Cardiac Death In Patients Research Articles

The risk and prevention of sudden death in patients with heart failure with reduced ejection fraction.

Patients with heart failure are at increased risk of sudden cardiac death. The methods to predict patients at high risk of sudden cardiac death in heart failure are neither sensitive nor specific; both overestimating risk in those with ejection fractions less than 35% and not identifying those at risk with ejection fractions greater than 35%. The absolute risk of sudden cardiac death in patients with heart failure have decreased over the past 20 years. New novel tools are being developed and tested to identify those at higher risk of sudden cardiac death. Reduction in the risk of sudden cardiac death has been achieved with the use of beta-blockers, spironolactone, sacubitril-valsartan, cardiac resynchronization and implantable cardioverter defibrillators. The use of contemporary treatments for patients with heart failure can reduce the risk of sudden cardiac death, but research is required to identify those at highest risk.

INCIDENCE AND DETERMINANTS OF INAPPROPRIATE SHOCK IN HYPERTROPHIC CARDIOMYOPATHY PATIENTS WITH SUBCUTANEOUS IMPLANTABLE DEFIBRILLATORS

Subcutaneous implantable defibrillators (S-ICD) are attractive for preventing sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM) as they mitigate risks of transvenous leads, although they may increase the risk of inappropriate shock (IAS). We retrospectively collected data on

Automatic implantable cardioverter defibrillator: when not to implant.

The implantable cardioverter-defibrillator (ICD) is the mainstay therapy for primary prevention of sudden cardiac death in patients with heart failure with a reduced ejection fraction. Current indications for prophylactic ICD are based on the results of randomized controlled trials dating back to 15-20 years ago, which have usually enrolled highly selected patients with few comorbidities and only a small number of patients aged >75 years. Existing literature suggest an age-dependent attenuation of the efficacy of the ICD. Because of the ageing of the population, there is need for data addressing device efficacy among older patients that also considers the impact of geriatric syndromes on health status. The assessment of frailty may be of value in identifying elderly patients who may or may not benefit from ICD placement for primary prevention of sudden cardiac death.

Implantable Cardioverter-Defibrillators and Wearable Defibrillators: Guidelines and Updates.

Implantable cardioverter-defibrillators (ICDs) have been a preferred treatment for ventricular arrhythmias. Clinical data have consistently supported their use; however, determining which patients will or will not benefit from treatment remains difficult.A documented episode of sustained ventricular tachycardia/ventricular fibrillation (VT/VF) without reversible cause warrants ICD implantation (class IA indication) to potentially treat episodes in the future.1 In patients without prior VT/VF, decreased left ventricular ejection fraction (LVEF) is the primary indication for preemptive ICD implantation. If the LVEF is ≤0.35 despite maximal guideline-directed medical therapy, or coronary revascularization was performed 90 or more days previously, then ICD implantation is a class I indication,1 in ischemic or nonischemic cardiomyopathy. An LVEF ≤0.35 in a patient with myocardial infarction (MI) who has been on medical therapy for 40 days also meets the guidelines for ICD implantation.1In addition to LVEF, other factors indicate which patients may benefit from ICD therapy. Diagnostic electrophysiologic studies (EPS), for example, have been part of risk-stratifying patients for more than 20 years. The Multicenter Unsustained Tachycardia Trial (Mustt) investigators categorized post-MI patients with nonsustained VT and an LVEF ≤0.40 according to whether ventricular arrhythmias were induced during EPS; the patients with inducible VT during EPS benefited from ICD implantation.2 Inducible VT/VF during EPS is also an indication for ICD implantation in patients with coronary artery disease who are at risk for ventricular arrhythmias, which present as unexplained syncope, immediately after MI.1Cardiac imaging is another diagnostic method that is playing a more prominent role in stratifying the risks of sudden death. In particular, cardiac magnetic resonance (CMR) has shown promise in evaluating intrinsic myocardial scarring and predicting cardiac death in patients with hypertrophic cardiomyopathy.3 However, its usefulness in determining the need for ICD therapy has not been fully established. An ongoing clinical trial, Cardioverter-Defibrillator Implantation to Prevent Tachyarrhythmias following Acute Myocardial Infarction (Protect-ICD) (NCT 03588286), is evaluating the use of both EPS and CMR to identify which post-MI patients could benefit from ICD treatment.It is unclear how best to monitor and prevent ventricular arrhythmias in patients with a decreased LVEF who are still undergoing optimal medical therapy within 90 days after MI. While being considered for ICD treatment, these patients may benefit from treatment with a wearable cardioverter-defibrillator. This vest-like device, which is worn under clothing, continuously monitors heart rhythm and delivers a shock to restore sinus rhythm in patients who have sustained VT/VF. Currently, using a wearable defibrillator is a class IIB indication in patients who are at high risk for sudden death but do not meet other immediate indications for ICD therapy.1 The Vest Prevention of Early Sudden Death Trial (VEST) investigators randomized post-MI patients with LVEF ≤0.35 in a 2:1 ratio to receive a wearable defibrillator and medical therapy (device group) or medical therapy alone (control group). There were no differences between groups in the primary outcome of arrhythmic death (device group, 1.6%; control group, 2.4%; P=0.18), whereas the overall mortality rate was lower in the device group (3.1% vs 4.9%; P=0.04).4An inherent limitation of the wearable defibrillator is compliance. For example, VEST trial participants wore it for only 14 hr/d, on average.4 In addition, the relatively low event rate suggests that the trial was underpowered to evaluate differences within the groups. Although no clear benefit was found with regard to arrhythmic death, the lower mortality rate in the defibrillator group suggested benefit from monitoring rhythm.In summary, ICD treatment remains important in managing ventricular arrhythmias. Current guidelines support ICD implantation in patients with prior episodes of VT/VF, and LVEF ≤0.35, or both. Further studies should clarify the value of wearable defibrillators and confirm the roles of EPS and CMR in determining which patients will benefit most from ICD implantation.

Association between circadian Holter ECG changes and sudden cardiac death in patients with Chagas heart disease

Objective: Chagas disease (ChD) is a parasitic illness, largely spread over South America. ChD usually causes progressive myocardium damage, either by direct parasite action or through autoimmune response. Sudden cardiac death (SCD) is prevalent in the early disease stages, being associated with a high variety of ectopic cardiac beats. This study aims at applying heart rate variability (HRV) and heart rate turbulence (HRT) techniques over Holter electrocardiogram (ECG) records to investigate the association with SCD in Chagas heart disease (ChHD). Approach: From a retrospective evaluation of a local database, the Holter records from 78 outpatients (34 female) were divided into groups: SCD deaths (20) and alive patients (56). To consider circadian autonomic changes, the analysis was performed in three periods: (a) entire 24 h record, (b) 12 h daylight period, and (c) the remaining 12 h including night rest. Eight variables were extracted using HRV and HRT approaches from each record and analysed together with the left ventricular ejection fraction (LVEF) estimated by echocardiography. Main results: The set of parameters was reduced by both the forward- and backward-stepwise approach and classification was performed using the k-nearest neighbours method and a leave-one-out cross-validation in a set of ten bootstrap trials, where SCD data were randomly taken and repositioned to balance the groups. The best 24 h model predicted SCD with 89.9% ± 0.9% accuracy using three HRV variables. The use of 12 h segments increased the accuracy up to 91.0% ± 1.2% in a model with the standard deviation parameter measured during the day (SDNNday) and night (SDNNnight). Although considered as playing a major role in SCD, LVEF did not show an association with SCD in this sample. Significance: The degree of HRV and its circadian changes are associated with SCD in ChHD patients.

Effects of renin-angiotensin system blockers on renal and cardiovascular outcomes in patients with diabetic nephropathy: a meta-analysis of randomized controlled trials.

This study aimed to evaluate the effect f angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) on renal or cardiovascular outcomes in patients with diabetic nephropathy (DN). PubMed, Embase, and Cochrane Library were searched for randomized controlled trials (RCTs) evaluating the treatment effects of ACEI and ARB on renal or cardiovascular outcomes in patients with DN until August 2017. The outcomes included end-stage renal disease (ESRD), doubling of serum creatinine levels, all-cause mortality, major cardiovascular events (MACEs), myocardial infarction (MI), stroke, and cardiac death. Relative risks (RR) with 95% confidence intervals (CIs) were used for calculating the summary results using a random-effects model. Twenty-four RCTs including 57,818 patients with DN and 891 events of ESRD, 1050 doubling of serum creatinine concentration, 4352 all-cause mortality, 6342 MACEs, 1073 MI, 2900 stroke, and 1674 cardiac deaths were reported. Overall, the summary results suggested that in patients with DN, receiving ACEI did not have a significant effect on ESRD, doubling of serum creatinine levels, all-cause mortality, MI, stroke, and cardiac death, while ACEI significantly reduced the risk of total MACEs. Furthermore, ARB therapy was associated with a low risk of ESRD and doubling of serum creatinine levels, while it did not differ significantly on all-cause mortality, MACEs, MI, stroke, and cardiac death in patients with DN. Patients with DN receiving ACEI had significantly reduced the risk of total MACEs, and ARB could reduce the incidence of ESRD and the doubling of serum creatinine levels.

One‐year clinical outcome of biodegradable polymer sirolimus‐eluting stent in diabetic patients: Insight from the ULISSE registry (ULtimaster Italian multicenter all comerS Stent rEgistry)

The ULISSE registry evaluated the real-world performance of the Ultimaster® biodegradable polymer sirolimus-eluting stent (BP-SES) in a multicenter-independent cohort of patients undergoing percutaneous coronary intervention, including a large proportion of diabetes mellitus (DM) patients. In this subgroup analysis, 1,660 consecutive patients, 2,422 lesions, treated with BP-SES enrolled in the ULISSE registry were divided in two groups: DM (485 patients, 728 lesions) and non-DM (1,175 patients, 1,694 lesions). Primary endpoint was target lesion failure (TLF), a composite endpoint of cardiac-death, target-vessel myocardial infarction (TV-MI), and clinically driven target lesion revascularization (TLR) at 1-year. Secondary endpoint was TLR at 1-year. At 1-year follow-up TLF occurred in 5% overall patients and was significantly higher in DM patients (8 vs. 3.7%; p = .001), due to more cardiac deaths (3.4 vs. 1.1%; p = .002). TLR occurred in 3.2% overall patients, and it was not significantly higher in DM compared to non-DM patients (4.4 vs. 2.8%; p = .114). The incidence of stent thrombosis was low and similar between groups (0.4 vs. 0.9%; p = .526). Insulin-treated DM (ITDM) patients showed higher rate of TLF as compared to non-ITDM patients (13 vs. 6.5%; p = .041), but similar rate of TLR (6 vs. 4%; p = .405). After adjustment for relevant comorbidities, DM was not significantly associated with TLF or cardiac death in patients undergoing BP-SES implantation. This study is the first all-comers evaluation of BP-SES in DM patients. Our findings show that DM patients, mostly those with ITDM, still represent a vulnerable population and experience significantly higher rate of TLF. Overall BP-SES efficacy is considerable, although not statistically significant higher rate of TLR is still present in DM compared to non-DM patients.

Fibroblast growth factor 21 inhibited ischemic arrhythmias via targeting miR-143/EGR1 axis.

Ventricular arrhythmia is the most common cause of sudden cardiac death in patients with myocardial infarction (MI). Fibroblast growth factor 21 (FGF21) has been shown to play an important role in cardiovascular and metabolic diseases. However, the effects of FGF21 on ventricular arrhythmias following MI have not been addressed yet. The present study was conducted to investigate the pharmacological action of FGF21 on ventricular arrhythmias after MI. Adult male mice were administrated with or without recombinant human basic FGF21 (rhbFGF21), and the susceptibility to arrhythmias was assessed by programmed electrical stimulation and optical mapping techniques. Here, we found that rhbFGF21 administration reduced the occurrence of ventricular tachycardia (VT), improved epicardial conduction velocity and shorted action potential duration at 90% (APD90) in infarcted mouse hearts. Mechanistically, FGF21 may improve cardiac electrophysiological remodeling as characterized by the decrease of INa and IK1 current density in border zone of infarcted mouse hearts. Consistently, in vitro study also demonstrated that FGF21 may rescue oxidant stress-induced dysfunction of INa and IK1 currents in cultured ventricular myocytes. We further found that oxidant stress-induced down-regulation of early growth response protein 1 (EGR1) contributed to INa and IK1 reduction in post-infarcted hearts, and FGF21 may recruit EGR1 into the SCN5A and KCNJ2 promoter regions to up-regulate NaV1.5 and Kir2.1 expression at transcriptional level. Moreover, miR-143 was identified as upstream of EGR1 and mediated FGF21-induced EGR1 up-regulation in cardiomyocytes. Collectively, rhbFGF21 administration effectively suppressed ventricular arrhythmias in post-infarcted hearts by regulating miR-143-EGR1-NaV1.5/Kir2.1 axis, which provides novel therapeutic strategies for ischemic arrhythmias in clinics.

Effect of PCI on QTC Dispersion in Patients with Angina

Background:‘Coronary heart disease (CHD) is now the leading cause of death worldwide; it is on the rise and has become a true pandemic that respects no borders. For the diagnosis of coronary artery disease, the 12 leads electrocardiogram (ECG) is the most readily available noninvasive test by which, in addition of diagnosis, localizing and estimating the size of myocardial ischemia can be determined. Abnormally high QT dispersion has been correlated with risk of arrhythmic death in various cardiac diseases including CAD. An increase in QTd is reported to predict the occurrence of life-threatening ventricular tachyarrhythmias and sudden cardiac death in patients with ischemic heart disease.
 Materials and Methods: This Cross sectional analytical study was conducted in Department of Cardiology, National Institute of Cardiovascular Diseases, Dhaka from January 2013 to December 2013. A total of 100 consecutive patients with angina based on predefined enrollment criteria were included in the study. .All patients were evaluated by history, clinical examination, biochemical analysis, and coronary angiogram (CAG) which was performed during index hospital admission. PCI was done only if the vessel was significantly stenosed.i,e. for LMCA - e”50%, for LAD, LCX and RCA it was e”70% as significant stenosis. Severity of stenosis of the involved vessels were categorized as severe( e”90%) and moderate(<90%).
 Results: Among the study population 76 (76%) patients were male and 24 (24%) patients were female. The left anterior descending artery (LAD) group comprised 37 patients and there were significant differences between before and after PCI QTc dispersion (90.5±38.9 vs 70.4±39.6 ms, p=0.001). The left circumflex artery (LCX) group was comprised of 6 patients and there were significant differences between before and after PCI QTc dispersion (62.2±41.9 vs 50.2±37.2 ms, p=0.001). The right coronary artery (RCA) group consisted of 18 patients, there being significant differences between before and after PCI QTc dispersion (84.9±40.7 vs 69.1±41.5 ms, p=0.001)
 Conclusion: PCI reduces QTc dispersion significantly among patients with angina. This QTc dispersion change is not influenced by sex, smoking, beta-blockers, hypertension, diabetes, renal impairment, stable or unstable angina but it depends upon the severity of coronary artery stenosis, involvement of coronary vessel and number of vessels.Reduction of QTc dispersion is a good sign of successful PCI that indicates successful reperfusion which carries an excellent prognostic value of revascularization.Further long term follow up will establish it.
 University Heart Journal Vol. 16, No. 1, Jan 2020; 33-39

Primary prevention of sudden cardiac death in patients with tetralogy of Fallot with implantable cardioverter defibrillator: Insights from the DAI-T4F study

Ventricular arrhythmias and sudden death are feared late complications in patients with tetralogy of Fallot. Selection of candidates for primary prevention implantable cardioverter defibrillator (ICD) remains challenging. To identify patients with tetralogy of Fallot at high-risk of sudden cardiac death in primary prevention. The DAI-T4F study is an ongoing national French registry including all patients with tetralogy of Fallot and ICD ( NCT03837574 ). Information have been collected prospectively since 2010. Cox proportional hazard models were used to identify factors associated with appropriate ICD therapies. Among 134 patients enrolled, 47 (35.1%) underwent ICD implantation for primary prevention (median age 49.1 years, 76.6% males). At baseline, 20 (42.6%) patients had NSVT, 17 (36.2%) had altered LVEF ≤ 35%, 16 (34.0%) had positive programmed ventricular stimulation, and 16 (34.0%) had QRS duration ≥ 180ms. During a median (IQR) follow-up duration of 5.3 (2.1–8.0) years, 14 (29.8%) patients had at least one appropriate ICD therapy. The annual incidence of appropriate ICD therapies were 2.8%, 4.6%, 6.3%, and 8.6% in patients with none, one, two, or ≥ three of these factors ( P for trend = 0.145). None of predictors, considered isolated, was significantly associated with ICD appropriate therapies. Patients with non-sustained ventricular tachycardia (NSVT) and positive programmed ventricular stimulation had a significant increased risk of ICD appropriate therapies (HR = 3.8, 95% CI: 1.1–14.3, P = 0.035), as well as patients with NSVT and QRSd ≥ 180 ms (HR = 7.2, 95% CI: 1.6–32.7, P = 0.003). No patient with severe altered LVEF without other risk factor had appropriate ICD therapy. Our data illustrate that specific risk stratification and primary prevention for sudden cardiac death in patients with tetralogy of Fallot may be improved. The value of a severely altered LVEF appears low in the absence of other risk factors.

P1581 The global myocardial work index is a powerful predictor of major arrhythmic events in patients with organic heart disease and reduced left ventricular ejection fraction

Abstract Background Current guidelines recommend implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with left ventricular ejection fraction (2DE LVEF) by two-dimensional echocardiography≤ 35%. However, new echocardiography parameters of LV function such as the mechanical dispersion (MD), the LVEF by three-dimensional echocardiography (3DE) and the global myocardial work index (GWI) have been reported to provide a more accurate stratification of the arrhythmic risk, and potentially improve ICD patient selection. Purpose We wanted to compare the arrhythmic risk predictive power of the new parameters of LV function with the conventional 2DLVEF. Material and Methods we prospectively enrolled 216 patients (63 ± 12 years, 88% men) with organic heart diseases and 2DE LVEF <50%, in whom we re-measured LVEF using 3DE, and obtained MD and GWI using 2DE speckle tracking. Major arrhythmic events were defined as sudden cardiac death, sustained ventricular tachycardia, ventricular fibrillation and appropriate ICD shocks. We assessed the predictive power of 4 different parameters: 2DE LVEF< 35%; 3DE LVEF< 35%; MD > 80 ms; and GWI< 672 mmHg% to identify patients at risk of major arrhythmic events. Results During a mean follow-up of 27 ± 24 months, 24 patients (10%) experienced sudden cardiac death, whereas 28 patients (13%) presented major arrhythmic events. The predictive power in terms of major arrhythmic events prediction (Harrel C statistics) improved from 0.67 (95%CI 0.57-0.76) for 2DE LVEF< 35%, to 0.73 (95%CI 0.64-0.82) for 3DE LVEF< 35%, and 0.77 (95%CI 0.68-0.86) for GWI < 672 mm Hg%. Whereas, MD > 80 ms showed a limited predictive power (HCS= 0.53, 95%CI 0.41-0.76)). Conclusions GWI< 672 mm Hg% was the most accurate predictor of major arrhythmic events among echocardiography parameters in patients with organic heart disease and LVEF < 50%.

Akut iskemik inmeli hastalarda repolarizasyon parametreleri ile inme şiddeti arasındaki ilişki

Purpose: The aim of this study was to investigate the relationship between repolarization parameters and National Institutes of Health Stroke Scale (NIHSS) score in patients with acute ischemic stroke. Materials and Methods: The study comprised 97 patients (males, 42; females, 55; 65 ± 16 years) with acute ischemic stroke. 17 patients were excluded. Patients were divided into two groups based on the calculated NIHSS score (Group 1, NIHSS score < 16; Group 2, NIHSS score ≥ 16). Demographic, clinical, and laboratory data for all patients were collected. A 12-lead resting ECG was recorded at admission to the neurology care unit in patients with acute ischemic stroke and were manually measured with a ruler. QTc, QTd, QTcd, Tpe, Tpe/QT parameters were measured. Results: There were no significant differences among demographic parameters of patients. We found that QTc, QTd, QTcd, Tpe, Tpe/QT parameters were significantly higher in Group 2 than Group 1 patients. Conclusion: In this study, we found that acute ischemic stroke has been shown to cause changes in repolarization parameters. Repolarization parameters are associated with stroke severity on admission in patients with acute ischemic stroke. Increased dispersion of repolarization parameters make independent contributions to the risk of arrhythmic cardiac death in patients with acute ischemic stroke. We suggested that especially severe ischemic stroke patients closely using cardiac monitoring during the first 24 h.

Medical therapy for heart failure in adult congenital heart disease: does it work?

### Learning objectives Heart failure (HF) is currently recognised as one of the most clinically important events resulting from the prolonged survival to adulthood of patients with congenital heart disease...

Absence of left bundle branch block and blood urea nitrogen predict improvement in left ventricular ejection fraction in patients with cardiomyopathy and wearable cardioverter defibrillators.

ObjectiveTo identify predictors of left ventricular ejection fraction (LVEF) improvement in patients with newly detected cardiomyopathy using wearable cardioverter defibrillators (WCDs).BackgroundWCDs are useful in preventing sudden cardiac death in patients with reduced LVEF <35% while awaiting implantable cardioverter defibrillator (ICD) placement. In many patients, LVEF improves and an ICD is not indicated.MethodsPatients who received WCDs from November 2013 to November 2015 were identified and followed over a period of 2 years. Clinical variables were examined. The primary outcome was improvement in LVEF ≥35%. Predictors of outcome were determined using a multivariate logistic regression model.ResultsA total of 179 patients were followed. Median age was 65 (interquartile range [IQR]: 56, 73) years, 69.3% were men. Median baseline LVEF was 20% (IQR: 15, 30). LVEF improved ≥35% in 47.5% patients, with patients being younger (62 vs 68.5 years, P = .006), having lower blood urea nitrogen (BUN) (19 vs 24 mg/dL, P = .002), fewer left bundle branch block (LBBB 9.5% vs 25.8%, P = .004), shorter QRS duration (98 vs 112 ms, P < .001), and higher use of angiotensin converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) (92.9% vs 74.4%, P = .001) compared to those without LVEF improvement. Absence of LBBB (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.11‐0.70), lower BUN (OR 0.13, 95% CI 0.02‐0.76), and ACEI/ARB use (OR 3.53, 95% CI 1.28‐9.69) were identified as independent predictors. Ventricular tachycardia/ventricular fibrillation was observed in three patients, all of whom received successful WCD shocks.ConclusionAbsence of LBBB, lower BUN, and ACEI/ARB use predicts LVEF improvement. WCDs help treat arrhythmic events.

Variability in Ventricular Repolarization Underlies Sudden Cardiac Death in Patients with HIV

Death from cardiovascular causes has emerged as a growing collateral problem in the era of antiretroviral therapy that has increased life expectancy of

At the heart of organ donation. Case reports of organ donation after cardiac death in two patients with successfully repaired AAST grade V cardiac injuries

BackgroundTrauma victims could be an important source of organs. This article presents two cases of successful organ donation and transplant, after Maastricht category III cardiac death in patients with successfully repaired AAST grade V traumatic cardiac injuries.Case presentationThe first donor was an adult patient with self-inflicted heart stab wound and non-survivable burn injury. The second one was an adult patient with blunt cardiac and abdominal trauma and an anoxic brain injury due to a car accident. The cardiac injury was promptly repaired in both patients. In the first case, adequate organ perfusion ante-mortem was achieved thanks to venoarterial extracorporeal membrane oxygenation and intensive care unit support. The above procedure allowed successful organ donation and transplantation even after Maastricht category III cardiac death. This is the first case reported where, for organ donation purposes, it was made necessary first thing to avoid the immediate death of the patient, due to a rare and frequently not survivable cardiac injury. The challenge of preserving organ perfusion, due to major burn injury effects, was faced afterwards.ConclusionsThe outcomes of these two cases suggest that a repaired heart injury should not be considered as an absolute contraindication to organ donation, even if it is associated with non-survivable major burns. Therefore, cardiac death could provide an opportunity for these kinds of patients to contribute to the pool of potential organ donors.

Coronary Atherosclerosis in Masters Athletes: Mechanisms and Implications for Cardiovascular Disease Risk.

This manuscript reviews the data on the mechanisms and significance of atherosclerotic cardiovascular disease (ASCVD) in masters athletes. It describes recent advances in understanding the biological pathway for the development and progression of ASCVD in athletes. It also reviews salient clinical trials, guidelines on managing ASCVD in masters athletes, and future research directions. Recent data have produced controversy as to whether high levels of physical activity and endurance training can promote ASCVD. Longstanding, vigorous endurance exercise may increase the development of calcified and non-calcified coronary plaques. There are no clinical trials to inform clinicians on how to manage masters athletes with occult ASCVD. We provide a review of the data on ASCVD in older athletes, the risks and benefits of exercise in active individuals with ASCVD, and our approach to evaluating and managing these patients. Vigorous physical exertion transiently increases the risk of acute coronary syndrome (ACS) and sudden cardiac death in patients with ASCVD. New research has demonstrated increases in both calcified and non-calcified plaque in athletes, although the dominant plaque type is usually calcific. The mechanisms mediating this possible increase in atherosclerosis in active individuals is uncertain, as is the prognostic implications of the increased atherosclerosis. The predominance of calcified plaque may indicate that coronary plaques in athletes are less prone to rupture and to produce acute coronary events. Some guidelines offer recommendations on the management of non-athletic patients with elevated CAC but data on athletes is scarce. Until additional studies are available, we suggest that athletes with CAC values > 100 Agatston units be managed as if they have preclinical ASCVD. They should be informed of the symptoms of angina and ACS and the importance of prompt medical attention should such symptoms occur. Serum calcium and parathyroid hormones levels should be measured to exclude hyperparathyroidism. Patients should undergo symptom-limited maximal exercise stress testing and aggressive lipid treatment to achieve low-density lipoprotein cholesterol (LDL-C) values < 70mg/dl.

Heart failure and its complications in patients with diabetes: Mounting evidence for a growing burden.

Heart failure (HF) is one of the major challenges in the management of diabetes patients. Among subjects with diabetes, up to 20% could have HF. Conversely, diabetes prevalence in HF patients varies greatly from more than 10% up to 50%. When it is present, the risk of mortality and rehospitalization increases substantially. In addition, current evidence points to an increased risk of atrial fibrillation and sudden cardiac death in patients with diabetes. The inter-relation between diabetes cardiomyopathy, left ventricular hypertrophy, coronary artery disease and renal dysfunction indicates complex and intricate pathways. Despite the great value of clinical assessment and echocardiography, there is insufficient data to suggest systematic screening for HF in asymptomatic patients with diabetes. There is little evidence to indicate that improved glycaemic control improves HF outcome in this population. In the case of established HF, the general guidelines apply in diabetes patients. However, recent advances concerning glucose-lowering treatment in patients with cardiovascular disease suggest that the choice of glucose-lowering agent is of crucial interest and should be based on the patient's phenotype. New drug classes, such as SGLT2 inhibitors, seem to be of particular benefit in these patients. In the future, new personalized strategies should aim at not only good control of the glycaemic level but also the reduction and possibly the prevention of HF onset.

Effect of Pre-Procedural Beta-Blocker on Clinical Outcome after Percutaneous Coronary Intervention in Acute Coronary Syndrome.

The efficacy of pre-procedural beta-blocker use in patients with acute coronary syndrome (ACS) is not well established in the current percutaneous coronary intervention (PCI) era. We investigate the effect of pre-procedural beta-blocker use on clinical outcomes in patients with ACS undergoing PCI. Among 44,967 consecutive cases of PCI enrolled in the nationwide, retrospective, multicenter registry (K-PCI registry), 31,040 patients with ACS were selected and analyzed. We classified patients into pre-procedural beta-blocker group (n = 8,678) and pre-procedural no-beta-blocker group (n = 22,362) according to the use of beta-blockers at least for two weeks before index PCI. Propensity score-matching analysis was performed and resulted in 7,445 pairs. The primary outcome was in-hospital cardiac death. In propensity score-matched populations, the pre-procedural beta-blocker group had a lower incidence of in-hospital cardiac death compared with the pre-procedural no-beta-blocker group (1.1% versus 2.0%, unadjusted odds ratio [OR]: 0.56, 95% confidence interval [CI]: 0.42-0.73, P < 0.01). In subgroup analysis, the pre-procedural beta-blocker group had a lower incidence of in-hospital cardiac death, compared with the pre-procedural no-beta-blocker group in ST-segment elevation myocardial infarction subpopulation (3.1% versus 6.1%, unadjusted OR: 0.49, 95% CI: 0.34-0.71, P < 0.01) and non-ST-segment elevation myocardial infarction subpopulation (1.5% versus 2.9%, unadjusted OR: 0.51, 95% CI: 0.33-0.79, P < 0.01). However, in unstable angina subpopulation, the in-hospital cardiac death rate was comparable between both groups. In conclusion, the use of pre-procedural beta-blocker was associated with a lower risk of in-hospital cardiac death in patients with ACS undergoing PCI. This result adds to the body of evidence that use of pre-procedural beta-blocker in patients with ACS might be reasonable.

Hemodynamic effects of myocardial bridging in patients with hypertrophic cardiomyopathy.

Myocardial bridging (MB) is linked to angina and myocardial ischemia and may lead to sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). However, it remains unclear how MB affect the coronary blood flow in HCM patients. The aim of this study was to assess the effects of MB on coronary hemodynamics in HCM patients. Fifteen patients with MB (7 HCM and 8 non-HCM controls) in their left anterior descending (LAD) coronary artery were chosen. Transient computational fluid dynamics (CFD) simulations were conducted in anatomically realistic models of diseased (with MB) and virtually healthy (without MB) LAD from these patients, reconstructed from biplane angiograms. Our CFD simulation results demonstrated that dynamic compression of MB led to diastolic flow disturbances and could significantly reduce the coronary flow in HCM patients as compared with non-HCM group (P < 0.01). The pressure drop coefficient was remarkably higher (P < 0.05) in HCM patients. The flow rate change is strongly correlated with both upstream Reynolds number and MB compression ratio, while the MB length has less impact on coronary flow. The hemodynamic results and clinical outcomes revealed that HCM patients with an MB compression ratio higher than 65% required a surgical intervention. In conclusion, the transient MB compression can significantly alter the diastolic flow pattern and wall shear stress distribution in HCM patients. HCM patients with severe MB may need a surgical intervention.NEW & NOTEWORTHY In this study, the hemodynamic significance of myocardial bridging (MB) in patients with hypertrophic cardiomyopathy (HCM) was investigated to provide valuable information for surgical decision-making. Our results illustrated that the transient MB compression led to complex flow patterns, which can significantly alter the diastolic flow and wall shear stress distribution. The hemodynamic results and clinical outcomes demonstrated that patients with HCM and an MB compression ratio higher than 65% required a surgical intervention.