History Of Ischemic Heart Disease Research Articles

Usage and risk with phosphodiesterase type 5 inhibitors in male patients with chronic ischemic heart disease on oral organic nitrates

Abstract Background Combining oral organic nitrates (OON) with phosphodiesterase type 5 (PDE5) inhibitors is contraindicated. Growing and liberal use of PDE5 inhibitors for erectile dysfunction among patients with ischemic heart disease (IHD) could pose serious health consequences especially among patients with IHD on OON. Purpose We hypothesize that concomitant prescription of OON and PDE5 inhibitors is prevalent and has increased in recent years, and further that possible co-exposure could be associated with an increased risk of ischemic stroke, myocardial infarction (MI) or acute coronary angiography (CAG). Methods During 2000–2018, we included all male patients with history of IHD between 18 and 85 years of age from nationwide Danish health registers. Patients with a history of pulmonary hypertension were excluded and not followed up afterwards if they developed the condition during follow-up. From this cohort, we identified an OON treated subgroup defined by two consecutively redeemed prescriptions of OON within 180 days from each other. Further, to become a case or control, patients had to redeem a prescription of OON within 180 days prior to the event or corresponding date among controls. Temporal trends during 2001–2018 of PDE5 inhibitor use were calculated among all male patients with IHD and the subgroup on OON. Among OON treated patients, we examined associations between PDE5 inhibitor use and risk of ischemic stroke, MI or CAG using a case-crossover design where each individual serves as his/her own control thereby controlling for time-invariant confounding. The case-crossover design compares an individual's exposure in an index period just before the event occurred to a reference period prior to the index period. We investigated periods of varying length (7, 14, 21 and 28 days). To account for possible temporal trends in the use of PDE5 inhibitors, we also conducted a case-time-control analysis using a control group matched on age and calendar year. Results We identified 249,541 male patients with IHD (median age 65 years [IQR 56–73]), and a subgroup of 42,073 (17%) on OON treatment (median age 70 years [IQR 62–77]). From 2001 to 2018, the use of PDE5 inhibitors saw a 6-fold increase among all male IHD patients and a 10-fold rise in the subgroup on OON (Figure 1). The risk of ischemic stroke, MI or CAG following exposure to PDE5 inhibitors was not increased in the OON subgroup in neither the case-crossover nor the case-time-control analyses (Figure 2). Conclusions The use of PDE5 inhibitors has increased 6-fold since 2001 among male patients with IHD, and 10-fold among patients on OON–notwithstanding an established absolute contraindication. However, we did not find any evidence of an increased risk of ischemic stroke, MI or acute CAG following exposure to PDE5 inhibitors in the OON subgroup. This suggests that patients on OON are adequately informed and comply with the recommended pause in OON medication prior to PDE5 inhibitor use. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Ib Mogens Kristiansens Almene FondandHelsefonden

Detection and prevalence of intra-cardiac thrombus in patients with embolic stroke of undetermined source

Abstract Background Embolic Stroke of Undetermined Source (ESUS) is defined as non-lacunar brain infarct without proximal arterial stenosis or known cardioembolic source (including atrial arrythmias). Little is known about the prevalence of intra-cardiac thrombus as a potential source of embolism in patients presenting with ESUS. Objectives To examine the use of contrast-enhanced electrocardiogram-gated computed tomography (CT) to elucidate the prevalence of intra-cardiac thrombus in patients suspected of ESUS. Methods We retrospectively investigated 101 consecutive patients who presented to our hospital with ESUS between January 2019 and March 2021 and underwent 2D echocardiography and CT as part of stroke etiology evaluation. Results In our study population (73.2±9.98 years, 41% female), CT detected intra-cardiac thrombus in 19 (18.8%) patients. Left ventricular thrombus (LVT) was found in 10 (9.9%) patients and left atrial/left atrial appendage in 8 patients. All of cases of LVT were detected by cardiac CT, while 2D echocardiography was able to detect only four of these cases. All cases of LVT were associated with significant coronary obstructive disease, while in 2 out of 10 patients, a previous history of ischemic heart disease was unknown. Using CT 2 patients after transcatheter aortic valve implantation were diagnosed with hypoattenuated leaflet thickening, and 3 patients with concomitant pulmonary embolism. In total, the finding of CT resulted in change of management, indication for anticoagulation instead of antiplatelets drugs, in 23 (22.7%) patients. Conclusion CT may help to improve the detection of intra-cardiac thrombus in patients presenting with ESUS and therefore provide relevant information for anticoagulation therapy and need of further coronary evaluation and intervention. The high prevalence of intra-cardiac thrombus in ESUS patients make the use of complementary 3D imaging important. Funding Acknowledgement Type of funding sources: None.

No dynamic changes in plasma ACE2 activity in patients with acute coronary syndrome

Abstract Background Angiotensin converting enzyme 2 (ACE2) is expressed in the human myocardium and blood vessels and degrades the vasoconstrictor peptide angiotensin (Ang) II. Plasma ACE2 activity is elevated in patients with cardiovascular disease (CVD) and is a predictor of major adverse cardiovascular events (MACE) in obstructive coronary artery disease. However, it is unknown whether acute coronary syndrome (ACS) causes dynamic changes in plasma ACE2 activity. Purpose We investigated dynamic changes in serial troponin-T and plasma ACE2 activity in patients presenting with ACS who underwent invasive coronary angiography (ICA). Methods Consecutive patients admitted with ACS from October-November 2019 were screened. Those meeting the Fourth Universal Definition of Myocardial Infarction who had both ICA and serial troponin-T testing were included. The study was approved by the hospitals Human Research Ethics Committee. All patients had routine plasma samples taken over 3 time-points for measurement of troponin-T; the same sample was used to measure plasma ACE2 activity. Catalytic ACE2 activity was measured using a validated, sensitive quenched fluorescent substrate-based assay. Serial median troponin and ACE2 activity levels were analysed using the Friedman test for repeated measures. Results Forty-nine patients were included. The mean age of participants was 63.9±11.0 years, and 36 (74%) patients were male. Overall, 16 (36%) patients presented with ST-elevation myocardial infarction (STEMI) and 29 (74%) with non-ST-elevation myocardial infarction (NSTEMI). Twenty-nine (59%) patients had a history of hypertension and 14 (29%) a history of ischaemic heart disease; 13 (27%) with priorMI, 11 (22%) had previous PCI and 2 (4%) had prior coronary artery bypass grafting. Over the 3 time points, there was a clear rise in median troponin-T levels representing myocardial injury (p<0.001), with no change in median plasma ACE2 activity (p=0.23, table 1). There was no difference in median ACE2 activity in those presenting with STEMI vs. NSTEMI (6.9 [2.1–9.5] vs. 6.0 [1.8–12.1], p=0.87), nor in those who underwent PCI to a culprit lesion compared to those who did not have a culprit lesion stented (5.8 [0.9–10.5] vs. 7.3 [2.8–14.9], p=0.37). Conclusions Patients with ACS had higher plasma ACE2 levels compared to levels previously reported in healthy controls. There were no dynamic changes in ACE2 activity in the setting of ACS, despite a significant rise in troponin-T. These results suggest that plasma ACE2 levels reflect underlying endothelial dysfunction rather than acute myocardial injury or infarction. Studies are now underway to assess if plasma ACE2 activity in ACS predicts MACE. Funding Acknowledgement Type of funding sources: None. Table 1

Inflammatory risk factors are not associated with coronary artery calcification in patients with myeloproliferative philadelphia-negative neoplasms

Abstract Background Myeloproliferative Philadelphia-negative Neoplasms (MPNs) are hematological cancers associated with chronic inflammation and endothelial dysfunction, conditions that may lead to development of premature atherosclerosis. Purpose To investigate whether biomarkers of inflammation and endothelial dysfunction are associated with the degree of atherosclerotic burden, measured by Coronary Artery Calcium Score (CACS), in patients with MPNs. Methods Patients with a validated MPN diagnosis; essential thrombocythemia (ET), polycythemia vera (PV) or myelofibrosis (MF), were recruited between 2016 and 2018 from one single specialized hematologic center. Patients filled out a standardized questionnaire on medical history, current medication, alcohol and smoking habits and family medical history. They were examined by cardiac computed tomography (CT), Endothelial Peripheral Arterial Tone (EndoPAT), and a range of blood analyses. The atherosclerotic burden was evaluated by CACS. High sensitivity C-reactive protein (hs-CRP) and Neutrophil:Lymphocyt Ratio (NLR) were used as indicators of chronic inflammation. EndoPAT was applied to evaluate endothelial dysfunction, which is linked to development of atherosclerosis. The JAK2V617F-mutation is a common gene mutation in MPN-patients. It affects the gene coding the Janus kinase 2 (JAK2) protein, and can be detected by qPCR of peripheral blood or bone marrow. The JAK2V617F-mutation is a risk factor associated with both chronic inflammation and endothelial dysfunction. Multivariable logistic regression analyses were used to identify associations between potential risk factors and a higher CACS value. Results Among 170 included patients, 161 patients completed cardiac CT (mean age 65.5 (SD 10.5), 52% men). Baseline data is presented in Table 1. JAK2V617F-mutation was found in 137 (85%) patients, 53 patients (35%, n=152) had hs-CRP>2.0 mg/L, 107 (67%, n=160) had NLR>2.15 and 32 (21%, n=154) had an abnormal EndoPAT. Overall, 66 patients (41%) had a CACS>100, with no significant difference between ET (41%), PV (42%) and MF (50%) (p=0.3). In patients with a history of ischemic heart disease (IHD), 92% had CACS>100, compared to 37% in patients without prior IHD (p=0.0003). Five independent factors associated with a CACS>100 were identified; age (OR: 1.3 [95% CI 1.1–1.4]), male sex (OR: 15.2 [95% CI 4.0–57.7]), prior IHD (OR: 15.9 [95% CI 1.2–202.4]), smoking (OR: 3.3 [95% CI 1.1–10.1]), and abnormal EndoPAT (OR: 4.8 [95% CI 1.1–20.0]) (Figure 1). Hs-CRP, NLR and JAK2V617F-mutation status were not significantly associated with CACS >100. Conclusion In this cohort of patients with MPNs, markers of chronic inflammation like hs-CRP and NLR were not associated with higher CACS, nor was the JAK2V617F-mutation. Traditional risk factors of cardiovascular disease seem to be sufficient to identify MPN patients with increased atherosclerotic burden, but measuring endothelial dysfunction provides additional information. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Department of Cardiology, Zealand University Hospital, Region Zealand, Denmark Table 1. Baseline characteristicsFigure 1. Odds ratio for CACS >100

Exercise ECG testing in patients without known ischemic heart disease: predictors of ischemia of downstream vasodilator stress cardiac magnetic resonance

Abstract Background In routine clinical practice, patients with chest pain and suspected stable ischemic heart disease (SIHD) usually undergo an exercise ECG stress test (ExECG) for ischemia detection. However, since the sensitivity of this technique is relatively low, concerns exist that many patients could remain underdiagnosed. We intend to assess the clinical and ExECG predictors of ischemia on subsequent vasodilator stress cardiac magnetic resonance (vs-CMR) to help select which patients should undergo downstream testing after an initial ExECG. Material and methods We retrospectively included 197 patients without previous history of ischemic heart disease who underwent an ExECG and a subsequent vs-CMR in the year after this test and who didn't undergo a revascularization procedure in this time frame. Clinical, ExECG and vs-CMR variables were included in the registry. vs-CMR was considered positive if ischemia was evident in at least one myocardial segment on stress first-pass perfusion without concomitant necrosis on late gadolinium enhancement imaging. We performed univariate and multivariate analysis to check for the association of variables with the risk of ischemia on vs-CMR. Results Mean time from ExECG to vs-CMR was 88.69±84.32 days and 37 vs-CMR were positive for ischemia. Male sex, less exercise time, less % of maximum predicted exercise capacity, less maximum double product (heart rate x systolic blood pressure) and less double product reserve (DPR = maximum double product - basal double product) were associated with ischemia on vs-CMR on univariate analyses. However, the only independent predictors of ischemia on vs-CMR on multivariate binary logistic regression were male sex (HR 2.62 [CI 95%: 1.13–5.76], p=0.016) and less DPR (HR 0.90 [CI 95%: 0.84–0.97] per 1000 increase, p=0.006). The risk score derived from these two variables had a moderate predictive power (ROC curves, AUC 0.657, p=0.003). The best cut-off point for the DPR was 12400, as derived from the Youden index. It allowed stratification of the risk of ischemia on vs-CMR, which ranged from 9% in women with >12400 DPR, 18.8% in men with >12400 DPR, 24.1% in women with ≤12400 DPR to 42.9% in men with ≤12400 DPR (p=0.005, Figure 1). Conclusions Male sex and less double product reserve on ExECG can moderately predict the risk of ischemia on subsequent vs-CMR in patients presenting with chest pain and without previous SIHD. This can help select patients who benefit most from vs-CMR for diagnostic purposes. Funding Acknowledgement Type of funding sources: None. Figure 1

Ocular Surface Temperature: Characterization in a Large Cohort of Healthy Human Eyes and Correlations to Systemic Cardiovascular Risk Factors.

Purpose: To characterize ocular surface temperature (OST) in healthy eyes and its association with systemic risk factors of cardiovascular and ischemic heart disease. Methods: This prospective cross-sectional study included consenting subjects who were examined at the Institute for Medical Screening in Sheba Medical Center. A Therm-App™ thermal imaging camera (Opgal LTD, Israel) was used for OST acquisition, and the mean OST of the medial canthal, lateral canthal, and central cornea regions were measured. Room and body temperatures were also recorded. Past medical and ocular history as well as data from various clinical examinations performed at the same visit were obtained. Results: Thermographic images were obtained from 186 subjects, 150 of which were included in the final analysis. OST was significantly higher in the medial canthal, central cornea, and lateral canthal regions in people with a history of ischemic heart disease (p = 0.02, p = 0.02, and p = 0.03, respectively). There were no significant OST differences (ANOVA test) associated with the presence of hypertension, diabetes mellitus, or active smoking status. Conclusions: OST correlated positively with the presence of ischemic heart disease. This correlation, its pathophysiological base, and its clinical application warrants further investigation.

Study the Value of Interleukin-6 As Diagnostic and Predictive marker of Cardiac Events in St Segment Elevation Myocardial Infarction

Abstract Background Owing to major changes in the biomarkers available for diagnosis, criteria for acute myocardial infarction have been revised. The current international consensus definition states that the term acute myocardial infarction (AMI) should be used when there is evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia. The present guidelines pertain to patients presenting with ischemic symptoms and persistent ST-segment elevation on the electrocardiogram (ECG). Most of these patients will show a typical rise in biomarkers of myocardial necrosis and progress to Q wave myocardial infarction. Separate guidelines have recently been developed by another task force of the ESC (European Society of Cardiology) for patients presenting with ischemic symptoms but without persistent ST segment elevation and for patients undergoing myocardial revascularization in general. Aim of the work The aims of this work are: To assess the diagnostic value of interleukin-6 compared to troponin I in ST segment elevation myocardial infarction. To assess the predictive value of elevated interleukin-6 in ST segment elevation myocardial infarction. Patients This prospective study was included sixty adult patients of both sexes meeting the American Heart Association (AHA) recommendations for diagnosis of ST segment elevation myocardial infarction from those attending the Critical Care Units, Critical Care Medicine Department, Faculty of Medicine, Ain Shams University to be included in the current study. Inclusion Criteria :Patients were fulfilled the criteria of diagnosis of acute coronary syndrome (ACS) and diagnosed as ST segment elevation MI according to American Heart Association (AHA) criteria which include patient ranging between 30 to 70 years and presented with active chest pain. Exclusion Criteria Patients were excluded from the study if they have: (1) Recent myocardial infarction in the last three months. (2) Recent cardiological intervention in the last three months. (3) Recent ischemic cerebrovascular stroke in the last three months. (4) Non ST segment elevation myocardial infarction and unstable angina according to electrocardiographic changes, cardiac markers and clinical condition of the patients. (5) Acute infectious diseases that leads to elevation of troponin I and interleukin-6. (6) Active immunological diseases. (7) Renal impairment. Methods The following data were obtained from each patient: Personal data: name, age, sex, occupation and special habits e.g. smoking. History of present illness regarding to clinical condition: onset, nature, duration, course, progression, characteristic site and radiating areas of the chest pain, relieving and aggravating factors, associated symptoms (as diaphoresis, nausea, vomiting, dyspnea and palpitation) and medication received and their effects. Medical history of diabetes mellitus (DM), hypertension (HTN), and history of ischemic heart disease (IHD). Family history of IHD, DM and HTN. Conclusion From this current study we revealed that: STEMI patients have increased level of interleukin-6 compared to those normal persons. Interleukin-6 may be a potentially useful marker for diagnosis of STEMI. Interleukin-6 may be helpful prognostic value for future cardiac mortality in STEMI patients. The level of interleukin-6 is not affected by the extent of myocardial damage and necrosis. Interleukin-6 is an inflammatory cytokine. Recommendations From this study we recommend the use of interleukin-6 level as good diagnostic marker for diagnosis of ST segment elevation myocardial infarction, Also this study recommend the use of interleukin-6 as good prognostic inflammatory marker in future adverse cardiac events and mortality occur after myocardial infarction STEMI type. Study limitations The results are interpreted in consideration of the small population of patients and short term follow up.

Ayurveda Approach for Ischemic Heart Disease - A Case Report

Vathaja Hruth Rogha mostly correlated to Ischemic Heart Disease (IHD) and to introduce desirable food & lifestyle (Pathayahara viharana) mentioned in authentic texts in Ayurveda. The patient was under the treatment from Heart Disease clinic at Bandaranaike Memorial Ayurvedic Research Institute. Sixty five year old male patient presented with very recent history of IHD diagnosed as Class II angina. Angiogram diagnosed as Triple Vessel Disease and Left Main Coronary Artery 50- 60 % stenosis. With reference to causative factors and clinical features it was diagnosed as Vathaja Hrud Rogha. After12 weeks of treatment continuously with Danyakashunti decoction, Lavangadi Choorna (herbal powder), Nawarathna kalkai (semi solid preparation) and Dashanga Guggulu pills including dietary and lifestyle modification. Symptoms of angina and breathlessness disappeared, the patient still under the follow up treatment in the heart disease clinic completed almost three years. The patient’s clinical evaluation and normal ECG confirms that the treatment principle in Ayurveda and herbal preparations for Vathaja Hrud Rogha would be effective treatment modality for the patients with Ischemic Heart Disease.

Factors that Predict Smoking Cessation among Older Koreans: Based on the Korea National Health and Nutrition Examination Survey 2016–2018

BackgroundTobacco smoking is associated with several diseases and deaths in older Koreans. This study aimed to evaluate the factors associated with smoking cessation in older Koreans. MethodsWe selected 579 subjects who started smoking before the age of 65 years from the Korea National Health and Nutrition Examination Survey 2016–2018. We excluded the subjects who quit smoking before the age of 65 years, and then categorized the rest of subjects into those who stopped smoking after the age of 65 years and those who are constant smokers. Multivariable logistic analysis was performed to evaluate the factors related to smoking cessation among older Koreans. ResultsAmong the participants, 66.1% were persistent smokers. After multivariable analysis, the factors significantly associated with smoking cessation were as follows: being in the age group of 75–79 years (adjusted odds ratio [aOR], 4.07; 95% confidence interval [CI], 2.12–7.83), being in the age group of 70–74 years (aOR, 3.10; 95% CI, 1.72–5.61), a family history of ischemic heart disease (aOR, 3.36; 95% CI, 1.09–10.35), and having had no cancer screening (aOR, 0.36; 95% CI, 0.18–0.70). ConclusionFurther efforts to identify the factors related to smoking cessation will help formulate a smoking cessation policy.

Safety of High-Intensity, Low-Volume Interval Training or Continuous Aerobic Training in Adults With Metabolic Syndrome.

The aim of the study was to evaluate the safety of high-intensity, low-volume interval training (HIIT-low volume) compared with moderate-intensity continuous aerobic training (MICT) in adults with metabolic syndrome. This is a controlled, randomized, clinical trial in patients without history of ischemic heart disease or diabetes, who underwent a supervised, 3 sessions/week, 12-week treadmill exercise program. The HIIT-low volume (n = 29) sessions consisted of 6 intervals with 1-minute, high-intensity phases at 90% of peak oxygen consumption (VO2peak). The MICT (n = 31) trained at 60% of VO2peak for 30 minutes. A new approach to record and classify all clinical events according to possible causality based on Naranjo's algorithm was developed. Patients were 50.8 ± 6.0 years old, 70% women, with body mass index of 30.6 ± 4.0 kg/m2 and VO2peak of 29.0 ± 6.3 mL·kg-1·min-1. In total, 60 clinical events were recorded in the HIIT-low volume group and 48 in the MICT group, with 59.3% classified as general disease. Only 21 events were classified as adverse reactions possibly related to exercise, without any serious adverse reactions. Both interventions had a similar incidence of musculoskeletal events (incidence rate ratio, 1.1; 95% confidence interval, 0.6-1.8), but HIIT-low volume had a higher incidence of cardiovascular events (incidence rate ratio, 2.9; 95% CI, 0.4-22.8) after adjusting for age, sex, and body mass index (HIIT-low volume: chest pain [n = 1] and symptoms of venous insufficiency of lower limbs [n = 2]; MICT: chest pain [n = 1]). The HIIT-low volume and MICT are safe in patients with metabolic syndrome. We recommend a muscle-conditioning program prior to both and to avoid HIIT-low volume in treadmill in patients with venous insufficiency of the lower limbs.Trial registration number NCT03087721.

ОСТРАЯ И ХРОНИЧЕСКАЯ СЕРДЕЧНАЯ НЕДОСТАТОЧНОСТЬ ПОСЛЕ ИНФАРКТА МИОКАРДА: КЛИНИЧЕСКИЕ И ФУНКЦИОНАЛЬНЫЕ МАРКЕРЫ

Вackground. The last decade has seen an increase in the number of people who have had myocardial infarction (MI). This phenomenon contributes to an increase in the long-term incidence of chronic cardiovascular diseases, including chronic heart failure. Purpose of the study. To identify the most significant clinical and functional indicators characterizing acute and chronic heart failure after myocardial infarction. Patient Characterization and Research Methods. This analysis included 186 patients who had myocardial infarction from January 2019 to January 2020: 86 people, the main subgroup, with signs of CHF above FC 2 (NYHA) (mean age 64.3 g) and 100 people, the comparison subgroup, without signs of CHF or had CHF 1 FC (NYHA) (mean age 62.6 l). After 1 year, clinical outcomes were assessed: cardiovascular death, repeated hospitalizations due to decompensation of CHF, death from other causes, stroke, repeated myocardial infarction, unplanned coronary revascularization. Results. In the acute period of myocardial infarction in the main subgroup (MI + CHF more than 2cl NYHA), all patients had symptoms of acute heart failure (AHF) in the form of Killip II and Killip III. Predictors of the development of chronic heart failure were the presence of a history of ischemic heart disease, confirmed in accordance with the recommendations, before myocardial infarction; decreased fraction of the left ventricle, detected before discharge and on the 30th day of myocardial infarction; the presence of atrial fibrillation (AF). One-year unfavorable outcomes in the main group were significantly more frequent. Subanalysis of long-term drug therapy showed that cardiovascular death was significantly less common in the subgroup of patients taking ARNI than in the subgroup of enalapril. Conclusion. In the present study, we studied postinfarction myocardial remodeling, which is realized in the form of the formation of a syndrome of acute and chronic heart failure. It has been shown that immediate reperfusion and restriction of the necrosis zone, as well as long-term use of drugs that inhibit SAS and RAAS, stimulating NPP, can inhibit the development of AHF and death. The CHF problem requires further fundamental research in order to develop new approaches that can affect more subtle mechanisms, such as the expression of specific genes involved in the disease, in order to reduce the persisting excess mortality for this pathology.

Prevalence and associated factors of self-reported ischaemic heart disease and/or stroke: a cross-sectional nationally representative community-based study of adults in Malawi in 2017

ObjectiveThis study aimed to assess the prevalence and associated factors of self-reported ischaemic heart disease (IHD) and/or stroke among adults in Malawi.DesignPopulation-based cross-sectional study.SettingNationally representative sample of general adult population...

Importance of In-Hospital Prospective Registry and Infectious Endocarditis Heart Team to Monitor and Improve Quality of Care in Patients with Infectious Endocarditis.

Aim: To investigate the value of prospective in-hospital registry data and the impact of an infectious endocarditis heart team approach (IEHT) on improvement in quality of care and monitor outcomes in hospitalized patients with IE. Methods: Between December 2014 and the end of 2019, 160 patients were hospitalized in one centre with the definite diagnosis of infectious endocarditis (IE) and entered in a prospective registry. From 2017, an IEHT was introduced. Propensity score matching was used to assess the impact of an IEHT approach on clinical outcomes. Results: Median age was 72.5 y (62.75–80.00), diabetes was present in 33.1%, chronic kidney disease in 27.5%, COPD in 17.5%, and a history of ischaemic heart disease in 30.6%. Prosthetic valve IE was observed in 43.8% and device-related IE in 16.9% of patients. Staphylococcus (37.5%) was the most frequent pathogen followed by streptococcus (24.4%) and enterococcus (23.1%). Overall, 30-day and 1-year mortality were 19.4% and 37.5%, respectively. The introduction of prospective data collection and IE heart team was associated with a trend towards reduction of adjusted 1-year mortality (26.5% IEHT vs. 41.2% controls, p = 0.0699). An IEHT clinical decision-making approach was independently associated with a shorter length of stay (p = 0.04). Conclusions: Use of a prospective registry of IE coupled with a heart team approach was associated with more efficient patient management and a trend towards lower mortality. Prospective data collection and dedicated IEHT have the potential to improve patient care and clinical outcomes.

Transient Acquired QT Interval Prolongation After Administration of Intravenous Ondansetron

A 62-year-old man with a history of stable ischemic heart disease presented to the emergency room with nausea, vomiting, and chest pain at rest. The chest pain was atypical in nature; it did not respond to nitroglycerin and did not worsen with exertion. He took only aspirin, metoprolol, and ramipril at home. The patient was normotensive and normoxemic. Serial high-sensitivity troponin test results were normal, and other bloodwork (including calcium and magnesium levels) was unremarkable, with the exception of a serum potassium level of 2.4 mmol/L. His presenting electrocardiogram (ECG; Fig. 1A ) showed sinus rhythm with a right bundle branch block and a mildly prolonged QTc interval (450 msec using Bazett’s formula1Bazett H. An analysis of the time-relations of electrocardiograms.Heart. 1920; 7: 353-370Google Scholar). However, conduction delays prolong the QRS interval, which affects the length of the QT interval without significant impact on the repolarization duration. Bogossian’s formula can correct the QTc interval in the presence of bundle branch blocks, and this yielded a normal QTc interval of 302 msec.2Bogossian H. Linz D. Heijman J. et al.QTc evaluation in patients with bundle branch block.Int J Cardiol Heart Vasc. 2020; 30: 100636PubMed Google ScholarFigure 1Electrocardiogram showing (A) sinus rhythm with a right bundle branch block (bbb) and mildly prolonged QTc interval; (B) ST changes with profound QTc interval prolongation; and (C) partial resolution of the ST changes.View Large Image Figure ViewerDownload Hi-res image Download (PPT) During his time in the emergency room, he experienced nausea and was given 4 mg of ondansetron intravenously. He was also given 40 mmol of KCl orally for his hypokalemia. Fifteen minutes later, the patient had a mild recurrence of atypical chest discomfort at rest, and another ECG Fig. 1B) was performed. This showed nonspecific ST changes with profound QTc interval prolongation, using both Bogossian’s formula (562 msec) and Bazett’s formula (628 msec). In addition to QTc interval prolongation, there was a dramatic difference in T wave morphology, including prolongation of the Tpeak–Tend interval. Ten minutes later, an ECG (Fig. 1C) and blood work were repeated, which showed a serum potassium level of 3 mmol/L, and partial resolution of the ST changes. The patient was not given any further QT-prolonging medication, and he was subsequently diagnosed with noncardiac chest pain after undergoing normal stress myocardial perfusion imaging. Severe hypokalemia is a known cause of QT interval prolongation.3Yelamanchi V.P. Molnar J. Ranade V. Somberg J.C. Influence of electrolyte abnormalities on interlead variability of ventricular repolarization times in 12-lead electrocardiography.Am J Ther. 2001; 8: 117-122Crossref PubMed Scopus (35) Google Scholar However, this patient’s initial ECG demonstrates a normal (by Bogossian’s formula) or only modestly prolonged (by Bazett’s formula) QTc interval. Subsequent administration of IV ondansetron resulted in profound transient QTc interval prolongation relative to this patient’s baseline, and marked changes in T wave morphology. It has been previously described that intravenous ondansetron administration can lead to QT interval prolongation and T wave changes. Our patient had a history of ischemic heart disease; the presence of structural heart disease increases the risk for acquired QT interval prolongation. Such prolongations of the QTc and Tpeak–Tend intervals are associated with increased risk of Torsades de Pointes and sudden cardiac death, with the risk increasing proportionally to QTc interval duration.4Thomas S. Behr E. Pharmacologic treatment of acquired QT prolongation and torsades de pointe.Br J Clin Pharmacol. 2016; 81: 420-427Crossref PubMed Scopus (67) Google Scholar, 5Hafermann M. Namdar R. Seibold G. et al.Effect of intravenous ondansetron on QT interval prolongation in patients with cardiovascular disease and additional risk factors for torsades: a prospective, observational study.Drug Healthc Patient Saf. 2011; 3: 53-58PubMed Google Scholar, 6Tse G. Gong M. Meng L. et al.Predictive value of Tpeak-Tend indices for adverse outcomes on acquired QT prolongation: a meta-analysis.Front Physiol. 2018; 9: 1226Crossref PubMed Scopus (18) Google Scholar These images demonstrate the importance of cautious administration of QT interval–prolonging medications, particularly in the presence of other risk factors for QT interval prolongation such as hypokalemia and underlying structural heart disease, even if the baseline QTc interval is not markedly prolonged.Novel Teaching Points•Proper assessment of the QT interval is important in the setting of a bundle branch block, as widening of the QRS will cause subsequent QT interval prolongation without significant impact on the duration of repolarization.•Bogossian’s formula is an alternative method for calculating the QT interval in the setting of a bundle branch block. However, no single formula is perfect for QTc interval calculation in every situation.•Caution is needed when prescribing medications that prolong the QT interval, especially for patients with an underlying predilection for QT interval prolongation.

Association of long–term exposure to PM2.5 with cause-specific mortality in elderly patients with the previous history of ischemic heart disease

BACKGROUND AND AIM: Numerous studies have reported an association between fine particulate matter (PM2.5) and cardiovascular disease (CVD) morbidity and mortality. However, the association between PM2.5 and mortality among those with a previous history of ischemic heart disease (IHD) is less understood. We aimed to evaluate whether long-term exposure to PM2.5 is related to mortality after hospital discharge in elderly patients with IHD. METHODS: We followed-up 306,418 IHD elderly patients residing in seven major cities between 2008 and 2016 using the Korean National Health Insurance Database and identified cause-specific mortality after the hospital admission. We linked the modelled PM2.5 data corresponding to each patient’s administrative districts. We used time-varying Cox hazard models after adjusting for the individual- and area-level confounders. Subgroup analyses were conducted by age group (65–74 vs ≥ 75), sex, and income- and wealth-based insurance premiums. RESULTS:Of a total of 306,418 IHD elderly patients, 43.1 (%) were male, mean age was 76.8 years, and 105,913 died during a mean follow-up of 21.4 years. The adjusted hazard ratio (HR) of all-cause mortality was 1.10 [95% confidence intervals (CI): 1.07, 1.14] per 10 μg/m3 increase in a 12–month moving average PM2.5. The HRs were greater for cause-specific mortality: 1.17 (95% CI: 1.11, 1.24), 1.17 (95% CI: 1.06, 1.30), and 1.25 (95% CI: 1.15, 1.35) for CVD, stroke, and IHD, respectively. The subgroup analyses showed that for all–cause mortality, 65–74 age group, men, and low wealth-based insurance premiums were more susceptible to PM2.5 exposure. CONCLUSIONS:We found an association between long-term exposure to PM2.5 and mortality among elderly IHD patients, particularly for CVD-related mortality. Our results suggest that those with a previous history of IHD were more susceptible to PM2.5 exposure. KEYWORDS: Cohort Studies, Ischemic heart disease, Mortality,Particulate matter, Republic of Korea

Evaluation of acute and chronic nephrotoxicity in patients received cisplatin-based chemotherapy: has anything changed over time?

The aim of this study was to determine the frequency and the risk factors of acute and chronic nephrotoxicity in patients who received cisplatin due to malignancy. Medical records of all patients who received cisplatin-based chemotherapy regimen between January 2013 and July 2019 were retrospectively evaluated. The data of 203 patients who met the study criteria were examined. The patients were evaluated for acute nephrotoxicity at 48h and late nephrotoxicity at 3rd month after first course of cisplatin. Early and late nephrotoxicity were defined by NCI CTCAE Version 4.0 criteria. The mean age of the study patients was 56.44 ± 12.69years, 78.8% were males and 21.2% were females. It is revealed that the incidence of cisplatin-induced acute nephrotoxicity was 9.2% and chronic nephrotoxicity was 37.9%. While the development of acute nephrotoxicity was associatedwith female gender, history of diabetes mellitus, history of ischemic heart disease and use of antiplatelet drug, the development of chronic nephrotoxicity was associatedwith older age, female gender and using of diuretics. High serum creatinine, urea and low eGFR value before treatment were found to be associated with both early and late nephrotoxicity (p < 0.05). There was no statistically significant relationship between acute or chronic nephrotoxicity and cumulative dose of cisplatin, hydration or intravenous magnesium supplementation. High initial serum creatinine value and low initial eGFR are the most important determinants of both early and late nephrotoxicity.

Risk factors predisposing to acute stroke in India: a prospective study.

Stroke is an important neurological disorder with significant morbidity and mortality. In India, the risk factors for stroke (obesity, diabetes mellitus, alcoholism, hypertension, and sedentary lifestyle) are mounting with economic growth and increasing the disease burden. To assess the severity and risk factors of stroke in India and identify any new predisposing factors. A multicentric (six tertiary care hospitals across India) prospective observational study (from September 2016 to July 2017) was conducted on 526 stroke patients, presenting within the first 24 h to examine the risk factors for ischemic and hemorrhagic strokes. Severity was determined using the National Institutes of Health Stroke Scale (NIHSS). Predominantly male (72.3%), 75% of the sample was >50 years old, with a mean body mass index (BMI) of 25.8 ± 4.3 kg/m2 and 14.6% obese patients. Hypertension and diabetes mellitus were the commonest comorbidities, followed by a history of ischemic heart disease and familial history of stroke. 20.5% of patients had mild strokes, 57.4% had moderate, 8.4% experienced moderate-severe strokes, whereas 7.2% had severe strokes. Regarding the admission diagnoses, 56.8% were ischemic, 18.6% were hemorrhagic, 1.1% had a transient ischemic attack, 6.6% suffered recurrent strokes, and 17% were other forms. The foremost risk factors for stroke in India, hypertension and diabetes, need to be controlled and treated like other global high-risk populations for stroke prevention. The NIHSS scores highlight the relationship between risk factors and stroke severity.

Zespół Kounisa – interdyscyplinarny problem na styku alergologii i kardiologii y

Life-threatening anaphylaxis is a systemic hypersensitivity reaction that may be allergic or non-allergic. Kounis syndrome is an acute coronary syndrome caused by an allergic reaction. Food, environmental factors, drugs, radiological contrast agents and some disease states are among the etiological factors that trigger an allergic reaction. Kounis syndrome is a relatively rarely recognized cause of myocardial infarction, which is most likely due to its underdiagnosis. The presented case concerns a patient with a history of ischemic heart disease after coronary angioplasty. Until the insect stings, the course of the angina was stable. The course of the allergic reaction was turbulent and met the criteria for anaphylactic shock. Subsequently, the patient developed unstable angina. The clinical picture and additional tests allowed to diagnose a myocardial infarction in the patient. The coincidence of myocardial infarction with a history of an insect sting allows for the recognition of an allergic reaction as a trigger for acute coronary syndrome. The described case highlights the need for a multidisciplinary approach to the patient and regular supervision during the use of specific immunotherapy in the course of allergy to Hymenoptera venom, as well as the inclusion of Kounis syndrome in the differential diagnosis of acute coronary syndromes.

Cognitive functions, quality of life in patients with dyscirculatory (vascular) encephalopathy II stage in northerners from the position of ICF

Objective. The aim of the study was to analyze cognitive functions, emotional disorders, the quality of life with the application of the International Classification of Functioning (ICF) in patients with chronic cerebrovascular diseases, dyscirculatory (vascular) encephalopathy II stage in the Komi Republic. Design and methods. In the clinics of the Komi Republic, we examined 126 people (mean age — 65,8 ± 10,1 years; women comprised 76 participants, 60,3 %, p ≤ 0,05) with dyscirculatory (vascular) encephalopathy. Complaints and anamnesis were analyzed, somatic and neurological status, cognitive functions, emotional status, and sleep were assessed. Results. Out of 126 patients, 44,5 % patients are employed (56 people). Among non-working patients with an established group of disability, 35,7 % (in 14,3 % disability 2nd degree (10 people), in 21,4 % — disability 3rd degree (15 people), p ≤ 0,05). Among the workers, 3 people (5,3%) had disability 3rd degree. Hypertension (HTN) I stage was detected in 10,6 %, HTN II stage — in 44,4 %, HTN III stage — in 45 % (p ≤ 0,05); 27,8 % had history of ischemic heart disease, 7,2 % — myocardial infarction, 19,1% — cerebrovascular accident, 8,6% — heart rhythm disturbances, 15,8 % — significant stenosis of the brachiocephalic arteries. Based on memory function assessment by ICF, none demonstrated normal results. Mild cognitive impairment was usually found, and there was no case of dementia. Dysfunction in the domain of blood pressure function was found in all patients. The dysfunction of blood vessels was found in all patients with chronic cerebral ischemia II stage. Daily activities were reduced due to the physical dysfunction. According to the total assessment of health status by the SF-36 scale, the physical and mental components of health were similarly decreased. Conclusions. The SF-36 (questionnaire for assessing the quality of life) and ICF (International Classification of Functioning, Disabilities and Health) complement each other. Cognitive scales are the basic tools for examination of patients with chronic cerebral ischemia, making diagnosis according to ICF, and treating cognitive, physical and emotional disorders in dyscirculatory (vascular) encephalopathy.

Evaluation of medication reconciliation process in internal medicine wards of an academic medical center by a pharmacist: errors and risk factors.

Medication reconciliation based on complete medication histories has been introduced to minimize medication errors and its associated healthcare costs in the transitions of care. In this study, to evaluate the routine process of medication reconciliation in an academic medical center, medication history taken at the time of admission by physicians and the first order prescribed in the hospital was compared to a comprehensive reconciliation form filled by a pharmacist using direct interview of the patients and caregivers, patient's insurance records and medication packages they brought from home. Two hundred and fifty-seven patients admitted in the internal wards of an academic medical center between June and September 2019 were investigated. In 6% of the patients, drug history was not included in the medical history form. Other patients were using 8.59 drugs in average, with a mean of 3.55 medication discrepancies in the history-taking process. Most commonly occurring errors were drug omissions (2.23 per patient on average) and incorrect frequency (0.96 per patient on average). There was a mean of 0.7 potentially harmful discrepancies for each patient. The mean number of drug discrepancies in new prescriptions from the hospital was 1.25, and almost half of patients had a potentially harmful discrepancies reordered in the hospital. There was no statistically meaningful relationship between patients' gender, physicians' gender, or the time of history taking and the total number of medication errors. History of ischemic heart disease was significantly associated with higher number of medication errors (p = 0.05). The results suggest that the medication reconciliation process in this academic center is inefficient. Using a systematic approach in medication reconciliation and gathering the best possible medication history, with a pharmacist who has better understanding of drugs' potential interactions and harmful errors can improve this process and prevent such errors in the future.