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Background Diabetic patients have an increased predisposition to thromboembolic events, in most cases originating from thrombi in the left atrial appendage (LAA). Remodeling of the LAA, which predisposes to thrombi formation, has been previously described in diabetic patients with atrial fibrillation, but whether remodeling of the LAA occurs in diabetics also in the absence of atrial fibrillation is unknown. To investigate the contribution of diabetes, as opposed to atrial fibrillation, to remodeling of the LAA, we went from humans to the animal model. Methods We studied by echocardiography the structure and function of the heart over multiple time points during the evolution of diabetes in the Cohen diabetic sensitive rat (CDs/y) provided diabetogenic diet over a period of 4 months; CDs/y provided regular diet and the Cohen diabetic resistant (CDr/y), which do not develop diabetes, served as controls. All animals were in sinus rhythm throughout the study period. Results Compared to controls, CDs/y developed during the evolution of diabetes a greater heart mass, larger left atrial diameter, wider LAA orifice, increased LAA depth, greater end-diastolic and end-systolic diameter, and lower E/A ratio—all indicative of remodeling of the LAA and left atrium (LA), as well as the development of left ventricular diastolic dysfunction. To investigate the pathophysiology involved, we studied the histology of the hearts at the end of the study. We found in diabetic CDs/y, but not in any of the other groups, abundance of glycogen granules in the atrial appendages , atria  and ventricles, which may be of significance as glycogen granules have previously been associated with cell and organ dysfunction in the diabetic heart. Conclusions We conclude that our rodent model of diabetes, which was in sinus rhythm, reproduced structural and functional alterations previously observed in hearts of human diabetics with atrial fibrillation. Remodeling of the LAA and of the LA in our model was unrelated to atrial fibrillation and associated with accumulation of glycogen granules. We suggest that myocardial accumulation of glycogen granules is related to the development of diabetes and may play a pathophysiological role in remodeling of the LAA and LA, which predisposes to atrial fibrillation, thromboembolic events and left ventricular diastolic dysfunction in the diabetic heart.

Despite the COVID-19 pandemic, cardiovascular disease is still the main cause of death in developed countries. Of these deaths, acute coronary syndromes (ACS) account for a substantial percentage of deaths. Improvement in ACS outcomes, are achieved by reducing the time from symptom onset until reperfusion or total ischemic time (TIT). Nevertheless, due to the overwhelming reality at the beginning of the pandemic, acute coronary syndrome (ACS) care may have been compromised. We evaluated delays in TIT based on the date and timing of admissions in patients with STEMI, by a timeline follow-up form, before and during the current COVID-19 pandemic. Between July 2018 and June 2020, two hundred and twelve patients diagnosed with ST-segment elevation myocardial infarction (STEMI) were admitted to our medical center. Upon presentation, cases were assigned a timeline report sheet and each time interval, from onset of symptoms to the catheterization lab, was documented. The information was later evaluated to study potential excessive delays throughout ACS management. Our data evidenced that during the COVID-19 pandemic ACS admissions were reduced by 34.54%, in addition to several in-hospital delays in patient's ACS management including delays in door-to-ECG time (9.43 ± 18.21 vs. 18.41 ± 28.34, p = 0.029), ECG-to-balloon (58.25 ± 22.59 vs. 74.39 ± 50.30, p = 0.004) and door-to-balloon time (57.41 ± 27.52 vs. 69.31 ± 54.14, p = 0.04). During the pandemic a reduction in ACS admissions occurred in our hospital that accompanied with longer in-hospital TIT due to additional tests, triage, protocols to protect and prevent infection within hospital staff, and maintenance of adequate standards of care. However, door-to-balloon time was maintained under 90 min.

Background With increasing life expectancy, the prevalence of nonagenarians with cardiovascular disease is steadily growing. However, this population is underrepresented in randomized trials and thus poorly defined, with little quality evidence to support and guide optimal management. The aim of the present study was to evaluate the clinical management, therapeutic approach, and outcomes of nonagenarians admitted to a tertiary care center intensive coronary care unit (ICCU). Methods We prospectively collected all patients admitted to a tertiary care center ICCU between July 2019 – July 2022 and compared nonagenarians to all other patients. The primary outcome was in-hospital mortality. Results A total of 3807 patients were included in the study. Of them 178 (4.7%) were nonagenarians and 93 (52%) females. Each year the prevalence of nonagenarians has increased from 4.0% to 2019, to 4.2% in 2020, 4.6% in 2021 and 5.3% in 2022. Admission causes differed between groups, including a lower rate of acute coronary syndromes (27% vs. 48.6%, p < 0.001) and a higher rate of septic shock (4.5% vs. 1.2%, p < 0.001) in nonagenarians. Nonagenarians had more comorbidities, such as hypertension, renal failure, and atrial fibrillation (82% vs. 59.6%, 23% vs. 12.9%, 30.3% vs. 14.4% p < 0.001, respectively). Coronary intervention was the main treatment approach, although an invasive strategy was less frequent in nonagenarians in comparison to younger subjects. In-hospital mortality rate was 2-fold higher in the nonagenarians (5.6% vs. 2.5%, p = 0.025). Conclusion With increasing life expectancy, the prevalence of nonagenarians in ICCU’s is expected to increase. Although nonagenarian patients had more comorbidities and higher in-hospital mortality, they generally have good outcomes after admission to the ICCU. Hence, further studies to create evidence-based practices and to support and guide optimal management in these patients are warranted.

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Gender F F F F F F F F Age 80 75 76 53 81 49 60 38 Smoking No No Yes Yes No No No No Diabetes mellitus No No No No Yes No Yes No Hypertension Yes Yes No No Yes No Yes No Dyslipidaemia Yes Yes Yes No Yes No Yes No Obesity No No No No Yes No Yes Yes COPD No No Yes No No No No No Psychiatric and/or neurologic disorders No Dementia No No No Anxiety, epilepsy Schizophrenia Wernicke's encephalopathy Ischaemic heart disease No No No No No No No No Other No No No No CAVB, PM No No No Table 2 Patients' clinical characteristics. Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Trigger Emotional Emotional Emotional Emotional Emotional Emotional Emotional Emotional Presenting symptom Pre-syncope Dyspnoea Chest pain Chest pain Chest pain Syncope Chest pain Chest pain ECG at presentation ST-segment STE lateral leads STE antero-lateral leads STE antero-lateral leads; hyperacute T TWI in lateral leads Ventricular pacing TWI antero-lateral leads No ST-T changes STE antero-lateral leads QTc (ms) 450 449 456 513 500 520 520 532 ECG at 48 h ST-segment Diffuse TWI Diffuse Subtle STE and TWI Diffuse subtle STE and bi-phasic T waves Diffuse TWI Ventricular pacing Diffuse TWI No ST-T STE antero-lateral leads QTc (ms) 512 589 501 507 520 419 460 506 Echocardiography at presentation EF Simpson % 23 28 30 30 15–20 20 35 30 Functional MR grade Mild–moderate Moderate Moderate–severe Mild–moderate Mild Mild–moderate Moderate–severe Moderate LVOTO (rest gradient, mmHg) No Yes (46) Yes (53) No No No No Yes (44) Hypokinesis pattern Mid-apical Mid-apical Mid-apical Mid-apical Mid-apical Mid-apical Mid-apical Mid-apical Echocardiography at follow-up EF Simpson % 45 39 45 44 55 55–60 40–45 65 Functional MR grade Mild Mild Moderate Mild No No No No Cardiac magnetic resonance imaging N/A N/A N/A N/A N/A No myocardial LGE No myocardial oedema N/A Initial Hs-TnT ng/L 109 106 346 348 484 49 37 200 Peak Hs-TnT ng/L 830 611 445 372 1120 59 70 200 CK U/L 224 176 231 218 119 68 54 48 Pro BNP pg/mL — 8486 — 2595 >35 000 145 1925 10 800 CRP-s-B mg/L 12.90 2.3 7.40 8.2 275 6.8 6.8 8.1 Coronary artery disease NOCa Normal coronary arteries RCA 80% stenosis Normal coronary arteries Normal coronary arteries Normal coronary arteries Normal coronary arteries Normal coronary arteries Ballooning on angiography — — — — Yes — — — Revascularization during admission — — Yes — No — — — Length of hospital stay, days 7 4 7 5 9 14 5 11 Remarkably, between 7 October and 25 November 2023, patients diagnosed with TCM made up approximately 8.5% of all acute coronary syndrome (ACS) cases admitted to Barzilai Medical Center. Patients with emotionally triggered TCM had higher LVEF at presentation, lower rate of in-hospital complications, shorter hospital stay and lower long-term mortality rate compared with patients with TCM triggered by physical stressor or without an apparent preceding stressor.2,5,6 However, among emotionally triggered cases, the effect on clinical presentation and outcomes of the intensity of the emotional stressor remains largely unknown. Compared with patients >50 years of age, younger individuals have an increased prevalence of coexisting neurological and/or psychiatric disorders, present more commonly with atypical forms of TCM and have higher rate of cardiogenic shock.9 In our cohort, 25% of individuals were under 50 years of age and 4 patients

Background Abdominal aortic aneurysm (AAA) is an asymptomatic condition characterized by progressive dilatation of the aorta. The purpose of this study is to identify important 2D-TTE aortic indices associated with AAA as predictive tools for undiagnosed AAA. Methods In this retrospective study, we evaluated the size of the ascending aorta in patients without known valvular diseases or hemodynamic compromise as predictive tool for undiagnosed AAA. We studied the tubular ascending aorta of 170 patients by 2-dimensional transthoracic echocardiography (2D-TTE). Patients were further divided into two groups, 70 patients with AAA and 100 patients without AAA with normal imaging results. Results Dilatation of tubular ascending aorta was measured in patients with AAA compared to the group with absent AAA (37.5 ± 4.8 mm vs. 31.2 ± 3.6 mm, p   <  0.001, respectively) and confirmed by computed tomographic (CT) (35.6 ± 5.1 mm vs. 30.8 ± 3.7 mm, p   <  0.001, respectively). An increase in tubular ascending aorta size was associated with the presence of AAA by both 2D-TTE and CT ( r  = 0.40, p   <  0.001 and r  = 0.37, p   <  0.001, respectively). The tubular ascending aorta (D diameter) size of ≥33 mm or ≥ 19 mm/m 2 presented with 2–4 times more risk of AAA presence (OR 4.68, CI 2.18–10.25, p  = 0.001 or OR 2.63, CI 1.21–5.62, p  = 0.02, respectively). In addition, multiple logistic regression analysis identified tubular ascending aorta (OR 1.46, p  < 0.001), age (OR 1.09, p  = 0.013), gender (OR 0.12, p  = 0.002), and LVESD (OR 1.24, p  = 0.009) as independent risk factors of AAA presence. Conclusions An increased tubular ascending aortic diameter, measured by 2D-TTE, is associated with the presence of AAA. Routine 2D-TTE screening for silent AAA by means of ascending aorta analysis, may appear useful especially in older patients with a dilated tubular ascending aorta (≥33 mm).

Guiding catheter damage and body wire intermingling are uncommon complications of standard operational procedures. Optimal application of this device includes replacing the small guiding catheter upon excessive resistance during stent insertion. Guiding catheter damage and body wire intermingling are uncommon complications of standard operational procedures. Optimal application of this device includes replacing the small guiding catheter upon excessive resistance during stent insertion.

Coronary Artery Ectasia (CAE) is a phenomenon characterized by locally or diffuse coronary artery dilation of one or more coronary arteries. In the present study, the prevalence of acquired coronary ectasia and coronary risk factors for CAE was analyzed in patients undergoing cardiac catheterization for suspected ischemic heart disease. We retrospectively analyzed 4000 patients undergoing coronary angiography for suspected coronary artery disease at our cardiac catheterization unit, and a total of 171 patients were selected. The study group was divided into three groups, 65 patients with CAE, 62 patients with significant obstructive coronary artery disease, and 44 patients with normal coronary angiograms as a control group. A negative correlation was observed between high-density lipoprotein cholesterol (HDL-C) and the presence of CAE (r = −0.274, p < 0.001). In addition, HDL-C (OR, 0.858; CI, 0.749–0.984; p = 0.029), low-density lipoprotein cholesterol (LDL-C)/HDL-C ratio (OR, 1.987; CI, 1.542–2.882; p = 0.034), and hemoglobin (OR, 2.060; CI, 1.114–3.809; p = 0.021) were identified as independent risk factors for the development of CAE. In fact, we observed that a one-unit increase in HDL-C corresponded to a 15% risk reduction in CAE development and that each unit increase in hemoglobin could potentially increase the CAE risk by 2-fold. Low HDL-C could significantly increase the risk of developing CAE in healthy individuals. Elevated hemoglobin could predispose to subsequent dilation and aneurysm of the coronary artery. This work suggests that disordered lipoprotein metabolism or altered hemoglobin values can predispose patients to aneurysmal coronary artery disease.

Resistant hypertension is associated with increased cardiovascular risk. The endothelin pathway has been implicated in the pathogenesis of hypertension, but it is currently not targeted therapeutically, thereby leaving this relevant pathophysiological pathway unopposed with currently available drugs. The aim of the study was to assess the blood pressure lowering efficacy of the dual endothelin antagonist aprocitentan in patients with resistant hypertension. PRECISION was a multicentre, blinded, randomised, parallel-group, phase 3 study, which was done in hospitals or research centres in Europe, North America, Asia, and Australia. Patients were eligible for randomisation if their sitting systolic blood pressure was 140 mm Hg or higher despite taking standardised background therapy consisting of three antihypertensive drugs, including a diuretic. The study consisted of three sequential parts: part 1 was the 4-week double-blind, randomised, and placebo-controlled part, in which patients received aprocitentan 12·5 mg, aprocitentan 25 mg, or placebo in a 1:1:1 ratio; part 2 was a 32-week single (patient)-blind part, in which all patients received aprocitentan 25 mg; and part 3 was a 12-week double-blind, randomised, and placebo-controlled withdrawal part, in which patients were re-randomised to aprocitentan 25 mg or placebo in a 1:1 ratio. The primary and key secondary endpoints were changes in unattended office systolic blood pressure from baseline to week 4 and from withdrawal baseline to week 40, respectively. Secondary endpoints included 24-h ambulatory blood pressure changes. The study is registered on ClinicalTrials.gov, NCT03541174. The PRECISION study was done from June 18, 2018, to April 25, 2022. 1965 individuals were screened and 730 were randomly assigned. Of these 730 patients, 704 (96%) completed part 1 of the study; of these, 613 (87%) completed part 2 and, of these, 577 (94%) completed part 3 of the study. The least square mean (SE) change in office systolic blood pressure at 4 weeks was –15·3 (SE 0·9) mm Hg for aprocitentan 12·5 mg, –15·2 (0·9) mm Hg for aprocitentan 25 mg, and –11·5 (0·9) mm Hg for placebo, for a difference versus placebo of –3·8 (1·3) mm Hg (97·5% CI –6·8 to –0·8, p=0·0042) and –3·7 (1·3) mm Hg (–6·7 to –0·8; p=0·0046), respectively. The respective difference for 24 h ambulatory systolic blood pressure was –4·2 mm Hg (95% CI –6·2 to –2·1) and –5·9 mm Hg (–7·9 to –3·8). After 4 weeks of withdrawal, office systolic blood pressure significantly increased with placebo versus aprocitentan (5·8 mm Hg, 95% CI 3·7 to 7·9, p<0·0001). The most frequent adverse event was mild-to-moderate oedema or fluid retention, occurring in 9%, 18%, and 2% for patients receiving aprocitentan 12·5 mg, 25 mg, and placebo, during the 4-week double-blind part, respectively. This event led to discontinuation in seven patients treated with aprocitentan. During the trial, a total of 11 treatment-emergent deaths occurred, none of which were regarded by the investigators to be related to study treatment. In patients with resistant hypertension, aprocitentan was well tolerated and superior to placebo in lowering blood pressure at week 4 with a sustained effect at week 40. Idorsia Pharmaceuticals and Janssen Biotech.

Cardiogenic shock complicating acute myocardial infarction is a complex clinical condition associated with dismal prognosis. Routine early target vessel revascularization remains the most effective treatment to substantially improve outcomes, but mortality remains high. Temporary circulatory support devices have emerged with the aim to enhance cardiac unloading and improve end-organ perfusion. However, quality evidence to guide device selection, optimal installation timing, and post-implantation management are scarce, stressing the importance of multidisciplinary expert care. This review focuses on the contemporary use of short-term support devices in the setting of cardiogenic shock following acute myocardial infarction, including the common challenges associated this practice.