Among 2.5 million patients who received the BNT162b2 mRNA vaccine in a large Israeli health care system, the incidence of myocarditis at 42 days was 2.13 cases per 100,000 persons, with the highest ...incidence (10.69 per 100,000 persons) among male patients between the ages of 16 and 29 years. Most cases of myocarditis were mild or moderate.
Myocarditis and pericarditis are inflammatory conditions of the heart that present a range of symptoms, often including chest pain, fatigue, breathlessness and palpitations that may be irregular due ...to cardiac rhythm disturbances. Myocarditis has been proposed to account for a fraction of cardiac injury among patients infected with SARS-CoV-2 and associated systemic inflammation; and it might be one of the reasons for the high mortality seen in COVID-19 patients. Furthermore, following vaccination with mRNA COVID-19 vaccines (ie, Comirnaty and Spikevax), myocarditis and pericarditis can develop within a few days of vaccination, particularly following the second dose. Based on recent reviewed data, the United States Food and Drug Administration (FDA) and the European Medicines Agency (EMA) have determined that the risk for both of these conditions is overall ‘very rare’ (~1 in 10 000 vaccinated people may be clinically affected), with the highest risk among younger males. Both EMA and FDA agree that the benefits of all authorised COVID-19 vaccines continue to outweigh their risks, given the threat of serious COVID-19 illness and related complications. Since myocarditis has a very wide clinical spectrum, ranging from mild to fulminant life-threatening disease, we present in this review a sum of the latest findings and considerations for the proper diagnosis and management of affected patients.
Abstract
Aims
To describe the cardiac magnetic resonance (CMR) imaging findings of patients who developed myocarditis following messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccination.
...Methods and results
The present study retrospectively evaluated patients with clinically adjudicated myocarditis within 42 days of the first Pfizer-BNT162b2 mRNA COVID-19 vaccination, between 20 December 2020 and 24 May 2021 who underwent CMR. A total of 15 out 54 patients (28%) with myocarditis underwent a CMR and were included, 100% males, median age of 32 years (interquartile range = 22.5–40). Most patients presented with chest pain (87%) and had an abnormal electrocardiogram (79%). The severity of the disease was mild in 67% and intermediate in 33%. All patients survived and one patient was readmitted during the study period. CMR was performed at a median of 65 days (range 3–130 days) following diagnosis. Median ejection fraction was 58% (range 51–74%) global- and regional wall motion abnormalities were present in one and three patients, respectively. Native T1 was available in 13/15 patients (2/3 in 3 T and 11/12 in the 1.5 T), with increased values among 6/13. Late gadolinium enhancement (LGE) was found among 13/15 patients with a median of 2% (range 0–15%) with inferolateral wall being the most common location (8/13). The patterns of the LGE were: mid-wall in six patients; epicardial in five patients; and mid-wall and epicardial in two patients.
Conclusions
Among patients who were diagnosed with post-vaccination clinical myocarditis, CMR imaging findings are mild and consistent with ‘classical myocarditis’. The short-term clinical course and outcomes were favourable.
To assess the external validity of the Dual Antiplatelet Therapy (DAPT) score decision tool in real world patients.
Retrospective study using an all comers PCI registry. We compared the rates of ...myocardial infarction (MI) and actionable bleeding between 12 vs. 12+ months DAPT stratified by DAPT score category.
Of 12,162 patients, 4471 (36.8%) completed a year of DAPT without events. The high DAPT score stratum patients were older and had a higher comorbidity burden. Overall, 12+ months DAPT duration was associated with reduced rates of MI (2.8% vs. 4.0%, p = 0.025) and similar rates of bleeding (2.6% vs. 1.9%, p = 0.281) compared to 12 months DAPT, but when stratified by DAPT score stratum, there was no difference in any of the outcomes in both high score group, (3.7% vs. 5.3%, p = 0.111 and 2.0% vs. 1.8%, p = 0.800, for MI and bleeding, respectively) and low score patients (2.7% vs. 3.1%, p = 0.656 and 2.8% vs. 2.0%, p = 0.308, for MI and bleeding, respectively). Overall clinical events (MI + bleeding) was again similar between patients treated with 12+ vs. 12 months DAPT (5.5% vs. 6.2%, p = 0.535 and 5.1% vs. 4.4%, p = 0.503 for high and low DAPT score, respectively).
for real world patients completing 1 year of DAPT post PCI, rates of MI, actionable bleeding, and their combination did not differ between those treated with 12+ vs. 12 months DAPT stratified by DAPT score stratum. Clinicians should be aware of the DAPT score's limitations. Further studies examining the validity of the DAPT score in larger cohorts are required.
•The external validity of the DAPT score has been disappointing.•In our study the DAPT score was relevant for use in 36% of patients 1 year post PCI.•The event rate for bleeding and ischaemia was similar to that of the DAPT trial.•The DAPT score could not identify patients more suitable for extended DAPT duration.
Adiponectin is a key component in multiple metabolic pathways. Studies evaluating associations of adiponectin with clinical outcomes in older adults have reported conflicting results. We investigated ...the association of adiponectin with mortality and cardiovascular disease (CVD) morbidity in a young, multiethnic adult population. We analyzed data from participants in the Dallas Heart Study without baseline CVD who underwent assessment of total adiponectin from 2000 to 2002. The primary outcome of all-cause mortality was assessed over median 10.4 years of follow-up using multivariable-adjusted Cox proportional hazards models. Secondary outcomes included CVD mortality, major adverse cardiovascular and cerebrovascular events (MACCE), and heart failure (HF). The study cohort included 3,263 participants, mean age 43.4 years, 44% women, and 50% black. There were 184 deaths (63 CVD), 207 MACCE, and 46 HF events. In multivariable models adjusted for age, gender, race, hypertension, diabetes, smoking, high-density lipoprotein cholesterol-C, hyperlipidemia, high-sensitivity C-reactive protein level, estimated glomerular filtration rate, and body mass index, increasing adiponectin quartiles were positively associated with all-cause mortality Q4 versus Q1 (hazard ratio HR = 2.27; 95% confidence interval CI 1.47, 3.50); CVD mortality Q4 versus Q1 (HR = 2.43; 95% CI 1.15, 5.15); MACCE Q4 versus Q1 (HR = 1.71; 95% CI 1.13, 2.60); and HF Q4 versus Q1 (HR = 2.95; 95% CI 1.14, 7.67). Findings were similar with adiponectin as a continuous variable and consistent across subgroups defined by age, gender, race, obesity, diabetes, metabolic syndrome, or elevated high-sensitivity C-reactive protein. In conclusion, higher adiponectin was associated with increased mortality and CVD morbidity in a young, multiethnic population. These findings may have implications for strategies aimed at lowering adiponectin to prevent adverse outcomes.
The Medina classification is the most widespread method to describe bifurcation lesions. However, little is known regarding its prognostic impact. Therefore, the aim of this study is to assess the ...prognostic significance of the Medina classification following percutaneous coronary intervention (PCI). From a prospective registry of 738 consecutive patients undergoing PCI for bifurcation lesions, 505 were treated with second-generation drug-eluting stents (DES). Of these, 407 (80.6%) presented with “true bifurcation” (TB) lesions (Medina class 1.0.1, 1.1.1, 0.1.1) and 98 (19.4%) in all other categories (“non-true bifurcation” = NTB). We compared rates of death and major adverse cardiac events (MACE: cardiac death, myocardial infarction, or target vessel revascularization) at 12 months and 3 years. Patients with TB had lower rates of previous bypass surgery (7.4% vs. 11.2%,
p
= 0.043). TB lesions were more likely to be calcified (33.9% vs. 28.6%,
p
= 0.003) and ulcerated (8.8% vs. 4.1%,
p
< 0.01). At 12 months, mortality was numerically higher for TB PCI (4.1% vs. 2.1%,
p
= 0.052) and MACE rates were higher (19.2% vs. 10.2%,
p
< 0.001). At 3 years, both all-cause death (10.1% vs. 5.1%,
p
= 0.002) and rates of MACE (37.2% vs. 17.6%,
p
< 0.001) were higher for TB PCI. After performing regression analysis, TB remained an independent predictor for poor outcomes (OR-2.28 at 12 months, CI 1.45–9.50,
p
= 0.007, OR-3.75 at 3 years, CI 1.52–6.77,
p
= 0.001 for MACE). In conclusion, TB lesions, according to the Medina classification, portend worse prognosis for patients undergoing bifurcation PCI. This may guide prognostication and decision-making in treatment.
The choice between mechanical valves (MVs) and bioprosthetic valves (BVs) in patients undergoing aortic valve surgery is complex, requiring a balance between the inferior durability of BV and the ...indicated long-term anticoagulation therapy with MV. This is especially challenging in the middle age group (< 70 years), which has seen an increased use of BV over recent years.
A meta-analysis of randomised controlled trials (RCTs), observational studies using propensity score matching (PSM) and inverse probability weighting (IPW) was conducted to examine the clinical outcomes of patients < 70 years of age undergoing aortic valve replacement. The primary outcome was overall long-term mortality. Secondary outcomes included bleeding events, reoperation, systemic thromboembolism, and cerebrovascular accident.
Fifteen studies (1 RCT, 12 PSM studies, and 2 IPW studies; aggregated sample size 16,876 patients) were included. Median follow-up was 7.8 years. Mortality was higher with BVs vs MVs (hazard ratio HR 1.22, 95% confidence interval CI 1.00-1.49), as was reoperation (HR 3.05, 95% CI 2.22-4.19). Bleeding risk was lower with BVs (HR 0.58, 95% CI 0.48-0.69), and the risk of stroke was similar in both valve types (HR 0.96, 95% CI 0.83-1.11)
This broadest meta-analysis comparing BV and MV suggests a survival benefit for MVs in patients < 70 years of age. This should lead to reassessment of current patterns used in the choice of valves for patients < 70 among the cardiothoracic surgery community.
Le choix entre les valves mécaniques (VM) et les valves bioprothétiques (VB) (appelées aussi bioprothèses valvulaires) chez les patients subissant une chirurgie valvulaire aortique est une décision complexe exigeant de soupeser la durabilité moindre des VB par rapport au traitement anticoagulant de longue durée indiqué dans les cas d’implantation d’une VM. Ce choix est particulièrement délicat dans le groupe d’âge moyen (< 70 ans) où le recours aux VB a augmenté au cours des dernières années.
Une méta-analyse d'essais contrôlés, randomisés (ECR), d’études d’observation utilisant l’appariement par score de propension (ASP) et la pondération selon la probabilité inverse (PPI) a été réalisée dans le but d’examiner les résultats cliniques chez des patients < 70 ans subissant un remplacement valvulaire aortique. Le critère d’évaluation principal était la mortalité globale à long terme. Les critères d’évaluation secondaires comprenaient les hémorragies, les réopérations, les thromboembolies systémiques et les accidents vasculaires cérébraux.
Quinze études (1 ECR, 12 études avec ASP et 2 études avec PPI, totalisant un échantillon de 16 876 patients) ont été incluses. La durée médiane du suivi a été de 7,8 ans. La mortalité a été plus élevée dans les cas de VB que dans les cas de VM (rapport des risques instantanés RRI : 1,22; intervalle de confiance IC à 95 % : 1,00-1,49), tout comme les réopérations (RRI : 3,05; IC à 95 % : 2,22-4,19). Le risque d’hémorragies a été plus faible dans les cas de VB (RRI : 0,58; IC à 95 % : 0,48-0,69) et le risque d’accidents vasculaires cérébraux a été similaire pour les deux types de valves (RRI : 0,96, IC à 95 % : 0,83-1,11).
Dans cette vaste méta-analyse comparant la VB à la VM, les résultats suggèrent des bienfaits sur le plan de la survie chez les patients < 70 ans porteurs d’une VM. Cette observation devrait inciter à une réévaluation des modalités utilisées actuellement en chirurgie cardiothoracique pour ce qui est du choix d’une valve chez les patients < 70 ans.
Despite increased recognition, frailty remains a significant public health challenge.
we aimed to assess the role of education and income, as well as neighborhood socioeconomic status, on physical ...activity and subsequent frailty in older adults.
Using a population-based cohort of older adults, this study examined the relationship between socioeconomic status (SES) factors, physical activity and frailty. The study included 1,799 participants (mean SD, 74.6 (6.2), 53.3% female) from the "National Health and Nutrition Survey of Older Adults Aged 65 and Over in Israel", conducted in 2005-2006. A follow-up interview was performed 12-14 years later in a subgroup of 601 subjects (mean SD, age 844; 56% women). Self-reported leisure-time physical activity (LTPA) was measured at both baseline and follow-up. SES measures were assessed at baseline. Frailty was measured at follow-up, using the Fried's Phenotype Model.
All SES measures were strongly and positively associated with LTPA (all p < 0.001). Eighty-two participants (14%) were classified as frail at follow-up. After age and sex adjustment and accounting for attrition bias using inverse probability weighting, baseline LTPA (OR = 2.77, 95% CI: 1.57-4.90, for inactivity; OR = 1.41, 95% CI: 0.75-2.68, for insufficient activity, compared with sufficient activity, P
< 0.001) was inversely associated with incident frailty. The association persisted after further adjustment for SES and comorbidity.
Among older individuals, multiple SES measures were positively associated with LTPA, which was a strong predictor of lower subsequent frailty risk.
Gonadotrophin releasing hormone (GnRH) agonists and antagonists reduce testosterone levels for the treatment of advanced and metastatic prostate cancer. Androgen deprivation therapy (ADT) is ...associated with increased risk of cardiovascular (CV) events and CV disease (CVD), especially in patients with preexisting CVD treated with GnRH agonists. Here, we investigated the potential relationship between serum levels of the cardiac biomarkers N-terminal pro-B-type natriuretic peptide (NTproBNP), D-dimer, C-reactive protein (CRP), and high-sensitivity troponin (hsTn) and the risk of new CV events in prostate cancer patients with a history of CVD receiving a GnRH agonist or antagonist.
Post-hoc analyses were performed of a phase II randomized study that prospectively assessed CV events in patients with prostate cancer and preexisting CVD, receiving GnRH agonist or antagonist. Cox proportional hazards models were used to determine whether the selected biomarkers had any predictive effect on CV events at baseline and across a 12-month treatment period.
Baseline and disease characteristics of the 80 patients who took part in the study were well balanced between treatment arms. Ischemic heart disease (66%) and myocardial infarction (37%) were the most common prior CVD and the majority (92%) of patients received CV medication. We found that high levels of NTproBNP (p = 0.008), and hsTn (p = 0.004) at baseline were associated with the development of new CV events in the GnRH agonist group but not in the antagonist. In addition, a nonsignificant trend was observed between higher levels of NTproBNP over time and the development of new CV events in the GnRH agonist group.
The use of cardiac biomarkers may be worthy of further study as tools in the prediction of CV risk in prostate cancer patients receiving ADT. Analysis was limited by the small sample size; larger studies are required to validate biomarker use to predict CV events among patients receiving ADT.
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