Current European Society Of Cardiology Research Articles

Angina and no obstruction on coronary angiography : New approaches to the diagnosis and treatment of vasomotor disorders

Clinical management of patients with angina and no obstructive coronary artery disease (ANOCA) is still challenging. This scenario affects up to 50% of patients undergoing diagnostic coronary angiography due to suspected coronary artery disease. Many patients report along and debilitating history before adequate diagnostics and management are initiated. This article describes the current recommendations for diagnostic assessments and treatment in patients with ANOCA. Focus is placed on invasive diagnostics in the catheter laboratory, pharmacological/interventional treatment as well as the patient journey. In patients with ANOCA, the current European Society of Cardiology (ESC) guidelines suggest that invasive assessments using acetylcholine and adenosine for the diagnosis of an underlying coronary vasomotor disorder should be considered. Acetylcholine is used to diagnose coronary spasm, whereas adenosine is used in conjunction with awire-based assessment for the measurement of coronary flow reserve and microvascular resistance. The invasive assessments allow the determination of what are referred to as endotypes (coronary spasm, impaired coronary flow reserve, enhanced microvascular resistance or acombination thereof). Establishing adiagnosis is helpful to: (a)initiate targeted treatment to improve quality of life, (b)reassure the patient that acardiac cause is found and (c)to assess individual prognosis. Currently, patients with ANOCA are often not adequately managed. Referral to specialised centres is recommended to prevent long and debilitating patient histories until expertise in diagnosis and treatment becomes more widespread.

Features of trastuzumab-related cardiac dysfunction: deformation analysis outside left ventricular global longitudinal strain.

Cancer therapy-related cardiac dysfunction due to trastuzumab has been well-known for many years, and echocardiographic surveillance is recommended every 3 months in patients undergoing trastuzumab treatment, irrespective of the baseline cardiotoxicity risk. However, the potential harm and cost of overscreening in low- and moderate-risk patients have become great concerns. This study aimed to identify the incidence of early cancer therapy-related cardiac dysfunction (CTRCD) and the behaviours of left and right heart deformations during trastuzumab chemotherapy in low- and moderate-risk patients. We prospectively enrolled 110 anthracycline-naïve women with breast cancer and cardiovascular risk factors who were scheduled to receive trastuzumab. The left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (LV-GLS), and right ventricular and left atrial longitudinal strains were evaluated using echocardiography at baseline, before every subsequent cycle and 3 weeks after the final dose of trastuzumab. The baseline risk of CTRCD was graded according to the risk score proposed by the Heart Failure Association (HFA) Cardio-Oncology Working Group and the International Cardio-Oncology Society (ICOS). CTRCD and its severity were defined according to the current European Society of Cardiology (ESC) guidelines. Twelve (10.9%) patients had asymptomatic CTRCD. All CTRCD occurred sporadically during the first 9 months of the active trastuzumab regimen in both low- and moderate-risk patients. While CTRCD was graded as moderate severity in 41.7% of patients and heart failure therapy was initiated promptly, no irreversible cardiotoxicity or trastuzumab interruption was recorded at the end of follow-up. Among the left and right heart deformation indices, only LV-GLS decreased significantly in the CTRCD group during the trastuzumab regimen. CTRCD is prevalent in patients with non-high-risk breast cancer undergoing trastuzumab chemotherapy. Low- and moderate-risk patients show distinct responses to trastuzumab. The LV-GLS is the only deformation index sensitive to early trastuzumab-related cardiac dysfunction.

ESC guidelines 2023 on the management of endocarditis : What is new?

In August 2023 the new European guidelines on the management of infective endocarditis were published by the European Society of Cardiology (ESC). Numerous recommendations were revised and supplemented by new ones. This review article outlines the essential modifications of the current ESC guidelines focusing on the prevention including antibiotic prophylaxis, the role of the endocarditis team, the revision of the diagnostic criteria, the paradigm shift towards oral antibiotic treatment, the timing and the indications for surgical treatment as well as the relevance of infections of cardiovascular implantable electronic devices.

Impact of appropriateness in clinical practice: data from a single-centre nuclear cardiology laboratory

Abstract Aims To verify the level of appropriateness of referral to our nuclear cardiology laboratory for stress myocardial perfusion imaging (MPI) and explore the correlation between test appropriateness patterns and ischaemia. Methods and results In 1870 consecutive patients (mean age 73 ± 12 years; 33% female) undergoing MPI, the level of imaging test appropriateness was evaluated according to the 2023 Appropriate Use Criteria (AUC) and the current European Society of Cardiology (ESC) guidelines for the management of chronic coronary syndromes. The evidence of moderate-to-severe ischaemia (i.e. summed difference score >7) was recorded. According to the AUC criteria, the MPI of 1638 (88%), 130 (7%), and 102 (5%) patients could be classified as ‘appropriate’, ‘inappropriate’, and ‘uncertain’, respectively. Similarly, in 1685 (90%) patients, the referral to MPI was adherent to ESC guidelines, while in 185 (10%), it was not. The majority of appropriate MPI tests showed the presence of moderate-to-severe ischaemia (55%), while only a limited number (10%; P < 0.05) of MPI tests with uncertain clinical appropriateness or clearly inappropriate indications did not. In patients managed adherently to ESC guidelines, invasive coronary angiography more frequently showed obstructive coronary artery disease (CAD) (93 vs. 47%, P < 0.001) and led to coronary revascularization (65 vs. 23%, P < 0.001) compared with patients managed non-adherently. Conclusion In a single-centre, single-national, single-modality population, the current rate of appropriate MPI tests is high. Appropriate referrals are associated with a higher probability of moderate-to-severe ischaemia and better downstream resource utilization than inappropriate ones.

Outbreak of severe myocarditis in England: Havoc by a harmless virus.

The World Health Organization (WHO) has been alerted to a concerning upsurge of severe myocarditis, an inflammatory heart condition, in neonates within Wales and South West England. The myocarditis cases are being intricately associated with enterovirus infection, belonging to the Picornaviridae family. The concerned pathogen poses a significant global disease burden, with an estimated 10 to 15 million symptomatic cases occurring annually in the United States alone. Neonates are particularly vulnerable with children under the age of one accounting for approximately 40% of enterovirus infections. A comprehensive literature search was conducted using various databases including ClinicalTrials, Google Scholar, PubMed, ScienceDirect, MEDLINE, and Ovid Resources. The search strategy included utilizing keywords such as "myocarditis," "Randomized controlled trials (RCTs). Only articles written in English were considered, and selection criteria included relevance to the research objectives, reasonable sample sizes, and robust methodology. In addition to the identified articles, meta-analyses, animal models and studies, and references from the selected articles were also examined to ensure a comprehensive review of the literature. Ten hospitalized neonates, reported in the United Kingdom (UK), with positive PCR tests were reported to have myocarditis, predominantly caused by coxsackieviruses. The current situation in the region has brought global attention. With this study, we hope to draw attention to the critical aspects of the illness and, more crucially, the present strategies required to control the disease outbreak in England. Current European Society of Cardiology (ESC) recommendations for the treatment of acute heart failure apply. Emerging research supports the use of immunosuppressive medication in some circumstances. Patients are advised to avoid aerobic activities for several months after healing. Neonatal enterovirus infections can vary in how they respond to IVIG therapy. The majority of enterovirus infections are self-limited, require no special therapy, and only little supportive care is required. The recent elevation in numbers for reported severe myocarditis in neonates within Wales and South West England, linked to enterovirus infection, poses a significant public health concern. Myocarditis caused by enteroviruses, particularly Group B coxsackieviruses, is associated with significant mortality rates. Diagnosis is supported by non-invasive techniques and cardiac enzyme blood tests. Treatment modalities primarily involve a palliative approach.

Risk factors in cardiovascular patients: Challenges and opportunities to improve secondary prevention.

Effective management of major cardiovascular risk factors is of great importance to reduce mortality from cardiovascular disease (CVD). The Survey of Risk Factors in Coronary Heart Disease (SURF CHD) II study is a clinical audit of the recording and management of CHD risk factors. It was developed in collaboration with the European Association of Preventive Cardiology and the European Society of Cardiology (ESC). Previous studies have shown that control of major cardiovascular risk factors in patients with established atherosclerotic CVD is generally inadequate. Azerbaijan is a country in the South Caucasus, a region at a very high risk for CVD. To assess adherence to ESC recommendations for secondary prevention of CVD based on the measurement of both modifiable major risk factors and their therapeutic management in patients with confirmed CHD at different hospitals in Baku (Azerbaijan). Six tertiary health care centers participated in the SURF CHD II study between 2019 and 2021. Information on demographics, risk factors, physical and laboratory data, and medications was collected using a standard questionnaire in consecutive patients aged ≥ 18 years with established CHD during outpatient visits. Data from 687 patients (mean age 59.6 ± 9.58 years; 24.9% female) were included in the study. Only 15.1% of participants were involved in cardiac rehabilitation programs. The rate of uncontrolled risk factors was high: Systolic blood pressure (BP) (SBP) (54.6%), low-density lipoprotein cholesterol (LDL-C) (86.8%), diabetes mellitus (DM) (60.6%), as well as overweight (66.6%) and obesity (25%). In addition, significant differences in the prevalence and control of some risk factors [smoking, body mass index (BMI), waist circumference, blood glucose (BG), and SBP] between female and male participants were found. The cardiovascular health index score (CHIS) was calculated from the six risk factors: Non- or ex-smoker, BMI < 25 kg/m2, moderate/vigorous physical activity, controlled BP (< 140/90 mmHg; 140/80 mmHg for patients with DM), controlled LDL-C (< 70 mg/dL), and controlled BG (glycohemoglobin < 7% or BG < 126 mg/dL). Good, intermediate, and poor categories of CHIS were identified in 6%, 58.3%, and 35.7% of patients, respectively (without statistical differences between female and male patients). Implementation of the current ESC recommendations for CHD secondary prevention and, in particular, the control rate of BP, are insufficient. Given the fact that patients with different comorbid pathologies are at a very high risk, this is of great importance in the management of such patients. This should be taken into account by healthcare organizers when planning secondary prevention activities and public health protection measures, especially in the regions at a high risk for CVD. A wide range of educational products based on the Clinical Practice Guidelines should be used to improve the adherence of healthcare professionals and patients to the management of CVD risk factors.

Radiomics of Late Gadolinium Enhancement Reveals Prognostic Value of Myocardial Scar Heterogeneity in Hypertrophic Cardiomyopathy

BackgroundLate gadolinium enhancement (LGE) scar burden by cardiac magnetic resonance is a major risk factor for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM). However, there is currently limited data on the incremental prognostic value of integrating myocardial LGE radiomics (ie, shape and texture features) into SCD risk stratification models. ObjectivesThe purpose of this study was to investigate the incremental prognostic value of myocardial LGE radiomics beyond current European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) models for SCD risk prediction in HCM. MethodsA total of 1,229 HCM patients (62% men; age 52 ± 16 years) from 3 medical centers were included. Left ventricular myocardial radiomic features were calculated from LGE images. Principal component analysis was used to reduce the radiomic features and calculate 3 principal radiomics (PrinRads). Cox and logistic regression analyses were then used to evaluate the significance of the extracted PrinRads of LGE images, alone or in combination with ESC or ACC/AHA models, to predict SCD risk. The ACC/AHA risk markers include LGE burden using a dichotomized 15% threshold of LV scar. ResultsSCD events occurred in 30 (2.4%) patients over a follow-up period of 49 ± 28 months. Risk prediction using PrinRads resulted in higher c-statistics than the ESC (0.69 vs 0.57; P = 0.02) and the ACC/AHA (0.69 vs 0.67; P = 0.75) models. Risk predictions were improved by combining the 3 PrinRads with ESC (0.73 vs 0.57; P < 0.01) or ACC/AHA (0.76 vs 0.67; P < 0.01) risk scores. The net reclassification index was improved by combining the PrinRads with ESC (0.25 [95% CI: 0.08-0.43]; P = 0.005) or ACC/AHA (0.05 [95% CI: −0.07 to 0.16]; P = 0.42) models. One PrinRad was a significant predictor of SCD risk (HR: 0.57 [95% CI: 0.39-0.84]; P = 0.01). LGE heterogeneity was a major component of PrinRads and a significant predictor of SCD risk (HR: 0.07 [95% CI: 0.01-0.75]; P = 0.03). ConclusionsMyocardial LGE radiomics are strongly associated with SCD risk in HCM and provide incremental risk stratification beyond current ESC or AHA/ACC risk models. Our proof-of-concept study warrants further validation.

Evaluation of the guideline-adherence of coronary angiography in patients with suspected chronic coronary syndrome – Results from the German prospective multicentre ENLIGHT-KHK project

With 900'000 coronary angiographies (CA) per year, Germany has the highest annual per capita volume in Europe. Until now there are no prospective clinical data on the degree of guideline-adherence in the use of CA in patients with suspected chronic coronary syndrome (CCS) in Germany. Between January 2019 and August 2021, 458 patients with suspected CCS were recruited in nine German centres. Guideline-adherence was evaluated according to the current European Society of Cardiology and German guidelines. Pre-test probability (PTP) for CAD was determined using age, gender, and a standardized patient questionnaire to identify symptoms. Data on the diagnostic work-up were obtained from health records. Patients were in mean 66.6years old, male in 57.3%, had known CAD in 48.4% and presented with typical, atypical, non-anginal chest pain or dyspnoea in 35.7%, 41.3%, 23.0% and 25.4%, respectively. PTP according to the European guidelines was in mean 24.2% (11.9%-36.5% 95% CI). 20.9% of the patients received guideline-recommended preceding non-invasive image guided testing. The use of CA was adherent to the European and German guideline recommendations in 20.4% and 25.4%, respectively. In multivariate-analysis, arterial hypertension and prior revascularization were predictors of guideline non-adherence. These are the first prospective clinical data which demonstrated an overall low degree of guideline-adherence in the use of CA in patients with suspected CCS in the German health care setting. To improve adherence rates, the availability of and access to non-invasive image guided testing needs to be strengthened. (German Clinical Trials Registry DRKS00015638 - Registration Date: 19.02.2019).

Suboptimal treatment of dyslipidemia in clinical practice

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Recent European Society of Cardiology (ESC) guidelines on the treatment of dyslipidemia recommend a target threshold &amp;lt;55 mg/dL of low density lipoprotein (LDL) cholesterol in patients with coronary artery disease. Some studies have suggested that most patients do not reach their LDL target. There is little evidence about the extend of this problem among patients treated in a University Hospital. Purpose Patterns of statin treatment and efficasy based on the achivement of LDL target level according to current and previous ESC guidelines. Methods We obtained clinical and laboratory data from 100 consecutive patients, whom were previously diagnosed and treated for coronary artery disease, and were readmitted at our hospital either for planned intervention or for signs or symptoms of ischemic heart disease. During the period between the 2 hospitalizations, all patients were under the supervision of their family physician or local cardiologyst. We analyzed patterns of statin treatment and their effect on cholesterol level regarding achivement of target threshold based on current and previous ESC guidelines. Results At first hospitalization, mean age was 65 +/- 9. 80% of the patinets were male. Mean total cholesterol levels were 190+/-52 mg/dl and mean LDL cholesterol levels were 133 +/-45 mg/dl on admission. On discharge a high intensity statin was prescribed in 75% of the patients, and a combination of Ezetimibe with statin was prescribed in 5% of them. On readmission mean total cholesterol levels were 163+/-46 mg/dl and mean LDL cholesterol levels were 109 +/-42 mg/dl. 79% of the patients were on a high intensity statin regime, and none of them were taking Ezetimibe. A target LDL chol &amp;lt;70 mg/dl recommended by 2016 ESC guidelines was reached in 21% of the patients, while a target LDL chol &amp;lt; 55 mg/dl recommended by 2019 ESC guidelines was reached in only 8% of the patients. Between the two hospitalizations, 39 (39%) of the patients had their lipid lowering therapy modified. 26 (26%) of them had an increase in statin dosage, all of them following their cardiologyst reccomendation. 13 patinets (13%) had a reduction in statin dosage and interruption of Ezetimibe treatment, despite the lack of any side effect. 4 of them following their cardiologyst reccomendation, 6 following their family physician, lab physician or pharmacist reccomendation and the last 3 patient decided on their own. Conclusions Implementation of guidelines in dyslipidemia treatment for secondary prevention in clinical practice is far from optimal even for patients discharged from an University Hospital. Additional efforts should be done to raise the awareness of all health care actors about the necessity of treatment with high dose statins and achivements of recommendet LDL target threshold for patienst with coronary artery disease.

Arterial hypertension management in patients with confirmed coronary heart disease: how far are we from meeting prevention goals?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction International registry studies offer useful information on the state of the cardiovascular risk factor management. The SURF CHD (Survey of Risk Factors in Coronary Heart Disease) II study is a clinical audit of the recording and management of major cardiovascular (CV) risk factors in patients with established coronary heart disease (CHD). CV risk factors’ control varies by countries and is typically insufficient, according to the prior studies. Purpose This study aimed to assess adherence to European Society of Cardiology (ESC) recommendations for secondary prevention of cardiovascular diseases based on the measurement of blood pressure (BP) control and its therapeutic management in patients with confirmed CHD at different hospitals in one of the regions at high risk for cardiovascular disease. Methods Eight public and private health care centres of Azerbaijan participated in the SURF CHD II study between November 2019 and April 2022. A one-page standard questionnaire of the study was used to collect information electronically on demographics, diagnostic category, risk factors, physical and laboratory data, and prescribed medications from consecutive patients aged ≥18 years with established CHD during outpatient visits. Uncontrolled arterial hypertension (AH) is identified as follows: systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. Results Data from 949 patients with CHD (the mean age 59.6±9.58 years; 27.3% female) were included in the study. Only 11.7% of participants were involved in a cardiac rehabilitation program. Previous history of AH was registered in 73,1% of participants, while uncontrolled SBP was detected in 59.6% of them. Regarding medications, 82.4% of patients were taking antihypertensive drugs: 52.2% were taking beta-blockers, 51.2% ACE inhibitors, 7.9% ARBs, and 31.7% calcium antagonists. Only 11.7% of participants were involved in a cardiac rehabilitation program. Conclusion The study results have shown that the implementation of the current ESC recommendations for CHD secondary prevention and in particular the control rate of BP is insufficient. Given the fact that patients are at very high risk with different comorbid pathologies, this is of great importance in the management of such patients. This should be taken into account by healthcare organizers when planning secondary prevention activities and public health protection measures, especially in the regions at high risk for cardiovascular disease.

The scale of scientific evidence behind the current ESC clinical guidelines.

European Society of Cardiology (ESC) clinical practice guidelines are currently considered as an essential tool supporting many cardiologists in clinical decision-making not only in Europe but all-over the world. In this study we analyzed these recommendations regarding their class of recommendations (COR) and level of evidence (LOE) to detect how solid is the scientific background behind these recommendations. We have abstracted all the current guidelines defined as "the guidelines available on the ESC website by 01 October 2022". All recommendations were classified according to their COR (Class I, IIa, IIb, or III) and LOE (A, B, or C). As every topic has different number of recommendations, we have used the median values in comparisons between different topics to give all the topics the same weight. Current ESC guidelines consist of 37 clinical topics including a total of 4289 recommendations. Their distribution was 2140 with a median of 49.9% in Class I, Class II and Class III were 1825 with a median of 42.6% and 324 with a median of 7.5% respectively. LOE A was only present in 667(15.5%) recommendations, 1285(30%) in LOE B, while LOE C was behind the majority of the recommendations, 2337 with a median of 54.5%. Although ESC guidelines are considered a gold standard for management of cardiovascular diseases, but surprisingly more than half of its recommendations are based on such scientific evidence. Deficiency in clinical trials is not the same across all guideline's topics, some are needier for clinical research.

Additive prognostic value of serum calcium to the ESC risk stratification in patients with acute pulmonary embolism

BackgroundHypocalcemia has been shown to be involved in the adverse outcomes of acute pulmonary embolism (APE). We aimed to determine the incremental value of adding hypocalcemia, defined as serum calcium level ≤ 2.12 mmol/L, on top of the European Society of Cardiology (ESC) prognostic algorithm, for the prediction of in-hospital mortality in APE patients, which in turn could lead to the optimization of APE management.MethodsThis study was conducted at West China Hospital of Sichuan University from January 2016 to December 2019. Patients with APE were retrospectively analyzed and divided into 2 groups based on serum calcium levels. Associations between hypocalcemia and adverse outcomes were assessed by Cox analysis. The accuracy of risk stratification for in-hospital mortality was assessed with the addition of serum calcium to the current ESC prognostic algorithm.ResultsAmong 803 patients diagnosed with APE, 338 (42.1%) patients had serum calcium levels ≤ 2.12 mmol/L. Hypocalcemia was significantly associated with higher in-hospital and 2-year all-cause mortality compared to the control group. The addition of serum calcium to ESC risk stratification enhanced net reclassification improvement. Low-risk group with serum calcium level > 2.12 mmol/L had a 0% mortality rate, improving the negative predictive value up to 100%, while high-risk group with serum calcium level ≤ 2.12 mmol/L indicated a higher mortality of 25%.ConclusionOur study identified serum calcium as a novel predictor of mortality in patients with APE. In the future, serum calcium may be added to the commonly used ESC prognostic algorithm for better risk stratification of patients suffering from APE.

Achievement of the ESC recommendations for secondary prevention of cardiovascular risk factors in high-risk patients with type 2 diabetes: A real-world national cohort analysis

AimTo assess compliance with European Society of Cardiology (ESC) secondary prevention recommendations in a nationwide contemporary population with diabetes mellitus (DM) and coronary artery disease. MethodWe conducted a retrospective observational study using linked health data in patients across Wales with DM undergoing percutaneous coronary intervention (2012–2017). The follow-up was for one year. We analysed the clinical characteristics, medications, target levels for HbA1c, low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C) and blood pressure against the ESC prevention guidelines. ResultsOverall, 3478 patients with diabetes had available data at 1-year post-PCI. Only 43% had HbA1c levels <53 mmol/L, but 81% had blood pressure < 140/80 (current ESC targets).Prescribing frequency of the newer hypoglycaemic agents (glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter 2 inhibitors) was suboptimal, with a higher rate in patients with HbA1c ≥53 mmol/mol.Only 51% & 27% of the patients had LDL-C levels <1.8 &1.4 mmol/L (2016 & 2019 guidelines recommendations respectively), and 55% & 34% had non-HDL-C levels <2.6 & 2.2 mmol/L (2016 & 2019 guidelines respectively). Of the uncontrolled LDL-C patients, 42% (2016 target) and 35% (2019 target) were prescribed high-intensity statins. Females were more likely to have LDL-C targets above the recommended level. ConclusionAchievement of ESC treatment goals in this very-high risk cohort for DM and hyperlipidaemia was far from optimal, with a low prescription rate of the guidelines-recommended therapy. Target goals for hypertension were met more frequently. An up-to-date analysis reflecting the current practice against the most recent guidelines is warranted.

695 PRESCRIBING A COMPREHENSIVE THERAPY WITH THE FOUR FOUNDATIONAL TREATMENTS OF HEART FAILURE WITH REDUCED EJECTION FRACTION AMONG IN-PATIENTS AT DISCHARGE

Abstract Background Current guidelines recommend that patients with heart failure and a reduced ejection fraction (HFrEF) should receive four foundational treatments, i.e. renin-angiotensin system inhibitor (RASi) or angiotensin-receptor neprilysin inhibitor (ARNi), β-blocker, mineralocorticoid receptor antagonist (MRA) and sodium-glucose cotransporter 2 inhibitor (SGLT2i). There is emerging consensus that simultaneous initiation or rapid sequencing provide greater benefit, enhancing tolerability of these therapies and improving outcomes. However, implementation of a comprehensive approach is limited by common underuse and underdosing, and paucity of data exists on initiating the four pharmacological pillars of HFrEF during hospitalization or at discharge. Aim To investigate the feasibility of a comprehensive pharmacological approach in patients with HFrEF at discharge after an episode of heart failure (HF) hospitalization in a tertiary referral center. Methods In-patients with HFrEF and a first HF hospitalization (2019-2021) were categorized according to the number/type of treatments prescribed at discharge. Prevalence of contraindications and cautions for HFrEF treatments – as defined by current European Society of Cardiology (ESC) guidelines on HF – was as assessed. Logistic regression models were fitted to assess predictors of number of treatments prescribed and risk of re-hospitalization. Results Among 305 patients with HFrEF, 49.2% received at least two current recommended drugs. A β-blocker was prescribed in 93.4% of patients, and a RASi/ARNi in 68.2%. Based on current recommendations, 46.2% of patients could receive four foundational drugs. An MRA was prescribed in 32.5% of patients and 100% of patients did not show contraindications to MRA use. Renal dysfunction was present in 13.1% of patients, while hypotension in 11.8%. Bradycardia and renal dysfunction were associated with lower number of drugs prescribed [adjusted OR (95% CI) 0.18 (0.06-0.50), and 0.50 (0.39-0.64), respectively]. A higher number of drugs used was associated with no rehospitalization during the 30 days after discharge [OR (95% CI) 0.22 (0.10-0.49) per number of pillars increase]. Conclusions Based on the presence/absence of contraindications, a quadruple therapy could be implementable in a contemporary cohort of HFrEF in-patients at discharge. Renal dysfunction and bradycardia were the main prevalent conditions limiting the achievement of a more comprehensive therapeutic approach. Use of a higher number of drugs was associated with lower risk of re-hospitalization within 30 days after discharge.

Main stem intervention-Is one stent better than two after all?

The current European Society of Cardiology (ESC) guideline recommendations give equal consideration to percutaneous coronary interventions (PCI) and bypass surgery for the treatment of main stem stenosis. Because of the anatomical setting, interventional treatment of main stem stenosis represents acomplex PCI procedure. For this reason, extensive planning of the PCI with the use of intravascular imaging is necessary to assess the extent of calcification in the main stem itself and also in the proximal vascular segment of the anterior interventricular branch (left anterior descending, LAD) and the circumflex branch (RCX). Furthermore, an assessment of the vessel diameter is necessary for planning the PCI as well as for stent selection. Especially in the case of severely calcified lesions, careful and routine dissection of the lesion to be treated is essential. For this purpose, so-called cutting balloons, scoring balloons or debulking devices (rotational atherectomy, orbital atherectomy) can be used. In the case of amain stem stenosis involving the bifurcation, the choice of stent strategy depends on the extent of calcification of the daughter vessels (LAD and RCX), as well as the complexity of the bifurcation stenosis. The superiority of the so-called double kissing (DK) crush technique over asingle stent strategy could be confirmed in arandomized trial and should be used in main stem bifurcation stenoses with pronounced calcification of the proximal segments of the LAD and RCX (stenosis length > 10 mm, and > 70% diameter stenosis). The already established 2‑stent strategies for the treatment of bifurcation stenosis could be modified or further developed. In preliminary studies the advantage of the so-called DK nano-crush technique and the DK culotte technique could be shown, whereby these initial results still have to be confirmed by larger randomized studies.

Heart failure in Fabry disease revisited: application of current heart failure guidelines and recommendations.

Fabry disease (FD) is often associated with heart failure (HF). However, data on HF prevalence, prognosis, and applicability of echocardiographic criteria for HF diagnosis in FD remain uncertain. We evaluated patients with genetically proven FD for symptoms and natriuretic peptides indicating HF. We then analysed the diagnostic utility of the currently recommended European Society of Cardiology (ESC) echocardiographic criteria for HF diagnosis and their relationship to natriuretic peptides. Finally, we examined the association between HF and echocardiographic criteria with mortality and cardiovascular events during follow-up. Of 116 patients with FD, 48 (41%) had symptomatic HF (mean age 58±11years, 62% male). HF with preserved ejection fraction (HF-pEF) was diagnosed in 43 (91%) patients, representing the dominant phenotype. Left ventricular mass index (LVMi) had the highest diagnostic utility (sensitivity 71% and specificity 83%) for HF diagnosis in FD, followed by E/e'>9 (sensitivity 76% and specificity 78%) and global longitudinal strain (GLS) <16% (sensitivity 54% and specificity 88%). Log N-terminal pro-brain natriuretic peptide correlated significantly with LVMi (r=0.60), E/e' (r=0.54), and GLS (r=0.52) (all Ps<0.001) but not with left ventricular ejection fraction (r=-0.034, P=0.72). During follow-up (mean 1208±444days), patients diagnosed with HF had a higher rate of all-cause mortality and worsening HF (33% vs. 1.5%, P<0.001). Abnormal LVMi, E/e'>9, and GLS<16% were all associated with higher all-cause mortality and worsening HF. This study found a high prevalence of symptomatic HF in FD patients. HF-pEF was the dominant phenotype. LVMi, E/e', and GLS yielded the highest diagnostic utility for HF diagnosis and were significantly correlated with natriuretic peptides levels. Echocardiographic criteria proposed by current ESC HF guidelines apply to Fabry patients and predict cardiovascular events. At follow-up, Fabry patients with HF diagnosis had high event rates and significantly worse prognosis than patients without HF.

Opinions of cardiologists on class II recommendations in current European Society of Cardiology 2018-2020 guidelines: YELLOW BOX

Objectives: We planned our survey study to evaluate the opinion of cardiologists about the class II recommendations on levels of evidence in the current European Society of Cardiology Guidelines (ESC). Our aim is to determine which diagnosis or treatment option most prefer by cardiologist when guidelines do not make clear recommendations. Methods: The survey was conducted on September 2020 with the participation of cardiologists (n = 102). Our survey covers ESC's guidelines published in 2018-2020 on diagnosis and treatment strategies in coronary artery disease, diabetes, heart valve disease, arrhythmia, dyslipidemia and heart failure. Our survey consisting of 40 questions was shared with the cardiologists via e-mail. Results: Participants answered all of the survey questions. The majority of the participants (79.41%) did not consider the addition of a second long-term antithrombotic medication in addition to aspirin for secondary prevention in diabetes mellitus (DM) and coronary artery disease (CAD) patients who are not at high risk of bleeding. The lowest low density lipoprotein (LDL) value achieved by the participant physicians with treatment in their practices was &amp;lt; 40 mg/dl in 32 (31.37%) participants . One of the striking results of the survey was that 51.96% of the participants stated that it was not possible to measure the lipoprotein a (Lp(a)) level in the center where they were carrying out their practices, and 34.31% did not consider the Lp(a) level in the treatment of dyslipidemia in terms of directing the treatment. As for patients with asymptomatic Wolff-Parkinson-White (WPW) syndrome, 58.82% of the participants considered catheter ablation therapy. Conclusions: Although there were different opinions on some recommendations, the participants were mostly in agreement. We think that these survey results, which were mostly based on expert opinions, may contribute to the guidelines to be published in the future with the increase of survey studies on these issues.

Patient delay in patients with st-elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Snedkermester Sophus Jacobsen og hustru Astrid Jacobsens fond Background/Introduction Rapid revascularisation therapy (primary percutaneous intervention (PCI)) is widely established as the most important factor in preventing myocardial damage after ST-Elevation Myocardial Infarction (STEMI)(1,2). Current ESC (European Society of Cardiology) guidelines recommends fast revascularisation therapy within 120 minutes of symptom onset(3). Despite this, previous studies have shown patient delay times above 120 minutes in more than 50% of patients(2,4). Reducing patient delay is therefore an important factor in the endeavour of decreasing myocardial damage and for prediction of outcome following STEMI. However, most knowledge on this field originates from registry-based studies(4). Previous studies conducted in Denmark, rely on data from danish quality databases containing data such as delay times, cardiac risk factors and procedure specific information. The few studies on this field using patient reported data, have focused on subpopulations or sex differences(5). Purpose The purpose of this study was to investigate the patient reported delay in STEMI patients and to compare the registered delay times to the physician reported delay in databases. Methods This single center study includes interviews of 129 patients hospitalized for STEMI between April and October 2021. The patients participated in semi-structured patient interviews conducted within 30 days of hospitalization. The main focus of the interviews was time of symptom onset and time of first medical contact, but other factors such as symptom presentation and perception, lifestyle choices and care seeking behaviour were also investigated. The patient reported delay times were then compared with the delay time registered in danish quality databases, using descriptive analysis and double-sided T-test. Results 148 patients were included to the study. Upon contact, 19 were lost to follow up. 16 patients had missing delay times in the database. The final study cohort consisted of 113 patients (93 men and 20 women) aged 30-94 years (mean: 62,7 years). We observed that on average patient reported delay times were 5 hours longer than the physician reported delay times in the databases, P=0.0080. The disagreement in delay times ranged from -25 hours to 159 hours. Conclusions We found a substantially longer delay time when comparing patient reported delay times with physician reported delay times. This is of high clinical importance in relation to proper prediction of outcomes, and to ensure the aiming of future information campaigns to populations most at need. As quality measures in this field relies on database registrations, it is imperative to address this discrepancy in order to improve patient delay times.

Novel options to maximize oral lipid lowering treatment : Role of bempedoic acid in combination treatment

Epidemiological, randomized, controlled, clinical and genetic studies confirm that low-density lipoprotein cholesterol (LDL-C) is acausative factor for atherosclerotic diseases. The current European Society of Cardiology and European Atherosclerosis Society (ESC/EAS) guidelines on the management of dyslipidemia recommend atarget LDL-C < 55 mg/dl and at least a50% reduction in baseline LDL‑C for high-risk patients; however, these target values are often not achieved in routine clinical practice, as shown by recent cross-sectional data from EUROASPIRE or DaVinci. Therefore, combination treatment is recommended, which, as with treatment of blood pressure, can improve the success of treatment. Bempedoic acid is anew substance, which is suitable for combination treatment and represents an alternative particularly for patients with statin-associated muscular symptoms. Bempedoic acid reduces LDL‑C by approximately 25% in statin-naïve patients and by some 18% in addition to statins. In a fixed doses combination with ezetimibe, bempedoic acid can lower LDL‑C by up to 45% in statin-naïve patients and by 38% (placebo-corrected) in addition to statins. Bempedoic acid is generally very well tolerated: however, it can lead to areversible increase in uric acid. Occasionally, aslight decrease in hemoglobin has been documented. Therefore, it is recommended that not only changes in lipid levels but also uric acid and hematological parameters should be monitored in the first 3months.

Update for the Performance of CT Coronary Angiography - Evidence-Based Application and Technical Guidance According to Current Consensus Guidelines and Practical Advice from the Clinical Routine.

Coronary CT angiography (cCTA) is a class 1 recommendation in the current guidelines by the European Society of Cardiology (ESC) for excluding significant coronary artery stenosis. To achieve optimal image quality at a low radiation dose, the imaging physician may choose different acquisition modes. Therefore, the consensus guidelines by the Society of Cardiovascular Computed Tomography (SCCT) provide helpful guidance for this procedure. The article provides practical recommendations for the application and acquisition of cCTA based on the current literature and our own experience. According to current ESC guidelines, cCTA is recommended in symptomatic patients with a low or intermediate clinical likelihood for coronary artery disease. We recommend premedication with beta blockers and nitrates prior to CT acquisition under certain conditions even with the latest CT scanner generations. The most current CT scanners offer three possible scan modes for cCTA acquisition. Heart rate is the main factor for selecting the scan mode. Other factors may be coronary calcifications and body mass index (BMI). · CCTA is a valid method to exclude coronary artery disease in patients with a low to intermediate clinical likelihood.. · Even with the latest generation CT scanners, premedication with beta blockers and nitrates can improve image quality at low radiation exposure.. · Current CT scanners usually provide retrospective ECG gating and prospective ECG triggering. Dual-source scanners additionally provide a "high pitch" scan mode to scan the whole heart during one heartbeat, which may also be achieved using single-source scanners with broad detectors in some cases.. · Besides the available scanner technology, the choice of scan mode primarily depends on heart rate and heart rate variability (e. g., arrhythmia).. · Soschynski M, Hagar MT, Taron J et al. Update for the Performance of CT Coronary Angiography. Fortschr Röntgenstr 2022; 194: 613 - 624.