Coronary microvascular disease (CMVD) is associated with adverse cardiovascular outcomes. However, there is no reliable and noninvasive quantitative diagnostic method available for CMVD. The use of a pressure wire to measure the index of microcirculatory resistance (IMR) is possible, but it has inevitable practical restrictions. We hypothesized that computation of the quantitative flow ratio could be used to predict CMVD with symptoms of ischemia and no obstructive coronary artery disease (INOCA). We retrospectively assessed the diagnostic efficiency of the quantitative flow ratio‑derived index of microcirculatory resistance (QMR) in 103 vessels from 66 patients and compared it with invasive IMR using the thermodilution technique. Patients were divided into the CMVD group (41/66, 62.1%) and non-CMVD group (25/66, 37.9%). Pressure-wire IMR measurements were made in 103 coronary vessels, including 44 left descending arteries (LADs), 18 left circumflex arteries (LCXs) and 41 right coronary arteries (RCAs). ROC curve analysis showed a good diagnostic performance of QMR for all arteries (area under the curve=0.820, 95% confidence interval 0.736-0.904, p<0.001) in predicting microcirculatory function. The optimal cut-off for QMR to predict microcirculatory function was 266 (sensitivity: 82.9%, specificity: 72.6%, and diagnostic accuracy: 76.7%). QMR is a promising tool for the assessment of coronary microcirculation. The assessment of the IMR without the use of a pressure wire may enable more rapid, convenient, and cost-effective assessment of coronary microvascular function.

The clinical significance and prognostic value of T cell involvement and programmed cell death-1 (PD-1)/programmed cell death ligand-1 (PD-L1) have not been established in lymphocytic fulminant myocarditis (FM). We investigated the prognostic impact of the number of CD4+, CD8+, FoxP3+, and PD-1+ T cells, as well as PD-L1 expression, in cardiomyocytes in lymphocytic FM. This is a single-center observational cohort study. Myocardial tissue was obtained from 16 consecutive patients at lymphocytic FM onset. The median follow-up was 140 days. Cardiac events were defined as a composite of cardiac death and left ventricular-assist device implantation. CD4, CD8, FoxP3, PD-1, and PD-L1 immunostaining was performed on myocardial specimens. The median age of the patients was 52 years (seven men and nine women). There was no significant difference in the number of CD4+ cells. The number of CD8+ cells and the CD8+/CD4+ T cell ratio were higher in the cardiac event group (Event+) than in the group without cardiac events (Event-) (P = 0.048 and P = 0.022, respectively). The number of FoxP3+ T cells was higher in the Event+ group (P = 0.049). Although there was no difference in the number of PD-1+ cells, cardiomyocyte PD-L1 expression was higher in the Event+ group (P = 0.112). Event-free survival was worse in the group with a high CD8+ cell count (P = 0.012) and high PD-L1 expression (P = 0.049). When divided into three groups based on the number of CD8+ cells and PD-L1 expression (CD8highPD-L1high [n = 8], CD8lowPD-L1high [n = 1], and CD8lowPD-L1low [n = 7]), the CD8highPD-L1high group demonstrated the worst event-free survival, while the CD8lowPD-L1high group had a favorable prognosis without cardiac events (P = 0.041). High myocardial expression of CD8+ T cells and PD-L1 may predict a poor prognosis in lymphocytic FM.

Although assessment of cardiovascular hemodynamics during exercise can provide clinical insights, it is challenging to acquire it in clinical settings. Accordingly, this preliminary study was to determine whether a novel elaboration on Systolic Time Interval measures (eSTICO) method of quantifying Cardiac Output and Stroke Volume was comparable to those obtained using a validated soluble gas (OpCircCO) method or calculation based on oxygen consumption (VO2CO) during exercise. For the present study, 14 healthy subjects (male: n=12, female: n= 2) performed incremental exercise on a recumbent cycle ergometer. At rest and during exercise, cardiac output (CO) was obtained via the eSTICO method while the OpenCircCO and VO2CO measures were obtained the last minute of each workload. At peak, there was no difference between eSTICO and OpCircCO (12.39±3.06 vs. 13.96±2.47 L/min, p>0.05) while there was a slight difference between eSTICO and VO2CO (12.39±3.06 vs. 14.28±2.55 L/min, p<0.05). When we performed correlation analysis with all subjects and all measures of CO at all WL, between eSTICO and OpenCircCO, there was a good relationship (r=0.707, p<0.001) with a Bland and Altman agreement analysis demonstrating a -1.6 difference (95% LoA: -6.3-3.5). Between eSTICO and VO2CO, we observed an r=0.865 (p<0.001) and a Bland and Altman agreement analysis with a -1.2 difference (95% LoA: -4.8-2.4). A novel exploitation of cardiac hemodynamics using systolic timing intervals may allow a relatively good assessment of cardiac output during exercise in healthy adults.

Introduction Atrial fibrillation (AF) is common in the intensive care unit (ICU) setting, and has been associated with adverse outcomes. In this context, there is increasing research interest in AF burden as a predictor of subsequent adverse events. However, the pathophysiology and drivers of AF burden in ICU are poorly understood. This study sought to evaluate the predictors of AF burden in critical illness associated new onset AF (CI-NOAF). Methods Out of 7,030 admissions a tertiary general intensive care unit between December 2015 and September 2018, 309 patients developed CI-NOAF. AF burden was defined as the percentage of monitored time in AF, as extracted from hourly interpretations of continuous ECG monitoring. Low and high AF burden groups were defined relative to the median AF burden. Clinical, laboratory and echocardiographic parameters were extracted, and multivariable modelling with binary logistic regression was performed to evaluate for independent associations with AF burden. Results The median AF burden was 7.0%. Factors associated with increased AF burden were age, dyslipidaemia, chronic kidney disease, increased creatinine, CHA2DS2-VASc score, ICU admission diagnosis category, amiodarone administration and left atrial area (LAA). Factors associated with lower AF burden were previous alcohol excess, burden of ventilation, the use of inotropes/vasopressors and beta blockers. On multivariate analysis, increased LAA, chronic kidney disease and amiodarone use were independently associated with increased AF burden, whereas beta blocker use was associated with lower AF burden. Conclusion Left atrial size and chronic cardiovascular comorbidities appear to be the primary drivers of CI-NOAF burden, whereas factors related to acute illness and critical care intervention paradoxically did not appear to be a substantial driver of arrhythmia burden. Further research is needed regarding drivers of AF and the efficacy of rhythm control intervention in this unique setting.

The main aim of this study was to investigate the impact of isolated coronary microvascular disease (CMD) as diagnosed via various modalities on prognosis. A systematic literature review of PubMed, Embase, and Cochrane library databases was conducted to identify relevant studies published up to March 2023. Included studies were required to measure coronary microvascular function and report outcomes in patients without obstructive coronary artery disease (CAD) or any other cardiac pathological characteristics. The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiac event (MACE). Pooled effects were calculated using random-effects models. A total of 27 studies comprising 18,204 subjects were included in the meta-analysis. Indices of coronary microvascular function measurement included coronary angiography-derived index of microcirculatory resistance (caIMR), hyperemic microcirculatory resistance (HMR), coronary flow reserve (CFR), and so on. Patients with isolated CMD exhibited a significantly higher risk of mortality (OR: 2.97, 95% CI, 1.91-4.60, P < 0.0001; HR: 3.38, 95% CI, 1.77-6.47, P = 0.0002) and MACE (OR: 5.82, 95% CI, 3.65-9.29, P＜0.00001; HR: 4.01, 95% CI, 2.59-6.20, P < 0.00001) compared to those without CMD. Subgroup analysis by measurement modality demonstrated a consistent and robust pooled effect estimates in various subgroups. CMD is significantly associated with an elevated risk of mortality and MACE in patients without obstructive CAD or any other identifiable cardiac pathologies. The utilization of various measurement techniques may have potential advantages in the management of isolated CMD.

The coronavirus disease 2019 (COVID-19) involves all organs of the body, of which the interaction with cardiovascular diseases is the most important. Numerous studies have reported that COVID-19 patients complicated with cardiovascular comorbidities (hypertension, coronary heart disease, chronic heart failure, cerebrovascular disease) are more likely to develop into critical illness and have higher mortality. Conversely, COVID-19 may also cause myocardial injury in patients through various pathological mechanisms such as direct virus attack on cardiomyocytes, overactivation of immune response, microthrombus formation, which may lead to fatal acute ST-segment elevation myocardial infarction, arrhythmia, acute worsening of chronic heart failure, etc. In addition, the symptoms of the so-called long-COVID may remain in some patients who survived the acute viral infection. Positional tachycardia has been widely reported, and cardiovascular autonomic disorders are thought to play a pathogenic role.

The management of patients with severe aortic stenosis (AS) may differ according to patient age. The aim of this analysis was to describe patterns of aortic valve replacement (AVR) use in European countries stratified by age. Procedure volume data for AVR, including surgical aortic valve replacement (sAVR) and transcatheter aortic valve implantation (TAVI), for the years 2015-2020 were obtained from national databases for twelve European countries (Austria, Czech Republic, Denmark, England, Finland, France, Germany, Norway, Poland, Spain, Sweden, and Switzerland). Procedure volumes were reported by patient age (<50 years, by five-year age groups between 50 and 85 years, and ≥85 years). Patients per million population (PPM) undergoing AVR each year were calculated using population estimates from Eurostat. AVR PPM varied widely between countries, from 508 PPM in Germany to 174 PPM in Poland in 2020. TAVI rates ranged from 61% in Switzerland and Finland to 25% in Poland. AVR PPM increased with age to a peak at 80-84 years, after which it decreased again. AVR procedures increased from 2015 to 2019 at an average annual rate of 3.9%. AVR increased more substantially in people aged ≥80 years than in younger age groups; these older age groups accounted for 30% of all AVR procedures in 2015 and 35% in 2019. TAVI accounted for an increasing proportion of all AVR procedures as patient age increased; an overall average of 96% of males and 98% of females aged ≥85 years received TAVI as the treatment modality, although adoption of TAVI differed between countries. There is considerable variation in the rates of AVR use and the adoption of TAVI versus sAVR between European countries. The use of TAVI has increased in recent years, particularly for older patients.  .

This meta-analysis brings comprehensive evaluation about still controversial association between the body mass index (BMI) and the outcomes of acute coronary syndrome (ACS). PubMed/ScienceDirect databases were systematically searched for studies with baseline parameters, primary (heart failure (HF), cardiogenic shock, cardiac arrest, reinfarction, stroke, death, total in-hospital complications) and secondary outcomes (reinfarction, stroke, death, total major adverse cardiovascular events (MACE)) in relation to BMI strictly classified into four groups (Underweight (<18.5 kg/m2), Normal weight (18.5-24.9 kg/m2), Overweight (25.0-29.9 kg/m2) and Obese (≥30.0 kg/m2), grouped into Mildly Obese (30.0-34.9 kg/m2) and Severely Obese (≥35.0 kg/m2)). We included 24 studies, with 585,919 participants (55.5% males), aged 66.8 years. Underweight was negatively associated with hypertension, hyperlipidemia and diabetes, and positively with primary outcomes (HF (Odds ratio (OR)=1.37, Confidence interval (CI) [1.15-1.63]), cardiogenic shock (OR=1.43, CI [1.04-1.98]), stroke (OR=1.21, CI [1.05-1.40]), overall death (OR=1.64, CI [1.20-2.26]), total in-hospital complications (OR=1.39, CI [1.24-1.56])) and secondary outcomes during 34-month follow-up (cardiovascular/overall death (OR=3.78, CI [1.69-8.49]/OR=2.82, CI [2.29-3.49]), respectively), total MACE (OR=2.77, CI [2.30-3.34])) (for all P<0.05). Obesity had positive association with hypertension, hyperlipidemia, diabetes and smoking, and negative with primary outcomes (reinfarction (OR=0.83, CI [0.76-0.91]), stroke (OR=0.67, CI [0.54-0.85]), overall death (OR=0.55, CI [0.49-0.63]), total in-hospital complications (OR=0.81, CI [0.70-0.93])) and secondary outcomes (cardiovascular/overall death (OR=0.77, CI [0.66-0.88]/OR=0.62, CI [0.53-0.72]), respectively), total MACE (OR=0.63, CI [0.60-0.77])) (for all P<0.05). This negative association with several primary outcomes (cardiogenic shock, overall death, total in-hospital complications) and secondary outcomes (cardiovascular/overall death, total MACE) was more pronounced in mild obesity (P<0.05). These results give an "obesity paradox" with a bimodal pattern (slightly U-shaped). Obesity is positively associated with traditional cardiovascular risk factors and negatively with primary and secondary outcomes, which confirms the persistence of overall "obesity paradox".

1. While the major causes of atherosclerotic cardiovascular disease are known, clinical audits continue to show inadequate risk factor control, even in the highest risk subjects. 2. More effective risk estimation methods may help, and advances in this field are outlined. 3. There exist excellent Guidelines on cardiovascular disease prevention, but their very length and complexity may limit their use. Other factors inhibiting guideline implementation are explored. 4. While new medications continue to be developed, the real challenges to effective CVD prevention are societal and political. Both nationally and at European levels, cohesive, integrated strategies with defined responsibilities and accountability are needed, together with empowerment of people to understand the concept of risk and what they can do about it. 5. There are profound health inequalities between and within countries that need to be addressed.

Meteorological factors and air pollutants are believed to be associated with cardiovascular disease. Ischemic heart disease (IHD) is a major public health issue worldwide. Few studies have investigated the associations among meteorological factors, air pollutants and IHD daily hospital admissions in Lanzhou, China. We conducted a distributed lag non-linear model (DLNM) on the basis of five years data, aiming at disentangling the impact of meteorological factors and air pollutants on IHD hospital admissions. All IHD daily hospital admissions recorded from January 1, 2015 and December 31, 2019 were obtained from three hospitals in Lanzhou, China. Daily air pollutant concentrations and meteorological data were synchronously collected from Gansu Meteorological Administration and Lanzhou Environmental Protection Administration. Stratified analyses were performed by sex and two age-groups. A total of 23555 IHD hospital admissions were recorded, of which 10477 admissions were for coronary artery disease (CAD), 13078 admissions were for acute coronary syndrome (ACS). Our results showed that there was a non-linear (J-shaped) relationship between temperature and IHD hospital admissions. The number of IHD hospital admissions were positively correlated with NO2, O3, humidity and pressure, indicating an increased risk of hospital admissions for IHD under NO2, O3, humidity and pressure exposure. Meanwhile, both extremely low (-12ºC) and high (30ºC) temperature reduced IHD hospital admissions, but the harmful effect increased with the lag time in Lanzhou, China, while the cold effect was more pronounced and long-lasting than the heat effect. Subgroup analysis demonstrated that the risk on CAD hospital admissions increased significantly in female and <65 years of age at -12ºC. Our findings added to the growing evidence regarding the potential impact of meteorological factors, air pollutants on policymaking from the perspective of hospital management efficiency.