Atherosclerotic peripheral artery disease (PAD) is a growing health issue that affects more than 200 million individuals worldwide, conferring a high risk of cardiovascular events and death. In spite ...of its high prevalence, PAD has often been neglected in the past and the heightened cardiovascular risk of patients with PAD has been consistently under-recognized by practitioners. Considering that an integrated approach to reduce cardiovascular events and lower limb complications is necessary in this setting, statins represent the cornerstone of therapy as reported by current American and European guidelines. Literature has extensive data about the importance of lipid-lowering therapy in patients with PAD demonstrating that statins reduce symptoms, cardiovascular events and mortality. Despite data extrapolated from many studies on coronary artery diseases, moderate-dose statin therapy seems to be safe, and the minor risks posed in terms of myopathy-related symptoms are greatly outweighed by benefits. Other lipid-lowering drugs did not show the same results in terms of outcome and they should not be considered as first line therapy in these patients. The role of anti-PCSK9 inhibitors is emerging in the literature but further data are necessary to understand their superiority over statins.
This comprehensive review explores the various scenarios of atherosclerosis, a systemic and chronic arterial disease that underlies most cardiovascular disorders. Starting from an overview of its ...insidious development, often asymptomatic until it reaches advanced stages, the review delves into the pathophysiological evolution of atherosclerotic lesions, highlighting the central role of inflammation. Insights into clinical manifestations, including heart attacks and strokes, highlight the disease’s significant burden on global health. Emphasis is placed on carotid atherosclerosis, clarifying its epidemiology, clinical implications, and association with cognitive decline. Prevention strategies, lifestyle modifications, risk factor management, and nuanced antithrombotic treatment considerations are critical to managing cardiovascular complications, thus addressing a crucial aspect of cardiovascular health.
Recently, 2019 ESC Guidelines on diabetes and prediabetes underlined the importance of low HRV (a marker of diabetic cardiovascular autonomic neuropathy).3 In fact, it has been associated with an ...increased risk of fatal and nonfatal coronary artery disease.4,5 Our study group also recently conducted a retrospective study on 85 patients referred for suspected angina to the Cardiology Unit of the University Hospital “Paolo Giaccone,” in Palermo, who underwent coronary angiography in the period between May 2015 and June 2017.6 We observed that the group with higher levels of Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) index, showed significantly reduced HRV parameters (SDANN, SDNN index, and RMSSD) compared to subject with normal insulin sensitivity (91.6 ± 22.5 vs 116.1 ± 25.32, p = 0.001; 70.9 ± 12.52 vs 85 ± 21.13, p = 0.007 and 27 ± 8.27 vs 40.11 ± 20.66, p = 0.004). ...greater values of HOMA-IR were associated with a reduction in HRV indices at Simple Linear regression, and this relation was confirmed for all the parameters taken into consideration, in particular for RMSSD (p <0.001). Being HRV impaired in patients with IR even in the absence of overt metabolic syndrome, it could be speculated that the autonomic impairment, highlighted with HRV reduction, can be an early event of cardiovascular events and chronotropic incompetence, so it could become a noninvasive marker to identify high risk patients deserving early treatment for organ damage prevention in IR condition.7 In conclusion, Habibi M et al1 should be congratulated for their comprehensive study which contributes to found an independent association of high RHR and low or high HRV, as surrogates of ANS function, with new onset AF in a multiethnic population.
Background
Several studies have evaluated the role of QRS duration (QRSd) or QRS narrowing as a predictor of response to cardiac resynchronization therapy (CRT) to reduce nonresponders.
Aim
Our study ...aimed to determine the correlation between the relative change in QRS index (QI) compared to clinical outcome and prognosis in patients who underwent CRT implantation.
Methods
A three‐centers study involving 398 patients with a CRT device was conducted. Clinical, echocardiographic and pharmacological variables, QRSd before and after CRT implantation and QI were measured.
Results
In a 6‐month follow‐up, a significant improvement in left ventricular ejection fraction (LVEF), left ventricular end‐diastolic and systolic volumes (LVEDV and LVESV) were observed. QI was related to reverse remodeling (multiple r‐squared: 0.48, adjusted r‐squared: 0.43, p = .001), and the cut‐off value that best predicted LV reverse remodeling after 6 months of CRT was 12.25% (AUC 0.7, p = .001). At 24 months, a statistically significant difference was found between patients with a QI ≤ 12.25% and those with a QI > 12.25% regarding NYHA class worsening (p = .04). The mean of the QI of patients who died from cardiovascular causes was lower than patients who died of other causes (p = .0179). A correlation between pre‐CRT QRSd/LVEDV and QI was observed (r = + 0.20; p = .0003). A higher QRSd/LVEDV ratio was associated with an improved LVEF, LVEDV, and LVESV (p < .0001) at follow‐up.
Conclusions
QI narrowing after CRT was related to greater echocardiographic reverse remodeling and a lower rate of adverse events (death or cardiovascular hospitalizations). The QI can improve the prediction of adverse events in a population with CRT regardless of comorbidities according to the Charlson Comorbidity Index. QI could be used to predict CRT response.
In a cohort of patients with juvenile myocardial infarction, we considered the red cell distribution width (RDW), hematocrit, hemoglobin, and elongation index values at the initial phase and at 3 and ...12 months from the acute event. In the initial phase, only the elongation index values turn out reduced if compared with those of the control group, and that only turn out to discriminate the infarcted ST-segment elevation myocardial infarction (STEMI) from non-STEMI. Dividing the patients according to the traditional risk factors and the extent of coronary heart disease, there are no significant variations in the analyzed parameters. No major changes are observed after 12 months from the acute event. Both to 3 and to 12 months from the infarct episode, the negative statistical correlation between RDW and the value of elongation index remains. These data make us reflect on the role of the degree of anisocytosis of red blood cell expressed by the RDW on the determinism of erythrocyte deformability, which plays its role in the microcirculation district and that is essential in the transfer of tissue oxygen.
Purpose
Only a few studies are available on dose-related effects of sacubitril/valsartan (angiotensin receptor neprilysin inhibition (ARNI)) in real-life patients with heart failure and reduced ...ejection fraction (HFrEF). We sought to investigate clinical and functional effects in real-life HFrEF patients receiving ARNI at a different cumulative dose.
Methods
This was an observational study in consecutive outpatients admitted for HFrEF from October 2017 to June 2019. The PARADIGM criteria were needed for enrolment. ARNI was uptitrated according to blood pressure, drug tolerability, renal function and kaliemia. At least 10-month follow-up was required in each patient. Clinical assessment, Kansas City Cardiomyopathy Questionnaire (KCCQ) score, 6-min walk test and strain echocardiography were performed in each patient on a regular basis during the observational period. At the end of the study, patients were divided into two groups based on the median yearly dose of the ARNI medication.
Results
A total of 90 patients, 64 ± 11 years, 82% males, were enrolled. The cut-off dose was established in 75 mg BID, and the study population was divided into group A (≤ 75 mg), 52 patients (58%), and group B (> 75 mg), 38 patients (42%). The follow-up duration was 12 months (range 11–13). NYHA class, KCCQ score and 6MWT performance ameliorated in both groups, with a quicker time to benefit in group B. The proportion of patients walking > 350 m increased from 21 to 58% in group A (
p
< 0.001), and from 29 to 82% in group B (
p
< 0.001). A positive effect was also disclosed in the left ventricular remodelling, strain deformation and diastolic function.
Conclusion
One-year ARNI treatment was effective in our real-life HFrEF patient population, leading to clinical and functional improvement in both study groups, slightly greater and with a shorter time to benefit in group B.
Objective Surgical management of moderate chronic ischemic mitral valve regurgitation is still debated. The aim of this study was to evaluate the effect of adding mitral valve repair to coronary ...artery bypass grafting on clinical outcomes and left ventricular remodeling in patients who underwent coronary artery bypass grafting alone versus coronary artery bypass grafting plus mitral valve repair in a randomized trial. Methods Between February 2003 and May 2007, 102 patients were eligible for this study and were randomly assigned to one of 2 groups by means of card allocation: coronary artery bypass grafting plus mitral valve repair (CABG plus MVR group; 48 patients, 47%) or coronary artery bypass grafting alone (CABG group; 54 patients, 53%). The 2 groups were similar regarding demographics, perioperative clinical data, and outcomes. There were differences regarding cardiopulmonary bypass ( P < .0001) and aortic crossclamp ( P < .0001) times. Exercise tests were performed for all survivors to evaluate tolerance to exercise and variability on grade of mitral regurgitation and systolic pulmonary arterial pressure. The study was blinded for physicians and nurses involved in postoperative care and clinical follow-up. The mean follow-up was 32 ± 18 months. Results Overall in-hospital mortality was 3% (3 patients). One (1.8%) patient died in the CABG group, and 2 (4.1%) patients died in the CABG plus MVR group. Survival rates ± standard error at 5 years for patients in the CABG and CABG plus MVR groups were 88.8% ± 3.2% and 93.7% ± 3.1%, respectively. A significant difference was found between the 2 groups with regard to mean New York Heart Association class ( P < .0001), left ventricular end-diastolic diameter ( P < .01), left ventricular end-systolic diameter ( P < .01), pulmonary arterial pressure ( P < .0001), and left atrial size ( P < .01). At follow-up, coronary artery bypass grafting alone was able to reduce mitral regurgitation grade in 40% of patients, whereas in the remaining patients mitral regurgitation grade remained stable or worsened. In the CABG group, among the 17 patients with mild mitral regurgitation and 12 patients with moderate mitral regurgitation at rest, 7 (40%) and 9 (75%) patients, respectively, had worsening in mitral regurgitation grade and pulmonary artery pressure during exercise. Conclusions The efficacy of adding mitral valve repair to coronary artery bypass grafting is well demonstrated by the improvement of New York Heart Association functional class and percentage of left ventricular ejection fraction and by the decrease of mitral regurgitation grade, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, pulmonary artery pressure, and left atrial size. Moreover, coronary artery bypass grafting alone left more patients with heart failure symptoms at rest and during exercise. Combined coronary artery bypass grafting and mitral valve repair have no effect on survival at short-term follow-up, and the trends that are evident will likely become more significant with time.
In recent years, several studies have used the measurement of carotid intima-media thickness (IMT) as a marker of early atherosclerosis: IMT has been shown to correlate significantly with the ...presence of coronary artery disease (CAD) and to predict fatal and not fatal cerebro- and cardio-vascular events. These findings highlight the importance of recognizing and managing early stages of atherosclerosis for effective cardiovascular prevention. Beyond traditional established cardiovascular risk factors, inflammation has been shown to be crucial throughout atherosclerosis from endothelial dysfunction to plaque rupture and thrombosis. Several studies have shown the existence of a strong relation between CAD and fibrinogen or highly sensitive C-reactive protein (hs-CRP) levels and their predictive role has been examined through stratification or multivariable statistical analyses: levels of these markers of inflammation have been independently associated with the incidence of coronary events after adjusting for traditional cardiovascular risk factors. Recent studies have further addressed the importance of therapeutical modulation of hs-CRP levels in high-risk patients for the prevention of vascular events. The strong relationship between hs-CRP and IMT may potentially account for the complex role of hs-CRP and IMT in the pathogenesis of cardiovascular events. However, beyond the utility of measuring markers of inflammation to assess patients with subclinical carotid atherosclerosis at higher risk of vascular events, further studies are needed to evaluate the therapeutic implications in this category of patients.
Leadless pacemaker (LPs) is a safe device and the implantation rates of this device is increasing. The device extraction and replacement are today a challenging procedures especially in case of ...infections, fragile and older patients or in unfavorable venous anatomy; LPs can be a valid alternative strategy in these cases. We report a case of management of a patient with multiple previous device replacements and extractions, with malfunction of transvenous pacemaker and with a fibrous membrane between the walls of the ventricular lead and the superior vena cava (SVC), who underwent a successful LP implantation.
Wellens syndrome is an abnormal electrocardiographic pattern characterized by biphasic (type A) or deeply inverted (type B) T waves in leads V2–V3. It is typically caused by temporary obstruction of ...the left anterior descending (LAD) coronary artery due to the rupture of an atherosclerotic plaque leading to occlusion. Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and even a rarer cause of Wellens Syndrome. It occurs when an intramural hematoma forms, leading to the separation of the tunica intima from the outer layers and creating a false lumen that protrudes into the real lumen, ultimately reducing blood flow and thus resulting in myocardial infarction. Here we report a case of SCAD presenting as an acute coronary syndrome with self-resolving chest pain, slightly elevated myocardial necrosis markers and electrocardiographic changes consistent with Wellens pattern type A first, and type B afterwards, that were not present upon arrival to the emergency department.
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