatory studied were also performed (activation of NLRP3 inflammasome; expression of peroxisome proliferator–activated receptor–α; transcriptional activation of p65/NF–κB and secretion of cytokines involved in cardiotoxicity (Interleukins 1β, 8, 6, CXCL–12).

Results
High fructose increases significantly cell mortality of cardiomyocytes exposed to doxorubicin and trastuzumab thorugh the activation of NLRP–3 and Myd–88 expression. Intracellular Ca++ levels were also increased of 4 times compared to non–fructose exposed cardiomyocytes; MDA and 4–HNA levels were increased of 48,3 and 51,2 % compared to non–fructose exposed cells (p&lt;0.001). Fructose increases IL–1, IL–6 and CXCL–12 expression in cardiomyocytes in a concentration dependent manner, compard to doxorubicin–trastuzumab group (p&lt;0.05).

Conclusion
Data of the present study indicate that fructose induces a pro–inflammatory phenotype in human cardiac cells exposed to anticancer cardiotoxic drugs, providing even more data on the harmful role of fructose as a key player of cardiotoxic phenomena.
FIBROSIS QUANTIFICATION IN RISK STRATIFICATION OF HYPERTROPHIC CARDIOMYOPATHY
Authors: Procopio M , Leo I , Borguezan Daros C , Bisaccia G , Licordari R 
Published: May 2024

Abstract
Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) is the gold–standard modality to assess myocardial scar. The extent of myocardial fibrosis is proportional to the risk of adverse outcomes and LGE is ≥15% of LV mass is one of the criteria for prophylactic implantable cardioverted defibrillator. Currently, there are various methods of quantifying the size of LGE which are unlikely to be interchangeable; data about the most reproducible one in Hypertrophic Cardiomyopathy (HCM) are sparse. The aim of our study was to compare the intra–observer and inter–observer reproducibility of 5 LGE quantification techniques in patients with HCM. 100 patients with HCM (apical pattern, n = 34; non–apical patterns, n = 66) undergoing CMR were assessed. A European Association of Cardiovascular Imaging (EACVI) level III operator quantified LGE using 5 techniques: 2SD, 5SD, 6SD, full width half maximum (FWHM) and manual thresholding methods and repeated the same measurements after 1 month, in order to assess intra–observer variability. The analysis was also performed by one EACVI level I operator and one EACVI level III operator in order to assess inter–observer variability. LGE volume was calculated in all patients and in patients with apical HCM and intra–observer and inter–observer variability were assessed. Assessment of LGE volume was highly reproducible when measured by two expert operators with all methods apart from the 2SD method, in which the size of LGE was greater. There was high intra–observer agreement with all methods, the manual one being that with the best intra–observer reproducibility (ICC 0.97 (95% CI 0.95–0.98). Both the FWHM (ICC 0.93, 0.87–0.96) and the 6SD methods (ICC 0.93, 0.88–0.96) yielded the highest inter–observer reproducibility between the expert operators. Inter–observer reproducibility between the EACVI level III and the EACVI level I operators was poor across quantification methods. Intra–observer and inter–observer reproducibility were high with manual and FWHM methods in the apical variant. In patients with HCM, LGE quantification techniques are not interchangeable and reproducibility depends on the method and operator expertise. The FWHM and the 6SD methods were the most reproducible methods in all patients; the first one was also the most reproducible method in apical HCM alongside the manual method. Whether various LGE quantification methods have different diagnostic and prognostic impact should be further investigated.
EFFECT OF ANTI–PCSK9 ANTIBODIES ON ARTERY STRUCTURE AND FUNCTION: THE NIGUARDA HOSPITAL COHORT
Authors: Maloberti A , Toscani G , Busti A , Tognola C , Intravaia R , De Censi L , Galasso M , Daus F , Giani V , Gualini E , Garofani I , Riccio A , Biolcati M , Fabbri S , Algeri M , Merlini P , Giannattasio C 
Published: May 2024

Abstract

Background
PCSK9 inhibitors antibodies (PCSK9–i) are a valid option to reduce LDL cholesterol in patients who failed to reach therapeutic target with maximized lipid–lowering therapies or in patient with statins intolerances. These antibodies reduce the frequency of new cardiovascular events, however if this effect is due only to LDL reduction or also to an improvement in arterial function and structure is yet to be proved. Our study aim was to evaluate aortic stiffness (Pulse Wave Velocity – PWV), carotid’s Intima–Media Thickness (IMT) and endothelial function (brachial Flow Mediated Dilatation – FMD) in patients treated with Alirocumab and Evolocumab.

Methods
This is a monocentric prospective longitudinal study on patients who received PCSK9–i administrations at the Niguarda Hospital’s cardiovascular rehabilitation and prevention unit. They underwent 3 evaluations of PWV, FMD and IMT (T0 the same day of the first injection, T1 after 6 months and T2 after 12 months of therapy).

Results
39 patients concluded the 12 months period. The group average age is 66.8 ± 7.6 years, most of them were male (64.1%). LDL cholesterol average levels were significantly reduced by the therapy (128.3 ± 27.7 vs 44.7 ± 29.3 mg/dL, p&lt;0.001), however, there were no significant changes in PWV (10.2 ± 3.0 vs 10.6 ± 2.5 m/s, p=0.404), FMD (8.6 ± 7.0 vs 8.9 ± 7.4 %, p=0.560) and IMT (768.7 ± 175.4 vs 733.5 ± 147.2 µm, p=0.270) values.

Conclusions
It was not possible to prove a significant effect of PCSK9–i on vascular properties, however, the stability of these indexes may suggest a deceleration of the atherosclerotic disease which it could have worsen in this population, especially considering the risk factors of our patients.
AN OUT OF HOSPITAL CARDIAC ARREST SURVIVOR WITH PRESUMED EMBOLIC MYOCARDIAL INFARCTION: ROLE OF MULTI–MODALITY IMAGING
Authors: Campobasso N 
Published: May 2024

Abstract

Background
Myocardial infarction with non–obstructive coronary arteries (MINOCA) refers to a puzzling clinical entity that is characterized by symptoms suggestive of acute coronary syndrome, demonstrates troponin elevation with inconclusive coronary angiogram. The underlying pathophysiologic mechanisms include atherosclerotic cause or non–atherosclerotic causes, such as coronary dissection or coronary embolus. A standardized approach that includes multimodality imaging is necessary to determine underlying aetiology and direct appropriate treatment.

Case Summary
A 57–year–old male was admitted to our hospital after experiencing cardiac arrest after physical exercise (swimming) treated immediately with cardiac pulmonary resuscitation and two defibrillator–delivered electrical shocks for shockable rhythm before return of spontaneous circulation. Relevant abnormal bloods included a hs–Troponin I elevation. Invasive coronary angiography demonstrated non–obstructed coronary arteries. Subsequent cardiac magnetic resonance imaging (MRI) demonstrated akinesia and an area of subendocardic late gadolinium enhancement in the inferior–lateral wall. This pattern was in keeping with an ischaemic cause, as a recent embolic myocardial infarction. Further investigations, including contrast bubble echocardiogram, were performed in order to identify a cause and source of the embolic infarction and led to the diagnosis of tunnel–like patent foramen ovale with right to left shunting, then confirmed on trans–oesophageal echocardiogram. The patient was treated as myocardial infarction most likely due to embolic phenomena in the presence of a PFO. Therefore, a transvenous ICD was implanted for secondary prevention and the patient underwent percutaneous closure of the PFO.

Discussion and Conclusion
MINOCA can occur in 5–15% of all acute coronary syndromes and represents a working diagnosis. It is important to identify the underlying aetiology of their presentation to appropriately manage them. In particular, where cardiac MRI demonstraded LGE areas ichaemic patterns, myocardial infarction due to secondary embolism should be considered and the next step in clinical management is to identify potential sources of emboli performing further assessments. Multi–modality imaging with cardiac MRI and echocardiogram (transthoracic, contrast bubble and trans–oesophageal) is important in correctly identifying any source of emboli and the diagnosis of any intra–cardiac shunt.
SPONTANEOUS CORONARY ARTERY DISSECTION PRESENTING AS ACUTE MYOCARDIAL INFARCTION IN A MIDDLE–AGED MAN: WHAT YOU WOULDN’T EXPECT
Authors: Roma A , Tontodonato M , Golia E , Coletta S , Ianniciello A , Mercone G , Limatola M , Rucco M , Pariggiano I , Calabrò P 
Published: May 2024

Abstract
Spontaneous coronary artery dissection (SCAD) is a rare cause of acute non atherothrombotic coronary syndrome. It predominantly affects female sex. Both diagnosis and therapeutic decision–making are challenging due to its unpredictable course and recurrence rate. We describe a case of a 50y old man with chest pain(CP), referred to our cathlab for primary percutaneous coronary intervention(PCI) through the Emergency Medical Service, with an anterior ST–segment elevation myocardial infarction(STEMI) detected on ECG. A type 2b SCAD starting from the Left Main(LM) involving proximal Left Anterior Descending (LAD) artery and circumflex artery(Cx) was detected. PCI with Drug–Eluting Stent(DES) implantation on LM and proximal LAD was deemed necessary due to ongoing ischemia and LM involvement. IntraVascular UltraSound(IVUS) on LAD and LM showed good stent deployment and confirmed a non–obstructive SCAD of Cx,left untreated. Patient was started with dual antiplatelet therapy and after 5 days in our cardiac intensive care unit(ICU) he was moved to cardiology unit. Few hours later he had recurrence of CP and an Inferior STEMI was detected. A progression of SCAD of the Cx with critical flow limitation in its proximal tract was found at coronary angiography. Then PCI with DES release was performed using a T and Small Protrusion technique on LM–LAD–Cx and cutting–balloon was used to fenestrate intima with a successful drainage of the intramural hematoma (IH) in the distal portion. Our case represents an uncommon presentation of SCAD, as STEMI involving a male patient. In a recent large cohort of SCAD patients only 10% were men. Male SCAD patients are younger, have less frequently prior MI, depression, emotional stress triggers and are less likely to have associated fibromuscular dysplasia. More often they report physical stress triggers and a more subtle clinical presentation. Conservative management remains the mainstay of treatment in the absence of ongoing ischemia, hemodynamic instability, or LM involvement. When PCI is indicated, it is often associated with an unfavorable course (difficult wiring of the lesion, propagation, and potential milking of the IH along the vessel).Cutting balloon technique has been increasingly used in the interventional approach to SCAD. Several questions remain unanswered about appropriate antithrombotic regimen, duration of ICU observation and the opportunity to perform coronary imaging to review the disease prior to a safe discharge.
NON–INVASIVE ASSESSMENT OF CARDIAC HEMODYNAMICS BY BIO–IMPEDANCE IN A PATIENT WITH HEART FAILURE AND EXCELLENT RESPONSE TO CARDIAC RESYNCHRONIZATION THERAPY
Authors: Giannotti Santoro M , Puccioni E , Pro F , Lapira F , Talini E , Vecchi A , Pasanisi E 
Published: May 2024

Abstract

Patient Presentation
We present a 78–year–old patient admitted to our Cardiology Unit for chronic heart failure with severe left ventricular dysfunction, atrial fibrillation, and recent percutaneous aortic valve replacement and an NYHA IIb class. His therapy was fully optimized. The patient was evaluated during the recovery period. An echocardiogram confirmed severe left ventricular dysfunction (LVEF = 30%). The ECG demonstrated atrial fibrillation with episodes of severe bradycardia and tachycardia. The QRS duration was 145 msec.

Diagnosis and Management
Cardiac pacing implantation was indicated for heart rate stabilization. To assess the patient‘s clinical status and optimize therapy, we performed a non–invasive bio–impedance Cardiac hemodynamic evaluation using the NICaS device before the implantation (Figure 1). This device provides accurate(1,2,3) information on cardiovascular, respiratory, and fluid parameters in a non–invasive and reproducible manner (Figure 2). The analysis revealed a low stroke volume (47 ml), low stroke index (26.0 ml/m2), low cardiac output (3.34 L/min), low cardiac index (1.85 L/min/m2), high peripheral resistance (2344 dyn*s/cm5), and high body water (38.0 kg) (see Figure 3). The patient underwent cardiac resynchronization therapy and defibrillator (CRTD) implantation. The patient was discharged with the same therapy as admission, except for the addition of a low dose of digitalis to improve rate control. Follow–Up: The first follow–up was performed after 3 months. Electronic control revealed regular device function, with ventricular pacing of 99%. The patient showed an improvement in dyspnea, with a NYHA class of I. The echocardiogram showed a significant improvement in the left ventricular ejection fraction (50%). We performed a repeat analysis with NICaS, demonstrating improvement in all hemodynamic parameters (Figure 3): stroke volume 60 ml (+13 ml), stroke index 35.5 ml/m2 (+9.5), cardiac output 5.11 L/min (+1.77), cardiac index 3.02 L/min/m2 (+1.17), peripheral resistance 1236 dyn*s/cm5 (–1108).

Conclusion
The non–invasive bioimpedance–based system – Nicas, allows for the accurate assessment and monitoring of the patient‘s hemodynamics. In our patient, the implantation of a CRTD has led to a significant improvement in clinical status, left ventricular ejection fraction, and all hemodynamic parameters, clearly demonstrated through an easy–to–use office non–invasive modality.
CARDIOGENIC SHOCK IN A PATIENT WITH SEVERE AORTIC VALVE STENOSIS AND MULTIVESSEL CORONARY DISEASE: ADVANCED THERAPEUTIC STRATEGIES
Authors: Agostini N , Guida G , Falcone S , Musazzi A , Castiglioni B 
Published: May 2024

Abstract
We describe a case of a 58 years old man. He was referred to emergency room for episodes of vomiting and epigastric pain for about a week. Upon admission he was confused with systolic–diastolic blood pressure values ​​70/40 mmHg, heart rate 120 bpm, sinus rhythm. pO2 was 80 mmHg and SO2 in air 97%. Lactate values 10, blood sugar &gt; 300 mg/dl. The electrocardiogram showed sinus tachycardia with the results of antero–septal necrosis and incomplete left bundle branch block. The fast echocardiogram showed a dilated left ventricle with severe depression of the ejection fraction (EF about 10–15%), severe low flow–low gradient aortic valve stenosis (AVA bidimensional was approximately 0.9 cm²), severe mitral valve insufficiency due to a dual mechanism. The dimension of Inferior vena cava was 1.5 cm, collapsible. There was thrombotic stratification in the apex of the left ventricle and VA coupling was 2. The patient was admitted to the ICU with stage C cardiogenic shock according to SCAI classification. We found a value of PVC 3 mmHg. After fluide challenge there was an increase in blood pressure values to 100/60 mmHg. Noradrenaline vasopressor was started and subsequently a low dose of adrenaline. Blood pressure values maintained around 90/60 mmHg and undergo a sudden drop after increasing the dosage of the vasopressor. Diuresis was approximately 50 ml/h, lactates clear completely after approximately 4 hours. After 6 hours, due to a new sudden reduction in blood pressure, the patient was referred for IABP and coronary angiography control. In the context of multivessel coronary artery disease and cardiogenic shock he was therefore a candidate for urgent cardiac surgery of aortic valve replacement, by–pass and mitral anulovalvuloplasty. This case gave us the opportunity to analyze how to proceed in such a critical conditions with the below conclusions: a) the choice of vasopressors and inotropes is limited in case of severe aortic valve stenosis b) the presence of left ventricular intracavitary thrombosis limits the choice of ventricular assistance system c) in case of cardiogenic shock and severe aortic valve stenosis the patient must be a candidate for valve replacement surgery as soon as possible.
FULMINANT EOSINOPHILIC MYOCARDITIS TREATED WITH STEROIDS AND INTRA–AORTIC BALLOON PUMP
Authors: Pazzanese V , Barone G , Galdieri C , Yacoub M , Baldetti L , Sacchi S , Ajello S , Scandroglio A 
Published: May 2024

Abstract

Background
Hypereosinophilic syndrome (HES) is a hematological disorders characterized by a chronic, unexplained hypereosinophilia (HE) with tissue damage. Cardiac involvement occurs in ∼20% of patients with HES and it carries a poor prognosis.Early detection and treatment of myocardial involvement improves prognosis. Immunosuppressive therapy represents the core treatment in the majority of patients with Eosinophilic Myocarditis.

Case Summary
50–year–old man with history of intrinsic asthma and HE was admitted for cardiogenic shock B stage according SCAI classification (heart rate was 130 bpm, systolic blood pressure was 90 mmHg and lactate &lt;2). EKG showed sinus tachycardia and diffuse ST segment depression. Echocardiography revealed severe left ventricular systolic dysfunction and mild pericardial effusion. Blood test showed leukocytosis (33x10^9/L) with HE (47%), mild hepato–renal damage, high TroponinT 3874 pg/mL and NT–proBNP 11060 ng/L. Coronary angiography was unremarkable. Pulmonary artery catheter was placed: IC 1,78 l/min/mq, CPO 0,63, WP 21, SVO2 60%, SVR 17 WU, RAP/WP 0.74. We reclassified patients as SCAI C with “mixed shock” due to inflammatory component and latent right ventricular dysfunction. Intra–aortic balloon pump (IABP) was placed and we performed endomyocardial biopsy (EMB). High dose of intra venous corticosteroids was started obtaining progressive improvement of hemodynamic parameters and reduction of inflammation parameters (Fig.1). EMB confirmed the diagnosis of myocarditis with initial transition into ‘’Loffler’s cardiomyopathy’’. Polymerase chain reaction (PCR) analysis did not detect cardiotropic viruses. After improvement of clinical status we performed cardiac MRI that revealed diffuse biventricular myocardial edema and the presence of subepicardial and mid–wall enhancement with non ischemic pattern,endocardial fibrosis and multiple left ventricular thrombi (Fig. 2). β–blockers and angiotensin–converting enzyme inhibitors were started and the patient was discharged at home with a complete myocardial recovery and immunosuppressive therapy based on corticosteroids and azathioprine.

Discussion
This case demonstrates the usefulness of myocardial biopsy in fulminant myocarditis. Treatment with corticosteroids resulted in rapid improvement. Early invasive monitoring allowed more precise hemodynamic characterization and mechanical circulatory support with IABP proved feasible and might have helped by unloading the left ventricle.