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.
Graphical Abstract
Graphical Abstract
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.
Purpose
Circulating endothelial progenitor cells (cEPCs) are vital to vascular repair by re-endothelialization. We aimed to explore the effect of proprotein convertase subtilisin kexin type 9 ...inhibitors (PCSK9i) on cEPCs hypothesizing a possible pleiotropic effect.
Methods
Patients with cardiovascular disease (CVD) were sampled for cEPCs at baseline and following the initiation of PCSK9i. cEPCs were assessed using flow cytometry by the expression of CD34
(+)
/CD133
(+)
and vascular endothelial growth factor receptor (VEGFR)-2
(+)
, and by the formation of colony-forming units (CFUs) and production of VEGF.
Results
Our cohort included 26 patients (median age 68 (IQR 63, 73) years; 69% male). Following 3 months of treatment with PCSK9i and a decline in low-density lipoprotein cholesterol levels (153 (IQR 116, 176) to 56 (IQR 28, 72) mg/dl),
p
< 0.001), there was an increase in CD34
(+)
/CD133
(+)
and VEGFR-2
(+)
cell levels (0.98% (IQR 0.37, 1.55) to 1.43% (IQR 0.90, 4.51),
p
= 0.002 and 0.66% (IQR 0.22, 0.99) to 1.53% (IQR 0.73, 2.70),
p
= 0.05, respectively). Functionally, increase in EPCs-CFUs was microscopically evident following treatment with PCSK9i (1 CFUs (IQR 0.0, 1.0) to 2.5 (IQR 1.5, 3),
p
< 0.001) with a concomitant increase in EPC’s viability as demonstrated by an MTT assay (0.15 (IQR 0.11, 0.19) to 0.21 (IQR 0.18, 0.23),
p
< 0.001). VEGF levels increased following PCSK9i treatment (57 (IQR 18, 24) to 105 (IQR 43, 245),
p
= 0.006).
Conclusions
Patients with CVD treated with PCSK9i demonstrate higher levels of active cEPCs, reflecting the promotion of endothelial repair. These findings may represent a novel mechanism of action of PCSK9i.
Since the diagnosis of cardiac amyloidosis (CA) is often delayed, echocardiographic findings are frequently indicative of advanced cardiomyopathy. We aimed to describe early echocardiographic ...features in patients subsequently diagnosed with CA. Preamyloid diagnosis echocardiographic studies were screened for structural and functional parameters and stratified according to the pathogenetic subtype (immunoglobulin light-chain AL or amyloid transthyretin ATTR). Abnormalities were defined based on published guidelines. Our cohort included 75 CA patients of whom 42 (56%) were diagnosed with AL and 33 (44%) with ATTR. Forty-two patients had an earlier echocardiography exam available for review. Patients presented with increased wall thickness (1.3 interquartile range {IQR} 1.0, 1.5 cm) ≥3 years before the diagnosis of CA and relative wall thickness was increased (0.47 IQR 0.41, 0.50) ≥7 years prediagnosis. One to 3 years before CA diagnosis restrictive left ventricular (LV) filling pattern was present in 19% of patients and LV ejection fraction ≤50% was present in 21% of patients. Right ventricular dysfunction was detected concomitantly with disease diagnosis. The echocardiographic phenotype of ATTR versus AL-CA showed increased relative wall thickness (0.74 IQR 0.62, 0.92 versus 0.62 IQR 0.54, 0.76, p = 0.004) and LV mass index (144 IQR 129, 191 versus 115 IQR 105, 146 g/m2, p = 0.020) and reduced LV ejection fraction (50 IQR 44, 58 versus (60 IQR 53, 60%, p = 0.009) throughout the time course of CA progression, albeit survival time was similar. In conclusion, increased wall thickness and diastolic dysfunction in CA develop over a time course of several years and can be diagnosed in their earlier stages by standard echocardiography.
In recent years, transcatheter aortic valve replacement (TAVR) has emerged as a revolutionary alternative for surgical aortic valve replacement (SAVR) for the treatment of severe symptomatic aortic ...stenosis in patients at high risk for surgery. Prosthetic aortic valve endocarditis is a serious complication after SAVR with high morbidity and mortality. Although numerous TAVR procedures have been performed worldwide, infective endocarditis (IE) after TAVR was reported in the literature in few cases only and in 0% to 2.3% of patients enrolled in large TAVR cohorts. Our aim was to review the literature for IE following TAVR and to discuss the diagnostic and management strategies of this rare complication. Ten case reports of IE after TAVR were identified, 8 of which were published as case reports and 2 of which were presented in congresses. Infective endocarditis occurred in a mean time period of 186 days (median, 90 days) after TAVR. Most cases were characterized by fever and elevated inflammatory markers. Infective endocarditis after TAVR shared some common characteristics with IE after SAVR, yet it has some unique features. Echocardiographic findings included leaflet vegetations, severe mitral regurgitation with rupture of the anterior leaflet, and left ventricle outflow tract to left atrium fistula. Bacteriologic findings included several atypical bacteria or fungi. Cases of IE were managed either conservatively by antibiotics and/or using surgery, and the overall prognosis was poor. Infective endocarditis after TAVR deserves prompt diagnosis and treatment. Until further evidence is present, IE after TAVR should be managed according to SAVR guidelines with modifications as needed on a case‐by‐case basis.
The authors have no funding, financial relationships, or conflicts of interest to disclose.
Background Cardiovascular disease remains a leading cause of death among women. Despite improvements in the management of patients with acute coronary syndrome (ACS), women with an ACS remain at ...higher risk. Methods and Results We performed a time-dependent analysis of the management and outcomes of women admitted with ACS who enrolled in the prospective biennial ACS Israeli Surveys between 2000 and 2016. Surveys were divided into 3 time periods (2000-2004, 2006-2010, and 2013-2016). Outcomes included 30-day major adverse cardiac events (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1-year mortality. Overall, 3518 women were admitted with an ACS. Their mean age (70±12 years) was similar among the time periods. Over the time course of the study, more women were admitted with non-ST-elevation ACS (51.9%, 59.6%, and 66.1%, respectively;
<0.001), and statins and percutaneous coronary intervention were increasingly utilized (66%, 91%, 93%, and 42%, 60%, and 68%, respectively;
<0.001 for each). Among women with ST-segment-elevation myocardial infarction, more primary percutaneous coronary interventions were performed (48.5%, 84.7%, and 95.3%, respectively;
<0.001). The rate of 30-day major adverse cardiac events has significantly decreased over the years (24.6%, 18.6%, and 13.5%, respectively;
<0.001). However, 1-year mortality rates declined only from 2000 to 2004 (16.9%, 12.8%, and 12.3%;
=0.007 for the overall difference), and this change was not significant after propensity matching or multivariate analysis. Conclusions Over more than a decade, 30-day major adverse cardiac events have decreased among women with ACS. Advances in pharmacological treatments and an early invasive approach may have accounted for this improvement. However, the lack of further reduction in 1-year mortality rates among women suggests that more measures should be provided in this high-risk population.
Large vessel vasculitis (LVV) is composed of conditions in which inflammation of blood vessel walls affects mainly large arteries, such as the aorta and its main branches, and in some cases the ...coronary arteries. Coronary artery involvement in systemic vasculitis is associated with significant morbidity and mortality. We present a case of a young patient diagnosed with extensive coronary disease diagnosed as Takayasu arteritis, when whom a concomitant diagnosis of Hodgkin’s lymphoma was made. The literature review revealed ten cases of malignancies associated with Takayasu arteritis. We discuss the complexity of the management of concurrent hematological malignancy with TAK and extensive coronary arteritis. This complicated and cross-disciplinary case also represents the pivotal importance of multi-disciplinary team decision in order to achieve the best clinical outcome of both disorders.
Aims
Endothelial microvascular dysfunction is a known mechanism of vascular pathology in cardiac amyloidosis (CA). Scientific evidence regarding the possible protective role of the amyloid ...transthyretin (ATTR) stabilizer, tafamidis, is lacking. Circulating endothelial progenitor cells (cEPCs) have an important role in the process of vascular repair. We aimed to examine the effect of tafamidis on cEPCs.
Methods and Results
Study population included patients with ATTR-CA. cEPCs were assessed using flow cytometry by the expression of CD34
(+)
/CD133
(+)
and vascular endothelial growth factor receptor (VEGFR)-2
(+)
and by the formation of colony-forming units (CFUs) and production of VEGF. Tests were repeated at pre-specified time-points up to 12 months following the initiation of tafamidis. Included were 18 ATTR-CA patients at a median age of 77 (IQR 71, 85) years and male predominance (
n
= 15, 83%). Following the initiation of tafamidis and during 12 months of drug treatment, there was a gradual increase in the levels of CD34
(+)
/VEGFR-2
(+)
(0.43 to 2.42% (IQR 1.53, 2.91)%,
p
= 0.002) and CD133
(+)
/VEGFR-2
(+)
(0.49 to 1.64% (IQR 0.97, 2.90)%,
p
= 0.004). Functionally, increase in EPCs-CFUs was microscopically evident following treatment with tafamidis (from 0.5 CFUs (IQR 0.0, 1.0) to 3.0 (IQR 1.3, 3.8)
p
< 0.001) with a concomitant increase in EPC’s viability as demonstrated by an MTT assay (from 0.12 (IQR 0.03, 0.16) to 0.30 (IQR 0.18, 0.33),
p
< 0.001). VEGF levels increased following treatment (from 54 (IQR 52, 72) to 107 (IQR 62, 129) pg/ml,
p
= 0.039).
Conclusions
Tafamidis induced the activation of the cEPCs pathway, possibly promoting endothelial repair in ATTR-CA.
Background Patients who have had an acute coronary syndrome ( ACS ) are at increased risk of recurrent cardiovascular events; however, paradoxically, high-risk patients who may derive the greatest ...benefit from guideline-recommended therapies are often undertreated. The aim of our study was to examine the management, clinical outcomes, and temporal trends of patients after ACS stratified by the Thrombolysis in Myocardial Infarction (TIMI) risk score for secondary prevention, a recently validated clinical tool that incorporates 9 clinical risk factors. Methods and Results Included were patients with ACS enrolled in the biennial Acute Coronary Syndrome Israeli Surveys ( ACSIS ) between 2008 and 2016. Patients were stratified by the TIMI risk score for secondary prevention to low (score 0-1), intermediate (2), or high (≥3) risk. Clinical outcomes included 30-day major adverse cardiac events (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1-year mortality. Of 6827 ACS patients enrolled, 35% were low risk, 27% were intermediate risk, and 38% were high risk. Compared with the other risk groups, high-risk patients were older, were more commonly female, and had more renal dysfunction and heart failure ( P<0.001 for each). High-risk patients were treated less commonly with guideline-recommended therapies during hospitalization (percutaneous coronary intervention) and at discharge (statins, dual-antiplatelet therapy, cardiac rehabilitation). Overall, high-risk patients had higher rates of 30-day major adverse cardiac events (7.2% low, 8.2% intermediate, and 15.1% high risk; P<0.001) and 1-year mortality (1.9%, 4.6%, and 15.8%, respectively; P<0.001). Over the past decade, utilization of guideline-recommended therapies has increased among all risk groups; however, the rate of 30-day major adverse cardiac events has significantly decreased among patients at high risk but not among patients at low and intermediate risk. Similarly, the 1-year mortality rate has decreased numerically only among high-risk patients. Conclusions Despite an improvement in the management of high-risk ACS patients, they are still undertreated with guideline-recommended therapies. Nevertheless, the outcome of high-risk patients after ACS has significantly improved in the past decade, thus they should not be denied these therapies.
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