Improved reproducibility for myocardial ASL: Impact of physiological and acquisition parameters

PURPOSE

To investigate and mitigate the influence of physiological and acquisition-related parameters on myocardial blood flow (MBF) measurements obtained with myocardial Arterial Spin Labeling (myoASL).

METHODS

A Flow-sensitive Alternating Inversion Recovery (FAIR) myoASL sequence with bSSFP and spoiled GRE (spGRE) readout is investigated for MBF quantification. Bloch-equation simulations and phantom experiments were performed to evaluate how variations in acquisition flip angle (FA), acquisition matrix size (AMS), heart rate (HR) and bloodT 1 $$ {\mathrm{T}}_1 $$ relaxation time (T 1 , B $$ {\mathrm{T}}_{1,B} $$ ) affect quantification of myoASL-MBF. In vivo myoASL-images were acquired in nine healthy subjects. A corrected MBF quantification approach was proposed based on subject-specificT 1 , B $$ {\mathrm{T}}_{1,B} $$ values and, for spGRE imaging, subtracting an additional saturation-prepared baseline from the original baseline signal.

RESULTS

Simulated and phantom experiments showed a strong dependence on AMS and FA (R 2 $$ {R}^2 $$ >0.73), which was eliminated in simulations and alleviated in phantom experiments using the proposed saturation-baseline correction in spGRE. Only a very mild HR dependence (R 2 $$ {R}^2 $$ >0.59) was observed which was reduced when calculating MBF with individualT 1 , B $$ {\mathrm{T}}_{1,B} $$ . For corrected spGRE, in vivo mean global spGRE-MBF ranged from 0.54 to 2.59 mL/g/min and was in agreement with previously reported values. Compared to uncorrected spGRE, the intra-subject variability within a measurement (0.60 mL/g/min), between measurements (0.45 mL/g/min), as well as the inter-subject variability (1.29 mL/g/min) were improved by up to 40% and were comparable with conventional bSSFP.

CONCLUSION

Our results show that physiological and acquisition-related factors can lead to spurious changes in myoASL-MBF if not accounted for. Using individualT 1 , B $$ {\mathrm{T}}_{1,B} $$ and a saturation-baseline can reduce these variations in spGRE and improve reproducibility of FAIR-myoASL against acquisition parameters.

Left ventricular ejection fraction digit bias and reclassification of heart failure with mildly reduced vs reduced ejection fraction based on the 2021 definition and classification of heart failure

AIMS

Aims were to evaluate (1) reclassification of patients from heart failure with mildly reduced (HFmrEF) to reduced (HFrEF) ejection fraction when an EF = 40% was considered as HFrEF, (2) role of EF digit bias, ie, EF reporting favouring 5% increments; (3) outcomes in relation to missing and biased EF reports, in a large multinational HF registry.

METHODS AND RESULTS

Of 25,154 patients in the European Society of Cardiology (ESC) HF Long-Term registry, 17% had missing EF and of those with available EF, 24% had HFpEF (EF≥50%), 21% HFmrEF (40%-49%) and 55% HFrEF (<40%) according to the 2016 ESC guidelines´ classification. EF was "exactly" 40% in 7%, leading to reclassifying 34% of the HFmrEF population defined as EF = 40% to 49% to HFrEF when applying the 2021 ESC Guidelines classification (14% had HFmrEF as EF = 41% to 49% and 62% had HFrEF as EF≤40%). EF was reported as a value ending with 0 or 5 in ∼37% of the population. Such potential digit bias was associated with more missing values for other characteristics and higher risk of all-cause death and HF hospitalization. Patients with missing EF had higher risk of all-cause and CV mortality, and HF hospitalization compared to those with recorded EF.

CONCLUSIONS

Many patients had reported EF = 40%. This led to substantial reclassification of EF from old HFmrEF (40%-49%) to new HFrEF (≤40%). There was considerable digit bias in EF reporting and missing EF reporting, which appeared to occur not at random and may reflect less rigorous overall care and worse outcomes.

Integrative review of electrocardiographic characteristics in patients with reduced, mildly reduced, and preserved heart failure

INTRODUCTION

Electrocardiographic (ECG) changes in heart failure with reduced, mildly reduced, and preserved ejection fractions can be critical in clinical assessment while waiting to perform echocardiograms or when it is unavailable. This integrative review aimed to identify ECG characteristics among hospitalized patients demonstrating three types of heart failure during acute decompensation.

METHODS

We searched an electronic database of PubMed, Web of Science, EMBASE, Scopus, Google Scholar, and ClinicalTrials.gov using medical subject headings (MeSH) terms and keywords. Sixteen studies were synthesized and reported.

RESULTS

Heart failure with reduced ejection fraction (HFrEF) was more common in men, comorbid with coronary artery diseases and diabetes mellitus, higher BNP/Pro-BNP, wide QRS, and left bundle branch block on ECG. On average, clients with heart failure with preserved ejection fraction (HFpEF) were older and more likely to have a history of atrial fibrillation, valvular heart diseases, hypertension, chronic obstructive pulmonary, and atrial fibrillation (AF) on ECG. Patients with mildly reduced (HFmrEF) were more similar to HFpEF in older patients, comorbid with hypertension, AF and valvular diseases, and AF on ECG.

CONCLUSIONS

ECG characteristics might be related to left ventricular ejection fraction. Demographics, BNP/Pro-BNP, and ECG changes might help differentiate different heart failure types. Therefore, ECG might be a prognostic tool while caring for heart failure patients when highly skilled resources are unavailable. These identified ECG characteristics help generate research hypotheses and warrant validation in future research.

The Biological Parallels Between Atherosclerosis and Cardiac Allograft Vasculopathy: Implications for Solid Organ Chronic Rejection

Atherosclerosis and solid organ chronic rejection are pervasive chronic disease states that account for significant morbidity and mortality in developed countries. Recently, a series of shared molecular pathways have emerged, revealing biological parallels from early stages of development up to the advanced forms of pathology. These shared mechanistic processes are inflammatory in nature, reflecting the importance of inflammation in both disorders. Vascular inflammation triggers endothelial dysfunction and disease initiation through aberrant vasomotor control and shared patterns of endothelial activation. Endothelial dysfunction leads to the recruitment of immune cells and the perpetuation of the inflammatory response. This drives lesion formation through the release of key cytokines such as IFN-y, TNF-alpha, and IL-2. Continued interplay between the adaptive and innate immune response (represented by T lymphocytes and macrophages, respectively) promotes lesion instability and thrombotic complications; hallmarks of advanced disease in both atherosclerosis and solid organ chronic rejection. The aim of this study is to identify areas of overlap between atherosclerosis and chronic rejection. We then discuss new approaches to improve current understanding of the pathophysiology of both disorders, and eventually design novel therapeutics.

Improved assessment of left ventricular ejection fraction using artificial intelligence in echocardiography: A comparative analysis with cardiac magnetic resonance imaging

BACKGROUND

Left ventricular ejection fraction (LVEF) measurement in echocardiography (Echo) using the recommended modified biplane Simpson (MBS) method is operator-dependent and exhibits variability. We aimed to assess the accuracy of a novel fully automated (Auto) artificial intelligence (AI) in view selection and biplane LVEF calculation compared to MBS-Echo, with cardiac magnetic resonance imaging (CMR) as reference.

METHODS

Each of the 301 consecutive patients underwent CMR and Echo on the same day. LVEF was measured independently by Auto-Echo, MBS-Echo and CMR. Interobserver (n = 40) and test-retest (n = 14) analysis followed.

RESULTS

A total of 229 patients (76%) underwent complete analysis. Auto-Echo and MBS-Echo showed high correlations with CMR (R = 0.89 and 0.89) and with each other (R = 0.93). Auto underestimated LVEF (bias: 2.2%; limits of agreement [LOA]: -13.5 to 17.9%), while MBS overestimated it (bias: -2.2%; LOA: 18.6 to 14.1%). Despite comparable areas under the curves of Auto- and MBS-Echo (0.93 and 0.92), 46% (n = 70) of MBS-Echo misclassified LVEF by ≥5% units in patients with a reduced CMR-LVEF <51%. Although LVEF bias variability across different LV function ranges was significant (p < 0.001), Auto-Echo was closer to CMR for patients with reduced LVEF, wall motion abnormalities, and poor image quality than MBS-Echo. The interobserver correlation coefficient of Auto-Echo was excellent compared to MBS-Echo (1.00 vs. <0.91) for different readers. True test-retest variability was higher for MBS-Echo than for Auto-Echo (7.9% vs. 2.5%).

CONCLUSION

The tested AI has the potential to improve the clinical utility of Echo by reducing user-related variability, providing more accurate and reliable results than MBS.

Sex Differences in the Progression and Long-Term Outcomes of Native Mild to Moderate Aortic Stenosis

BACKGROUND

There are limited data on the sex differences in the hemodynamic progression and outcomes of early-stage aortic stenosis (AS).

OBJECTIVES

The authors sought to determine sex differences in hemodynamic progression and outcomes of mild to moderate native AS.

METHODS

This was a retrospective observational cohort study including patients with mild to moderate native tricuspid AS from the Cleveland Clinic echocardiographic database between 2008 and 2016 and followed until 2018. All-cause mortality, aortic valve replacement (AVR), and disease progression assessed by annualized changes in echocardiographic parameters were analyzed based on sex.

RESULTS

The authors included 2,549 patients (mean age, 74 ± 7 years and 42.5% women) followed over a median duration of 5.7 years. There was no difference in all-cause mortality between sexes irrespective of age, baseline disease severity, progression to severe AS, and receipt of AVR. Relative to men, women had similar all-cause mortality but lower risk of AVR (adjusted HR: 0.81 [95% CI: 0.67-0.91]; P = 0.009) at 10 years. On 1:1 propensity-matched analysis, men had a significantly faster disease progression represented by greater increases in the median of annualized change in mean gradient (2.10 vs 1.15 mm Hg/y, respectively, P < 0.001), maximum transvalvular velocity (0.42 vs 0.28 m/s/y), left ventricular end-diastolic diameters (0.15 vs 0.048 mm/m2.7/y) (P = 0.014). Women have significantly higher left ventricular ejection fraction, filling pressures, and left ventricular septum thickness over time on follow-up echocardiograms compared with men.

CONCLUSIONS

Women with mild to moderate AS had slower hemodynamic progression of AS, were more likely to have preserved left ventricular ejection fraction and concentric left ventricular hypertrophy in addition to lower incidence of AVR compared with men despite similar mortality. These findings provide further evidence that there are distinct sex-specific longitudinal echocardiographic and clinical profiles in patients with AS.

Persistence of significant secondary mitral regurgitation post-cardiac resynchronization therapy and survival: a systematic review and meta-analysis : Mitral regurgitation and mortality post-CRT

Cardiac resynchronization therapy (CRT) significantly reduces secondary mitral regurgitation (MR) in patients with severe left ventricular systolic dysfunction. However, uncertainty remains as to whether improvement in secondary MR correlates with improvement with mortality seen in CRT. We conducted a meta-analysis to determine the association of persistent unimproved significant secondary MR (defined as moderate or moderate-to-severe or severe MR) compared to improved MR (no MR or mild MR) post-CRT with all-cause mortality, cardiovascular mortality, and heart failure hospitalization. A systematic search of PubMed, EMBASE, and Cochrane Library databases till July 31, 2022 identified studies reporting clinical outcomes by post-CRT secondary MR status. In 12 prospective studies of 4954 patients (weighted mean age 66.8 years, men 77.8%), the median duration of follow-up post-CRT at which patients were re-evaluated for significant secondary MR was 6 months and showed significant relative risk reduction of 30% compared to pre-CRT. The median duration of follow-up post-CRT for ascertainment of main clinical outcomes was 38 months. The random effects pooled hazard ratio (95% confidence interval) of all-cause mortality in patients with unimproved secondary MR compared to improved secondary MR was 2.00 (1.57-2.55); p < 0.001). There was insufficient data to evaluate secondary outcomes in a meta-analysis, but limited data that examined the relationship showed significant association of unimproved secondary MR with increased cardiovascular mortality and heart failure hospitalization. The findings of this meta-analysis suggest that lack of improvement in secondary MR post-CRT is associated with significantly elevated risk of all-cause mortality and possibly cardiovascular mortality and heart failure hospitalization. Future studies may investigate approaches to address persistent secondary MR post-CRT to help improved outcome in this population.

Percutaneous Patent Foramen Ovale Closure: Stroke and Beyond

Over 750,000 individuals suffer from stroke annually in the United States, with 87% of these strokes being ischemic in nature. Roughly 40% of ischemic strokes occur in individuals 60 years of age or under. A quarter of all ischemic strokes have no identifiable cause despite extensive workup and are deemed cryptogenic in nature. Patent Foramen Ovales (PFO) has been postulated in stroke causation by either paradoxical embolization or platelet activation in the tunnel of the defect. The incidence of PFO is reported to be 15-25% in the general population but rises to 40% in patients with cryptogenic stroke. While the initial trials evaluating PFO closures were non-revealing, subsequent long-term follow-ups, as well as recent trials evaluating PFO closures in cryptogenic stroke patients 60 years of age or under, demonstrated the superiority of percutaneous closure compared to medical therapy alone, leading to FDA approval of PFO closure devices. In this review, we review the diagnosis of PFO, postulated stroke mechanisms, literature supporting PFO closure, patient selection for percutaneous closure, procedural considerations, and associated procedural complications.

Immediate results of transcatheter aortic valve implantation

OBJECTIVE

Aim: To assess, analyze and present early postoperative results of transcatheter aortic valve implantation in patients with aortic stenosis.

PATIENTS AND METHODS

Materials and Methods: During the period from 2017 to 2023, we examined in total 77 patients with severe aortic stenosis and high risk of surgery who were eligible for the TAVI procedure at the "Heart Institute Ministry of Health of Ukraine".

RESULTS

Results: Before implantation, the mean and maximum aortic valve gradients were 53.7±19.1 mm Hg and 90.1±28.8 mm Hg, respectively. The mean and maximum aortic valve gradients after implantation were 9.67±3.18 and 18.7±6.41, respectively (p<0.001). The calculated left ventricular ejection fraction was 57.5±8.22% before surgery and 58.8±7.91% after surgery (p=0.412). After the procedure, moderate (2) degree of paravalvular aortic regurgitation was observed in 2 patients and light degree - in 21 patients. Before surgery, mitral regurgitation of 2-3 degrees was observed in 15 patients, and only in two patients after TAVI The survival rate of our patients was 96.4% after 180 days of supervision. In-hospital and 30-day mortality was 1.8%, while 180-day mortality was 3.6%. No deterioration was observed in patients with moderate aortic regurgitation during echocardiographic studies performed at 1, 3 and 6 months after TAVI.

CONCLUSION

Conclusions: TAVI is rapidly emerging as a life-saving alternative for patients who are inoperable or at high risk of surgery due to comorbidities. The selection of patients for TAVI is important to optimize procedural and long-term outcomes. It is important for cardiologists in our country to refer patients with severe aortic stenosis after diagnosis to centers that perform TAVI.

Cardiac Involvement in LAMA2-Related Muscular Dystrophy and SELENON-Related Congenital Myopathy: A Case Series

Background

LAMA2-related muscular dystrophy (LAMA2-MD) and SELENON-related myopathy (SELENON-RM) are two rare neuromuscular diseases characterized by proximal and axial muscle weakness, scoliosis, spinal rigidity, low bone quality and respiratory impairment. Cardiac involvement has previously been described in retrospective studies and case reports, but large case series and prospective studies in unselected cohorts are lacking.

Objective

The objective of this study is to conduct prevalence estimations, perform cardiac phenotyping, and provide recommendations for clinical care.

Methods

In this case series including two time points, we conducted comprehensive assessments with electrocardiography (ECG) and transthoracic echocardiography (TTE). ECGs were systematically assessed for a large subset of variables. TTE included left and right ventricular ejection fraction (LVEF/RVEF) and left ventricular global longitudinal strain (GLS), the latter being a more early and sensitive marker of left ventricular dysfunction.

Results

21 LAMA2-MD (M = 5; 20±14 years) and 10 SELENON-RM patients (M = 7; 18±12 years) were included. In most patients, QRS fragmentation and Q waves, markers of heterogeneous ventricular activation, were present both at baseline and at follow-up. GLS was abnormal (age specific in children, > -18% in adults) in 33% of LAMA2-MD and 43% of SELENON-RM patients at baseline. Reduced LVEF (<52% in males, <54% in females and <55% in pediatric population) was observed in three LAMA2-MD patients at baseline and in none of the SELENON-RM patients. GLS and LVEF did not change between baseline and follow-up. RVEF was normal in all patients.

Conclusion

ECG abnormalities and abnormal GLS are prevalent in LAMA2-MD and SELENON-RM, yet abnormal LVEF was only seen in LAMA2-MD patients. One LAMA2-MD patient had a clinically relevant deterioration in LVEF during 1.5-year follow-up. We advise routine screening of all patients with LAMA2-MD or SELENON-RM with ECG and echocardiography at diagnosis, minimally every two years from second decade of life and if new cardiac signs arise.

Upper airway and tracheostomy management in patients with COVID-19: A long-term acute care hospital (LTACH)

OBJECTIVE

Describe the tracheostomy and ventilation management of patients admitted due to COVID-19 as facilitated by speech language pathologists (SLPs) and otolaryngologists within the long-term acute care hospital (LTACH) setting.

STUDY DESIGN

Retrospective cohort study.

SETTING

Long-term acute care hospital.

SUBJECTS AND METHODS

A retrospective chart review was conducted on all patients admitted to RML Specialty Hospital for respiratory failure secondary to COVID-19 from April 1, 2020 to November 30, 2021. Demographic information, laryngeal findings, and tracheostomy management was reviewed. Descriptive statistics and chi-square analysis were performed.

RESULTS

Amongst the 213 subjects, 80.0 % arrived on mechanical ventilation. 23.0 % required otolaryngology consultation during LTACH stay due to poor Passy Muir Valve (PMV) or tracheostomy capping tolerance. 35 (71.4 %) of those consulted had abnormal laryngeal findings on exam with subglottic/tracheal stenosis and laryngeal edema being most common at 38.8 % and 20.4 %, respectively. 28.6 % of those with laryngeal findings were decannulated by discharge. Mechanical ventilator weaning and decannulation success were 86.6 % and 62.5 %, respectively. No association (p > 0.05) between number of intubations and abnormal laryngeal findings were found. No association (p > 0.05) between number of intubations or prone-positioning and decannulation success at discharge were found.

CONCLUSION

LTACHs can serve a specific role in upper airway rehabilitation and tracheostomy care in the post COVID-19 period. SLPs and otolaryngologists should be involved in the care of these patients to help facilitate decannulation and return to normal laryngeal function.

Clinical risk associated with COVID-19 among 86000 patients with congenital heart disease

OBJECTIVE

To determine the magnitude of any excess risk of mortality and hospitalisation due to COVID-19 infection in patients with congenital heart disease (CHD) in the UK healthcare system.

METHODS

Matched case-control study within the Clinical Practice Research Datalink study of anonymised general practice records in the National Health Service in England. Patients with CHD were stratified for disease severity according to the European Society of Cardiology guidelines. Presence of a positive COVID-19 test, hospitalisation with a diagnosis of COVID-19 and COVID-19-related mortality were compared in case and control groups.

RESULTS

86 441 patients with CHD and 335 839 controls were studied. Of patients with a positive COVID-19 test, patients with CHD were more likely than controls to be hospitalised (22.4% vs 14.5%; OR=1.77 (95% CI 1.60 to 1.96); p=2.11e-28) and suffer COVID-19-related death (6.1% vs 3.8%; OR=1.60 (95% CI 1.35 to 1.89); p=7.00e-08). The excess risk of COVID-19 hospitalisation and death rose with increasing physiological severity of CHD (presence of pulmonary vascular disease and/or cyanosis), rather than anatomical complexity.

CONCLUSIONS

In this study of the COVID-19 pandemic experience, using population health records in over 86000 patients with CHD in England, patients with CHD with COVID-19 were at around 50-75% higher risk of hospitalisation and mortality compared with matched controls with COVID-19. We provide the first primary care-derived estimates for COVID-19 hospitalisation and case-fatality rates in patients with CHD. Some factors predictive of worse COVID-19 outcome in general populations (such as non-white ethnic group), and other CHD-specific comorbidities (such as pulmonary hypertension), influenced outcomes among patients with CHD.

Evaluation of cardiac electromechanics in patients with newly diagnosed hypertension

OBJECTIVES

This study aimed to investigate the relationship between subclinical left ventricular (LV) systolic dysfunction and ECG parameters in newly diagnosed hypertension patients.

METHODS

In this cross-sectional study, adults diagnosed with hypertension based on 24-h ambulatory blood pressure monitor recordings were included. The patients were classified into two groups based on the presence of subclinical LV systolic dysfunction according to LV global longitudinal strain (LVGLS). Findings were compared between the two groups.

RESULTS

A total of 244 patients (female, 55.7%) were included. Based on LVGLS, 82 (33.6%) patients had subclinical LV systolic dysfunction. The proportion of early repolarization pattern (ERP) on ECG was significantly higher in patients with subclinical LV systolic dysfunction than in patients with normal LV systolic function [24 (28.6%) vs. 8 (5%), P < 0.001]. PR and corrected QT intervals were also significantly longer in patients with subclinical LV systolic dysfunction than in patients with normal LV systolic function [median (interquartile range), 148 (132-158) vs. 141 (127-152), P = 0.036 and 443 (427-459) vs. 431 (411-455), P = 0.007, respectively]. According to multivariate regression analysis ERP, early (E) wave velocity/late (A) wave velocity (E/A), and LV mass index were independently associated with subclinical LV systolic dysfunction.

CONCLUSION

In newly diagnosed hypertension patients, the ERP on admission ECG could be a sign of subclinical systolic dysfunction.

Updates in the Management of Coronary Artery Disease: A Review Article

Coronary artery disease (CAD) remains a significant health challenge, imposing substantial burdens on individuals and healthcare systems worldwide. CAD's impact stems from artery narrowing and blockage, leading to severe complications like heart attacks and heart failure. Collaborative efforts by researchers, professionals, and governments have fostered advancements in comprehending and managing this cardiovascular ailment. Evolving CAD management embraces modern diagnostics, cutting-edge pharmaceuticals, invasive procedures, lifestyle modifications, and cardiac rehabilitation. This comprehensive approach aims to amplify outcomes and elevate the quality of life for CAD-affected individuals. This review delves into innovative treatments, pivotal breakthroughs, and recent trends in clinical practices that collectively shape CAD management. The exploration encompasses novel diagnostic technologies enabling early detection and risk assessment. Moreover, it investigates recent breakthroughs in medications that profoundly impact platelet disorders, lipid reduction, and angina. Precision medicine's role in tailoring treatment strategies based on patient characteristics is thoroughly examined. Advances in invasive procedures, like percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), have revolutionised coronary revascularisation, substantially improved long-term outcomes, and reduced restenosis rates. The increasing significance of lifestyle changes and cardiac rehabilitation in CAD management, augmenting treatment options and patient recovery, are meticulously scrutinized. While these strides are pivotal, research continues to chart new paths in CAD management, from innovative drugs to collaborative multidisciplinary care models. Staying attuned to the latest advancements and embracing a patient-centric approach can collectively reduce CAD's impact and facilitate the lives of those grappling with this chronic cardiovascular disorder.

Experience and Outcomes of Primary Percutaneous Coronary Intervention in a Tertiary Care Hospital in South Punjab, Pakistan

BACKGROUND

Primary percutaneous coronary intervention (PCI) is the emergency procedure and gold standard for the treatment of ST-Elevation Myocardial Infarction (STEMI).

OBJECTIVE

To share the experience and outcomes of primary PCI in a tertiary care hospital in South Punjab, Pakistan.

METHODS

A descriptive cross-sectional study was planned from the 1st of April, 2023 to the 30th of September, 2023. All patients presenting with acute STEMI undergoing primary PCI were included in the study. Data regarding patient demographics, risk factors, procedural characteristics, time variables, and in-hospital events was observed.

RESULTS

A total of 1132 patients were included in the study. There were 934 (82.5%) males. Smoking is the most common risk factor among all the patients. Anterior wall myocardial infarction is the most common STEMI and the left anterior descending artery is the culprit vessel in 58.3% (n=660) of patients. Single vessel disease was present in 34.6% (n=392) of the patients. Thrombolysis in Myocardial Infarction (TIMI )Flow III was achieved in 80% (n=906) of patients after primary PCI. The average total ischemic time of the patients included in the study was 5 hours and 48 minutes, with a standard deviation of 3 hours and 55 minutes. Our mortality was 3.5% (n=40).

CONCLUSION

Our patients take a longer time to present to the PCI-capable centers. Despite their late presentation, primary PCI has better outcomes for treating acute STEMI.

Cardiovascular Compatibility of Proton Pump Inhibitors: Practice Recommendations

This manuscript aims to critically evaluate the current evidence regarding adverse cardiovascular effects associated with proton pump inhibitors (PPIs) in patients with coronary artery disease (CAD). It also provides guidance for the selection of the most appropriate PPI within the context of cardiovascular polypharmacy and emphasizes the importance of establishing consensus among clinicians on the need to prescribe PPIs with limited cytochrome P450 (CYP450) enzyme inhibition to reduce the risk of drug interactions. PPIs are among the most widely used drugs for the treatment of gastroesophageal reflux disease (GERD) and the prevention of gastrointestinal (GI) bleeding. The manuscript reports the proceedings from the first practice recommendations meeting on the cardiovascular compatibility of PPIs in an Indian setting. A panel of eight Indian experts in cardiology and gastroenterology reviewed 14 consensus statements. Available literature was searched and summarized, and after multiple rounds of review, consensus was achieved for these statements. Based on the available evidence, the consensus panel highlights that a PPI with minimal drug-drug interaction (DDI) is recommended, especially in patients requiring clopidogrel or polypharmacy. Rabeprazole appears to be a good option in cases where co-prescription is indicated, owing to its optimal acid suppression and minimal drug interaction profile.

Frequency and correlates of subjective cognitive complaints and objective cognitive screening results in African American adults following COVID-19 infection

Background

Subjective cognitive complaints are frequent following COVID-19 infection, but assessment of whether these complaints map onto objective cognitive findings may not be routine in busy clinical settings. Consequently, opportunities to confirm these complaints and to provide follow-up referrals and appropriate care may be missed, thereby impacting patients' functional independence and quality of life. African Americans are vulnerable to poor outcomes from COVID-19, and thus represent a minority group in whom subjective concerns are especially important to investigate. Towards this end, we examined the frequency and correlates of subjective complaints and objective screening results of African American patients referred to the Post-Acute Sequelae of SARS-CoV-2 (PASC) Clinic at Grady Memorial Hospital, a large county teaching hospital in Atlanta, Georgia.

Methods

Eighty seven African American patients (mean age = 52.5, SD = 10.5, range = 30-73) were evaluated between January 28, 2021-October 14, 2021 in the Grady PASC clinic. They ranged from 1 to 17 months post positive SARS-COV-2 antigen testing. Patients were administered a subjective cognitive complaint questionnaire (PROMIS Cognitive Function Scale Short Form 8a) as well as cognitive screening measures including the Mini-Cog (3 item recall, clock) and the Digit Symbol Substitution Test (timed visuomotor sequencing). Mood was assessed via the Patient Health Questionnaire-9, and anxiety via the Generalized Anxiety Disorders Scale. Published norms were used to identify clinically elevated scores.

Results

Sixty six (76%) patients denied experiencing meaningful cognitive concerns, and of these, 25 (38%) had positive cognitive screens indicating impaired performance on objective testing. Of 21 patients with subjectively elevated cognitive concerns, 17 (81%) also had positive cognitive screens. There were no significant differences in sociodemographic factors (p values = .07-.71), days post-acute positive SARS-COV-2 Antigen Test (p = .99), disease severity (p values = .67-.75), or COVID-19 comorbidity indices (medical conditions (p values = .20-.77), substance abuse (p = .79), psychiatric history (p values = .11-.99) in those with or without subjective complaints and objective cognitive findings. However, patients with subjective complaints and objective cognitive findings reported more post-COVID-19 anxiety (p = .02) and depression (p = .001).

Conclusions

Findings indicate a high concordance between subjective complaints on the PROMIS Cognitive Scale and objectively confirmed cognitive impairments in African Americans. Further, almost 40% who reported no cognitive complaints screened positive for cognitive impairment. Although depression and anxiety are associated with subjective complaints, they do not account for positive cognitive screening results, as those patients without depressive complaints also had similar rates of positive objective screens. The findings suggest that cognitive screening using assessment tools should be routinely performed in African Americans, especially those reporting cognitive symptoms on outcome scales. While future studies are needed to assess long-term outcomes, we highly recommend follow-ups in those with positive screens to characterize the specific domains that are impacted and that could affect activities of daily living and quality of life.

Non-eligibility for pivotal HFpEF/HFmrEF outcome trials and mortality in a contemporary heart failure cohort

Pivotal outcome trials targeting heart failure with preserved (HFpEF) and mildly-reduced ejection fraction (HFmrEF) may have excluded patients at highest risk of poor outcomes. We aimed to assess eligibility for HFpEF/HFmrEF outcome trials in an unselected heart failure cohort and its association with all-cause mortality. Among 32.028 patients presenting to a tertiary care center emergency unit for any reason between August 2018 and July 2019, we identified 407 admissions with evident HFpEF and HFmrEF. Eligibility criteria for pivotal trials CHARM-Preserved, I-PRESERVE, TOPCAT, PARAGON-HF, EMPEROR-Preserved and DELIVER were assessed by chart review. The proportions of admissions fulfilling HFpEF/HFmrEF trial eligibility criteria were 88% for CHARM-Preserved, 40% for I-PRESERVE, 35% for TOPCAT, 28% for PARAGON-HF, 51% for EMPEROR-Preserved, and 49% for DELIVER. During a median follow-up of 1.9 years, death-from-any-cause occurred in 121 cases (30%). Twenty-four-month overall survival estimates for non-eligible and eligible admissions were 53% vs. 76% for CHARM-Preserved (HR=2.32, 95% CI: 1.47-3.67, p<0.001), 62% vs. 87% for I-PRESERVE (HR=2.97, 1.85-4.77, p<0.001), 67% vs. 84% for TOPCAT (HR=2.04, 1.29-3.24, p = 0.002), 68% vs. 85% for PARAGONHF (HR=2.28, 1.33-3.90, p = 0.003), 64% vs. 81% for EMPEROR-Preserved (HR=1.90, 1.27-2.84, p = 0.002), and 65% vs. 80% for DELIVER (HR=1.71, 1.14-2.57, p = 0.010). Exclusion criteria independently predicting death were eGFR <20 ml/min/1.73 m2, COPD with home oxygen therapy, and severe valvular heart disease. Conclusively, in a contemporary HFpEF/HFmrEF cohort, non-eligibility for outcome trials predicted for strongly increased mortality. HFpEF/HFmrEF patients at highest mortality risk were likely underrepresented in previous outcome trials and their treatment remains an unmet medical need.

Chronic kidney disease is a key risk factor for aortic stenosis progression

BACKGROUND

Rapid progression of aortic stenosis (AS) has been observed in patients undergoing dialysis, but existing cross-sectional evidence is contradictory in non-dialysis-dependent chronic kidney disease (CKD). The present study sought to evaluate whether CKD is associated with the progression of AS over time in a large cohort of patients with AS.

METHODS

We retrospectively studied all consecutive patients diagnosed with AS [peak aortic jet velocity (Vmax) ≥2.5 m/s] and left ventricular ejection fraction ≥50% in the echocardiography laboratories of two tertiary centers between 2000 and 2018. The estimated glomerular filtration rate (eGFR) (mL/min/1.73 m2) was calculated from serum creatinine values. Patients were divided into five CKD stages according to the baseline eGFR. Annual rates of change in the aortic valve area (AVA) were determined by a linear mixed-effects model.

RESULTS

Among the 647 patients included, 261 (40%) had CKD. After a median follow-up of 2.9 (interquartile range 1.8-4.8) years, the mean overall rate of change in AVA was -0.077 (95% confidence interval -0.082; -0.073) cm2/year. There was an inverse relationship between the progression rate and kidney function. The more severe the CKD stage, the greater the AVA narrowing (P < .001). By multivariable linear regression analysis, the eGFR was also negatively associated (P < .001) with AS progression. An eGFR strata below 45 mL/min/1.73 m2 was associated with higher odds of rapid progression of AS than normal kidney function. During the clinical follow-up, event-free survival (patients free of aortic valve replacement or death) decreased as CKD progressed. Rapid progression of AS in patients with kidney dysfunction was associated with worse outcomes.

CONCLUSIONS

Patients with CKD exhibit more rapid progression of AS over time and require close monitoring. The link between kidney dysfunction and rapid progression of AS is still unknown and requires further research.

Effect of Thrombolysis on Circulating Microparticles in Patients with ST-Segment Elevation Myocardial Infarction

Objective

We demonstrated that circulating microparticles (MPs) are increased in patients with coronary heart disease (both chronic coronary syndrome (CCS) and acute coronary syndrome). Whether thrombolysis affects MPs in patients with ST-segment elevation myocardial infarction (STEMI) with or without percutaneous coronary intervention (PCI) is unknown.

Methods

This study was divided into three groups: STEMI patients with thrombolysis (n = 18) were group T, patients with chronic coronary syndrome (n = 20) were group CCS, and healthy volunteers (n = 20) were the control group. Fasting venous blood was extracted from patients in the CCS and control groups, and venous blood was extracted from patients in the T group before (pre-T) and 2 hours after (post-T) thrombolysis. MPs from each group were obtained by centrifugation. After determining the concentration, the effects of MPs on endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) in rat myocardial tissue in vitro were detected by immunohistochemistry and western blotting. Changes in nitric oxide (NO) and oxygen free radicals (O2•-) were also detected. The effect of MPs on vasodilation in isolated rat thoracic aortae was detected.

Results

Compared with that in the control group (2.60 ± 0.38 mg/ml), the concentration of MPs was increased in patients with CCS (3.49 ± 0.72 mg/ml) and in STEMI patients before thrombolysis (4.17 ± 0.58 mg/ml). However, thrombolysis did not further increase MP levels (post-T, 4.23 ± 1.01 mg/ml) compared with those in STEMI patients before thrombolysis. Compared with those in the control group, MPs in both CCS and STEMI patients before thrombolysis inhibited the expression of eNOS (both immunohistochemistry and western blot analysis of phosphorylation at Ser1177), NO production in the isolated myocardium and vasodilation in vitro and stimulated the expression of iNOS (immunohistochemistry and western blot analysis of phosphorylation at Thr495), and the generation of O2•- in the isolated myocardium. The effects of MPs were further enhanced by MPs from STEMI patients 2 hours after thrombolysis.

Conclusion

Changes in MP function after thrombolysis may be one of the mechanisms leading to ischemia-reperfusion after thrombolysis.

Beyond MACE: a multidimensional approach to outcomes in clinical trials for older adults with stable ischemic heart disease

The global population of older adults is expanding rapidly resulting in a shift towards managing multiple chronic diseases that coexist and may be exacerbated by cardiovascular illness. Stable ischemic heart disease (SIHD) is a predominant contributor to morbidity and mortality in the older adult population. Although results from clinical trials demonstrate that chronological age is a predictor of poor health outcomes, the current management approach remains suboptimal due to insufficient representation of older adults in randomized trials and the inadequate consideration for the interaction between biological aging, concurrent geriatric syndromes, and patient preferences. A shift towards a more patient-centered approach is necessary for appropriately and effectively managing SIHD in the older adult population. In this review, we aim to demonstrate the distinctive needs of older adults who prioritize holistic health outcomes like functional capacity, cognitive abilities, mental health, and quality of life alongside the prevention of major adverse cardiovascular outcomes reported in cardiovascular clinical trials. An individualized, patient-centered approach that involves shared decision-making regarding outcome prioritization is needed when any treatment strategy is being considered. By prioritizing patients and addressing their unique needs for successful aging, we can provide more effective care to a patient population that exhibits the highest cardiovascular risks.

Potential for Dose Reduction in CT-Derived Left Ventricular Ejection Fraction: A Simulation Study

BACKGROUND

Measuring left ventricular ejection fraction (LVEF) is important for detecting heart failure, e.g., in treatment with potentially cardiotoxic chemotherapy. MRI is considered the reference standard for LVEF, but availability may be limited and claustrophobia or metal implants still present challenges. CT has been shown to be accurate and would be advantageous, as LVEF could be measured in conjunction with routine chest-abdomen-pelvis oncology CT. However, the use of CT is not recommended due to the excessive radiation dose. This study aimed to explore the potential for dose reduction using simulation. Using an anthropomorphic heart phantom scanned at 13 dose levels, a noise simulation algorithm was developed to introduce controlled Poisson noise. Filtered backprojection parameters were iteratively tested to minimise differences in myocardium-to-ventricle contrast/noise ratio, as well as structural similarity index (SSIM) differences between real and simulated images at all dose levels. Fifty-one clinical CT coronary angiographies, scanned with full dose through end-systolic and -diastolic phases, were located retrospectively. Using the developed algorithm, noise was introduced corresponding to 25, 10, 5 and 2% of the original dose level. LVEF was measured using clinical software (Syngo.via VB50) with papillary muscles in and excluded from the LV volume. At each dose level, LVEF was compared to the 100% dose level, using Bland-Altman analysis. The effective dose was calculated from DLP using a conversion factor of 0.026 mSv/mGycm.

RESULTS

In the clinical images, mean CTDIvol and DLP were 47.1 mGy and 771.9 mGycm, respectively (effective dose 20.0 mSv). Measurements with papillary muscles excluded did not exhibit statistically significant LVEF bias to full-dose images at 25, 10 and 5% simulated dose. At 2% dose, a significant bias of 4.4% was found. With papillary muscles included, small but significant biases were found at all simulated dose levels.

CONCLUSION

Provided that measurements are performed with papillary muscles excluded from the LV volume, the dose can be reduced by a factor of 20 without significantly affecting LVEF measurements. This corresponds to an effective dose of 1 mSv. CT can potentially be used for LVEF measurement with minimal excessive radiation.

Clinical features and 28-day mortality predictors of vaccinated patients admitted to a COVID-19 ICU hub in Italy

BACKGROUND

COVID-19 vaccination has been proved to be effective in preventing hospitalization and illness progression, even though data on mortality of vaccinated patients in the intensive care unit (ICU) are conflicting. The aim of this study was to investigate the characteristics of vaccinated patients admitted to ICU according to their immunization cycle and to outline the risk factors for 28-day mortality. This observational study included adult patients admitted to ICU for acute respiratory failure (ARF) due to SARS-CoV-2 and who had received at least one dose of vaccine.

RESULTS

Fully vaccination was defined as a complete primary cycle from < 120 days or a booster dose from > 14 days. All the other patients were named partially vaccinated. One-hundred sixty patients (91 fully and 69 partially vaccinated) resulted eligible, showing a 28-day mortality rate of 51.9%. Compared to partially vaccinated, fully vaccinated were younger (69 [60-77.5] vs. 74 [66-79] years, p 0.029), more frequently immunocompromised (39.56% vs. 14.39%, p 0.003), and affected by at least one comorbidity (90.11% vs 78.26%, p 0.045), mainly chronic kidney disease (CKD) (36.26% vs 20.29%, p 0.035). At multivariable analysis, independent predictors of 28-day mortality were as follows: older age [OR 1.05 (CI 95% 1.01-1.08), p 0.005], history of chronic obstructive pulmonary disease (COPD) [OR 3.05 (CI 95% 1.28-7.30), p 0.012], immunosuppression [OR 3.70 (CI 95% 1.63-8.40), p 0.002], and admission respiratory and hemodynamic status [PaO2/FiO2 and septic shock: OR 0.99 (CI 95% 0.98-0.99), p 0.009 and 2.74 (CI 95% 1.16-6.48), p 0.022, respectively].

CONCLUSIONS

Despite a full vaccination cycle, severe COVID-19 may occur in patients with relevant comorbidities, especially immunosuppression and CKD. Regardless the immunization status, predisposing conditions (i.e., older age, COPD, and immunosuppression) and a severe clinical presentation were predictors of 28-day mortality.

Current use of cardiac MRI in animals

Cardiovascular magnetic resonance (CMR) imaging has evolved to become an indispensable tool in human cardiology. It is a non-invasive technique that enables objective assessment of myocardial function, size, and tissue composition. Recent innovations in magnetic resonance imaging scanner technology and parallel imaging techniques have facilitated the generation of parametric mapping to explore tissue characteristics, and the emergence of strain imaging has enabled cardiologists to evaluate cardiac function beyond conventional metrics. As veterinary cardiology continues to utilize CMR beyond the reference standard, clinical application of CMR will further expand our capabilities. This article describes the current use of CMR and adoption of more recent advances such as T1/T2 mapping in veterinary cardiology.

Factors Associated With Maintenance of an Improved Ejection Fraction: An Echocardiogram-Based Registry Study

Background Heart failure with improved ejection fraction (EF) is increasingly recognized as a sizable and distinct entity. While the features associated with improvedEF have been explored and new guidelines have emerged, factors associated with sustaining an improved EF over time have not been defined. We aimed to assess factors associated with maintenance of an improved EF in a large real-world patient cohort. Methods and Results A total of 7070 participants with heart failure with improved EF and a subsequent echocardiogram performed after at least 9 months of follow-up were included in a retrospective cohort study conducted at the Cleveland Clinic in Cleveland, Ohio. Multiple logistic regression models, adjusted for demographics, comorbidities, and medications were built to identify characteristics and therapeutic interventions associated with maintaining an improved EF. Mean age (SD) was 64.9 (13.8) years, 62.7% were men, and 75.1% were White participants. White race and the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors were associated with maintaining the EF at least 9 months after EF improvement. In contrast, male sex or having atrial fibrillation/flutter, coronary artery disease, history of myocardial infarction, presence of an implanted cardioverter-defibrillator, and use of loop diuretics were associated with a decline in EF after previously documented improvement. Conclusions Continued use of renin-angiotensin-aldosterone system inhibitors was associated with maintaining the EF beyond the initial improvement phase.

Nationwide in-hospital mortality and morbidity analysis of COVID-19 in advanced chronic kidney disease, dialysis and kidney transplant recipients

Background

Patients with advanced chronic kidney disease (CKD), end-stage kidney disease (ESKD), and kidney transplants (KT) are at an elevated risk for COVID-19 infection, hospitalization, and mortality. A comprehensive comparison of morbidity and mortality between these populations with kidney disease and individuals without any kidney disease is lacking.

Methods

We analysed the 2020 Nationwide Inpatient Sample (NIS) database for non-elective adult COVID-19 hospitalizations, categorizing patients into advanced CKD, ESKD, KT, and kidney disease-free cohorts. Our analysis included a description of the distribution of comorbidities across the entire spectrum of CKD, ESKD, and KT. Additionally, we investigated in-hospital mortality, morbidity, and resource utilization, adjusting for potential confounders through multivariable regression models.

Results

The study included 1,018,915 adults hospitalized for COVID-19 in 2020. The incidence of advanced CKD, ESKD, and KT in this cohort was 5.8%, 3.8%, and 0.4%, respectively. Patients with advanced CKD, ESKD, and KT exhibited higher multimorbidity burdens, with 90.3%, 91.0%, and 75.2% of patients in each group having a Charlson comorbidity index (CCI) equal to or greater than 3. The all-cause in-hospital mortality ranged from 9.3% in kidney disease-free patients to 20.6% in advanced CKD, 19.4% in ESKD, and 12.4% in KT patients. After adjusting for potential confounders at both the patient and hospital levels, CKD stages 3-5; ESKD; and KT were found to be associated with increased odds of mortality, with adjusted odds ratios (aOR) of 1.34, 1.80, 2.66, 1.97, and 1.69, respectively.

Conclusion

Patients hospitalized for COVID-19 with advanced CKD, ESKD, or KT demonstrated a higher burden of comorbidities and increased mortality rates compared to those without kidney disease. After adjusting for confounders, CKD stages 3-5; ESKD; and KT were identified as independent risk factors for in-hospital mortality, illustrating a dose-response relationship between the odds of mortality and adverse outcomes as CKD progressed from stages 3 to 5. Our study highlights the necessity for enhanced management of comorbidities, targeted interventions, and vigorous vaccination efforts to mitigate the risk of adverse outcomes in the vulnerable populations of patients with CKD, ESKD, and KT.

Building and Optimizing the Interdisciplinary Heart Team

A multidisciplinary care team model, or Heart Team approach, has become a central tenet of cardiovascular care. Though initially applied to the management of heart transplantation and subsequently complex coronary artery disease, the Heart Team is now utilized broadly across cardiovascular medicine, including in the treatment of valvular disease, pulmonary embolism, cardiogenic shock, high-risk pregnancies in patients with pre-existing cardiovascular disease, and adult congenital heart disease. The Heart Team model improves interdisciplinary collaboration among specialties, adherence to societal guidelines, and shared decision-making with patients and families. In this review, we highlight the development and rationale supporting the Heart Team model, address the challenges of implementing a multidisciplinary care team, and discuss the optimal methods to continue to build, optimize, and implement this approach.

Direct deep learning-based survival prediction from pre-interventional CT prior to transcatheter aortic valve replacement

PURPOSE

To investigate survival prediction in patients undergoing transcatheter aortic valve replacement (TAVR) using deep learning (DL) methods applied directly to pre-interventional CT images and to compare performance with survival models based on scalar markers of body composition.

METHOD

This retrospective single-center study included 760 patients undergoing TAVR (mean age 81 ± 6 years; 389 female). As a baseline, a Cox proportional hazards model (CPHM) was trained to predict survival on sex, age, and the CT body composition markers fatty muscle fraction (FMF), skeletal muscle radiodensity (SMRD), and skeletal muscle area (SMA) derived from paraspinal muscle segmentation of a single slice at L3/L4 level. The convolutional neural network (CNN) encoder of the DL model for survival prediction was pre-trained in an autoencoder setting with and without a focus on paraspinal muscles. Finally, a combination of DL and CPHM was evaluated. Performance was assessed by C-index and area under the receiver operating curve (AUC) for 1-year and 2-year survival. All methods were trained with five-fold cross-validation and were evaluated on 152 hold-out test cases.

RESULTS

The CNN for direct image-based survival prediction, pre-trained in a focussed autoencoder scenario, outperformed the baseline CPHM (CPHM: C-index = 0.608, 1Y-AUC = 0.606, 2Y-AUC = 0.594 vs. DL: C-index = 0.645, 1Y-AUC = 0.687, 2Y-AUC = 0.692). Combining DL and CPHM led to further improvement (C-index = 0.668, 1Y-AUC = 0.713, 2Y-AUC = 0.696).

CONCLUSIONS

Direct DL-based survival prediction shows potential to improve image feature extraction compared to segmentation-based scalar markers of body composition for risk assessment in TAVR patients.

Comparison of Electrocardiographic Parameters by Gender in Heart Failure Patients with Preserved Ejection Fraction via Artificial Intelligence

BACKGROUND

Heart failure (HF) causes high morbidity and mortality worldwide. The prevalence of HF with preserved ejection fraction (HFpEF) is increasing compared with HF with reduced ejection fraction (HFrEF). Patients with HFpEF are a patient group with a high rate of hospitalization despite medical treatment. Early diagnosis is very important in this group of patients, and early treatment can improve their prognosis. Although electrocardiographic (ECG) findings have been adequately studied in patients with HFrEF, there are not enough studies on these parameters in patients with HFpEF. There are very few studies in the literature, especially on gender-specific changes. The current research aims to compare gender-specific ECG parameters in patients with HFpEF based on the implications of artificial intelligence (AI).

METHODS

A total of 118 patients participated in the study, of which 66 (56%) were women with HFpEF and 52 (44%) were men with HFpEF. Demographic, echocardiographic, and electrocardiographic characteristics of the patients were analyzed to compare gender-specific ECG parameters in patients with HFpEF. The AI approach combined with machine learning approaches (gradient boosting machine, k-nearest neighbors, logistic regression, random forest, and support vector machines) was applied for distinguishing male patients with HFpEF from female patients with HFpEF.

RESULTS

After determining the parameters (demographic, echocardiographic, and electrocardiographic) to distinguish male patients with HFpEF from female patients with HFpEF, machine learning methods were applied, and among these methods, the random forest model achieved an average accuracy of 84.7%. The random forest algorithm results showed that smoking, P-wave dispersion, P-wave amplitude, T-end P/(PQ*Age), Cornell product, and P-wave duration were the most influential parameters for distinguishing male patients with HFpEF from female patients with HFpEF.

CONCLUSIONS

The proposed model serves as a valuable tool for physicians, facilitating the diagnosis, treatment, and follow-up for distinguishing male patients with HFpEF from female patients with HFpEF. Analyzing readily accessible electrocardiographic parameters empowers medical professionals to make informed decisions and provide enhanced care to a wide range of individuals.

The Association between Birthweight and Use of Cardiovascular Medications: The Role of Health Behaviors

BACKGROUND

There is limited evidence on the effect of low birthweight on the use of cardiovascular medications and the role of health behaviors. This study aims to determine the independent effect of low birthweight and its combination with adult health behaviors on the number of dispensed cardiovascular medications.

METHODS

We included 15618 participants with information on birthweight and self-reported health behaviors. Dispensed cardiovascular medications were identified from the Prescribed Drug Register based on a three-digit level Anatomical Therapeutic Chemical classification code (C01 to C10 and B01) and categorized into 0, 1, and ≥2 different types of medications. We applied multinomial logistic regression models estimating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Participants with low birthweight had a higher estimated OR of using ≥2 types of cardiovascular medications (OR = 1.46, 95% CI = 1.06, 2.01). Further, an increased risk for using ≥2 types of cardiovascular medications was found in participants with poor health behaviors for normal (OR = 2.17, 95% CI = 1.80, 2.62) and high (OR = 1.84, 95% CI = 1.29, 2.62) birthweight. The strongest effect on using ≥2 types of cardiovascular medications was found for low birthweight and poor health behaviors (OR = 3.14, 95% CI = 1.80, 5.50).

CONCLUSION

This cohort study provides evidence that low birthweight increases the risk of using more types of cardiovascular medications in adulthood. This study also suggests that ideal health behaviors reduce this risk.

Total Cholesterol Levels and Risk of Mortality or Heart Failure Rehospitalization in Patients With Valvular Heart Disease

Low total cholesterol (TC) levels have been found to significantly increase mortality risk in patients experiencing heart failure. However, it is unclear whether the same relation applies specifically to patients with valvular heart disease (VHD). This study included patients with significant VHD from the China Valvular Heart Disease Study. Patients with atherosclerotic cardiovascular disease were excluded. The primary end point of this study was a combined indicator of either all-cause mortality or rehospitalization because of heart failure (HF). The association between TC and the primary outcome was evaluated using Cox proportional hazard models. The cut-off value of TC for predicting mortality or rehospitalization was determined by the maximally selected rank test. The study population comprised 6,235 patients with VHD. Over a 2-year follow-up period, there were 393 deaths and 265 HF rehospitalizations. The adjusted hazard models showed that for every 1 mmol/L decrease in TC, there was a 1.19-fold increased risk of death or HF rehospitalization (adjusted hazard ratio 1.19, 95% confidence interval 1.09 to 1.30, p <0.001). The optimal cut-off value of TC was 3.53 mmol/L; patients at or below this level had significantly higher mortality and HF rehospitalization rates. After adjustment for confounding factors, low TC levels (≤3.53 mmol/L) remained a significant risk factor for patients with aortic regurgitation, mitral regurgitation, and tricuspid regurgitation. Decreased TC levels are associated with an increased risk of death or HF rehospitalization among patients with VHD.

Cellular immune response to SARS-CoV-2 in patients with primary antibody deficiencies

Introduction

Primary antibody deficiencies (PAD) are inborn defects of the immune system that result in increased susceptibility to infections. Despite the reduced response to vaccination, PAD patients still benefit from it by reducing the risk of severe infections and complications. SARS-CoV-2 vaccines are recommended in PAD patients, but their immune effects are poorly studied. Here, we analyze virus-specific T-cell responses in PAD patients after booster vaccination against SARS-CoV-2.

Patients and methods

The study included 57 adult PAD patients on long-term immunoglobulin replacement therapy (IgRT) diagnosed with X-linked agammaglobulinemia (XLA; n = 4), common variable immunodeficiency (CVID; n = 33), isotype defects or IgG subclass deficiency (n = 6), and unclassified IgG deficiency (n = 14). Of those, 49 patients (86%) received vaccination against SARS-CoV-2 using mRNA vaccine (Pfizer-BioNTech). T-cell responses were assessed at a median of 21 (13 - 30) weeks after the booster dose (mainly the third dose) using commercially available interferon-gamma release assay (IGRA) with recombinant SARS-CoV-2 spike S1 protein.

Results

Vaccinated PAD patients showed an increased (3.8-fold, p = 0.004) release of IFN-γ upon S1 stimulation. In this group, we also documented higher serum levels of anti-SARS-CoV-2 IgG (4.1-fold, p = 0.01), although they were not associated with IGRA results. Further subgroup analysis revealed very similar IGRA responses in CVID and unclassified IgG deficiencies that were 2.4-fold increased compared to XLA and 5.4-fold increased compared to patients with isotype defects or IgG subclass deficiencies (e.g., vs. CVID: p = 0.016). As expected, CVID and XLA patients showed decreased serum titers of anti-SARS-CoV-2 antibodies compared to other studied groups (e.g., CVID vs. unclassified IgG deficiency: 4.4-fold, p = 0.006). The results did not depend directly on IgRT mode or dose, number of vaccine doses and time from the last booster dose, and clinical manifestations of PAD. Interestingly, anti-SARS-CoV-2 titers were positively correlated with serum immunoglobulin levels before IgRT (e.g., for IgA: r = 0.45, p<0.001; for IgG: r = 0.34, p = 0.009) and the percentage of peripheral blood NK cells (r = 0.48, p<0.001).

Conclusions

Our results documented satisfactory in vitro cellular immune response in PAD patients after booster SARS-CoV-2 vaccination. Therefore, even patients with agammaglobulinemia should benefit from vaccination due to the apparent induction of cell-mediated immunity, which, together with IgRT, grants comprehensive protection against the pathogen.

Serum levels of 25-OH vitamin D levels predict cognitive impairments among acute coronary syndrome patients

BACKGROUND

The cognitive impairment after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) has become a crucial clinical concern that cannot be ignored. However, studies on the early warning factors of cognitive impairment after PCI are still insufficient.

METHODS

This study reviewed the postoperative cognitive function of 284 patients who underwent PCI in our hospital from June 2019 to June 2022. During the 21-day follow-up, all participants included in the analysis were divided into the cognitive impairment (CI) group (n = 82) and the noncognitive impairment (NCI) group (n = 186) according to their Montreal cognitive assessment (MoCA) scale. Participants' serum 25(OH)D3 levels on admission and serum neuron-specific enolase (NSE), glial fibrillary acidic protein (GFAP) and S100β levels were measured 21 days after surgery.

RESULTS

Age more than 65 years, hypertension, operation time longer than 60 min, left ventricular ejection fraction less than 50% and serum 25(OH)D3 less than 31.41 ng/ml were the risk factors for cognitive dysfunction in ACS patients 21 days after PCI. Serum levels of 25(OH)D3, NSE, S100β and GFAP were significantly higher in patients with cognitive impairment than in patients without cognitive impairment.

CONCLUSION

Postoperative serum NSE, S100β and GFAP levels were significantly negatively correlated with serum 25(OH)D3 levels at admission. The serum 25(OH)D3 level is a risk factor and predictor of cognitive impairment in patients with ACS after PCI.

Do Heart Failure Biomarkers Influence Heart Failure Treatment Response?

PURPOSE OF REVIEW

Heart failure (HF) is one of the leading causes of cardiac morbidity and mortality around the world. Our evolving understanding of the cellular and molecular pathways of HF has led to the identification and evaluation of a growing number of HF biomarkers. Natriuretic peptides remain the best studied and understood HF biomarkers, with demonstrated clinical utility in the diagnosis and prognostication of HF. Less commonly understood is the utility of HF biomarkers for guiding and monitoring treatment response. In this review, we outline the current HF biomarker landscape and identify novel biomarkers that have potential to influence HF treatment response.

RECENT FINDINGS

An increasing number of biomarkers have been identified through the study of HF mechanisms. While these biomarkers hold promise, they have not yet been proven to be effective in guiding HF therapy. A more developed understanding of HF mechanisms has resulted in an increased number of available pharmacologic HF therapies. In the past, biomarkers have been useful for the diagnosis and prognostication of HF. Future evaluation on their use to guide pharmacologic therapy is ongoing, and there is promise that biomarker-guided therapy will allow clinicians to begin personalizing treatment for their HF patients.

The Burden of Neonatal Referrals on a Pediatric Cardiology Service: A Local Center Experience

BACKGROUND

Congenital heart disease (CHD) is a common occurrence in live births, with some exhibiting critical congenital heart disease; therefore, cardiology services should be available around the clock to ensure timely diagnosis and management. This study aims to describe the workload and the need for pediatric cardiac services in a maternity hospital for newborn referrals. Moreover, the study describes the indications for neonatal cardiology consultations.

METHODS

The prospective cohort study was conducted over four months, from January to April 2022, in the Prince Sultan Cardiac Center Al Qassim region of Saudi Arabia. Prince Sultan Cardiac Center's pediatric cardiology department provides cardiac services to the Maternity and Children Hospital Buraidah Al Qassim. Out of the total 2,606 live births during the study period, the cardiology team evaluated 352 neonates. Neonates less than 30 days of age who were born in the maternity hospital were enrolled in the study. The outborn babies referred from other centers as suspected congenital heart disease for whom a cardiac evaluation was done were excluded. In addition, babies assessed in the emergency room and born elsewhere were excluded. Only new consultations have been considered, excluding follow-up consultations.

STATISTICAL ANALYSIS

Data about patients' demographic, clinical and echocardiographic findings were recorded on Google Forms and converted to a Google spreadsheet. The Google spreadsheet's inbuilt statistical software was used for analysis. Categorical data were presented as percentages, and numerical data as median and range.

RESULTS

The cardiology team evaluated 352 neonates from 2,606 live births over four months, accounting for 13.5 per 100 live births. The median weight was 2.8 kilograms, with a 0.5-4.3 kilogram range. Males comprised 187 (53%), and females comprised 165 (47%). Moreover, full-term, preterm, and post-term accounted for 236 (67%), 113 (32%), and 3 (0.8%) of patients, respectively. The common indications for neonatal cardiac referral were respiratory distress 60 (17%), infants born to diabetic mothers 50 (14%), abnormal fetal echocardiogram 49 (13.9%), family history of abortion or neonatal death 31 (8.8%), and congenital anomalies 30 (8.5%). Systolic murmur was the commonest clinical finding that prompted cardiology referrals 82 (23.2%), followed by desaturation 38 (10.7%) and dysmorphic features 31 (8.8%). Among the congenital cardiac defects, an isolated atrial septal defect (ASD) was seen in 66 (18.5%), isolated patent ductus arteriosus in 50 (14.2%), and ventricular septal defect in 21 (5.9%). Moreover, 13 (4.4%) lesions were critical CHDs. Finally, 27 (7.6%) had a diagnosis of pulmonary hypertension.

CONCLUSION

Knowing the burden of neonatal cardiac assessment on pediatric cardiology services in any maternity center may help the healthcare authorities to allocate resources and optimize the delivery of cardiac services among the neonatal population. Properly allocating pediatric cardiologists to the needed centers may optimize neonatal cardiac services. Moreover, it may decide on the number of pediatric cardiologists that need to be trained each year to meet the requirements of neonatal cardiac services.

CT measured pulmonary artery to ascending aorta ratio stratified by echocardiographically obtained systolic pulmonary artery pressure values for noninvasive detection of pulmonary hypertension in patients with severe aortic valve stenosis

BACKGROUND

Transthoracic echocardiography (TTE) offers a measurement method for the determination of pulmonary hypertension (PH) in patients with severe aortic valve stenosis (AS) with determination of maximal tricuspid regurgitation velocity (TRVmax) and systolic pulmonary artery pressure (sPAP). Radiological parameters for noninvasive detection of PH, most importantly computed tomography (CT) based PA/AA-ratio = ratio of pulmonary artery diameter (PA) and ascending aorta diameter (AA), are also included in the latest ESC guidelines. The aim of the present study was to define cut-off values for PA/AA-ratio taking also into account cardiovascular biomarkers to determine criteria for noninvasive diagnosis of PH.

METHODS

194 patients with severe AS undergoing transcatheter aortic valve replacement (TAVR) underwent pre-procedural TTE and CT with measurement of PA/AA-ratio. Additionally, common cardiovascular biomarkers were determined.

RESULTS

TAVR patients with an sPAP ≥ 40 mmHg or a TRVmax ≥ 2.9 m/s had a PA/AA-ratio ≥ 0.80 in an AUROC analysis. The cut-off value of ≥ 0.80 resulted in a significantly higher mortality rate (log-rank test: p = 0.034) in these patients in a Kaplan-Meier analysis regarding 1-year survival after TAVR. Significant differences in biomarker expression between patients with a PA/AA-ratio ≥ 0.80 or < 0.80 occurred for BNP (p = 0.001), cTnI (p = 0.032), GDF-15 (p = 0.002) and H-FABP (p = 0.015).

CONCLUSION

PA/AA-ratio ≥ 0.80 is a promising radiological parameter that can provide information about mortality in patients with severe AS undergoing TAVR; combined with biomarkers it may contribute to noninvasive detection of PH in patients with severe AS.

Unveiling the Influence of Smoking and Uncontrolled Lipid Profile in the Development of ST-Elevation Myocardial Infarction

We report a case of a 25-year-old male with the traditional risk factor for coronary artery disease (CAD), such as frequent smoking, while the other risk factors such as familial history of CAD were denied and hypertension, obesity, diabetes mellitus, or coagulation factors were not found. Patient was admitted with anterior ST-elevation myocardial infarction. Coronary angiography showed high intracoronary thrombus burden and total occlusion of the proximal segment of left anterior descending artery. Percutaneous coronary intervention was then performed as the treatment of choice, and resulted with no residual stenosis after. The patient had a smooth and progressive recovery.

Changing haemodynamic status of patients referred for transcatheter aortic valve intervention during the COVID-19 pandemic

INTRODUCTION

Delays in the diagnosis and referral of aortic stenosis (AS) during the coronavirus disease 2019 (COVID-19) pandemic may have affected the haemodynamic status of AS patients. We aimed to compare clinical and haemodynamic characteristics of severe AS patients referred for transcatheter aortic valve implantation (TAVI) or balloon aortic valvuloplasty (BAV) before the pandemic versus two subsequent periods.

METHODS

This study compared three 1‑year historical cohorts: a pre-COVID-19 group (PCOV), a 1st-year COVID-19 group (COV-Y1) and a 2nd-year COVID-19 group (COV-Y2). The main parameters were baseline New York Heart Association (NYHA) functional class, left ventricular ejection fraction (LVEF) and left ventricular end-diastolic pressure (LVEDP). Demographics, procedural characteristics and 30-day clinical outcomes were assessed. The transition time between heart team decision and TAVI was examined. Pairwise group comparisons were performed (PCOV vs COV-1Y and COV-1Y vs COV-2Y).

RESULTS

A total of 720 patients were included with 266, 249 and 205 patients in the PCOV, COV-Y1 and COV-Y2 groups, respectively. BAV was performed in 28 patients (4%). NYHA class did not differ across the cohorts. Compared to PCOV, LVEF was slightly lower in COV-Y1 (58% (49-60%) vs 57% (45-60%), p = 0.03); no difference was observed when comparing COV-Y1 and COV-Y2. LVEDP was higher in COV-Y1 than in PCOV (20 mm Hg (16-26 mm Hg) vs 17 mm Hg (13-24 mm Hg), p = 0.01). No difference was found when comparing LVEDP between COV-Y1 and COV-Y2. Thirty-day mortality did not differ between groups. Transition time was reduced in the COVID era. Duration of hospital stay declined over the study period.

CONCLUSIONS

Patients undergoing TAVI during the COVID-19 pandemic had more advanced AS illustrated by lower LVEF and higher LVEDP, but there were no differences in clinical outcome. The TAVI pathway became more efficient.

Common Cardiovascular Diseases in Women

Cardiovascular disease is a leading cause of death for women in the United States. This article encompasses the epidemiology/etiology, clinical presentation, diagnostic assessment, management, and prognosis of some common cardiovascular disorders seen in women with a special focus on pregnancy.

Progression of Non-Significant Mitral and Tricuspid Regurgitation after Surgical Aortic Valve Replacement for Aortic Regurgitation

Little is known about the natural history of non-significant mitral and tricuspid regurgitation (MR and TR) following surgical aortic valve replacement (SAVR) for aortic regurgitation (AR). We retrospectively analyzed 184 patients (median age 64 (IQR, 55-74) years, 76.6% males) who underwent SAVR for AR. Subjects with significant non-aortic valvulopathies, prior/concomitant valvular interventions, or congenital heart disease were excluded. The cohort was evaluated for MR/TR progression and, based on the latter's occurrence, for echocardiographic and clinical indices of heart failure and mortality. By 5.8 (IQR, 2.8-11.0) years post-intervention, moderate or severe MR occurred in 20 (10.9%) patients, moderate or severe TR in 25 (13.5%), and either of the two in 36 (19.6%). Patients who developed moderate or severe MR/TR displayed greater biventricular disfunction and functional limitation and were less likely to be alive at 7.0 (IQR, 3.4-12.1) years compared to those who did not (47.2 vs. 79.7%, p < 0.001). The emergence of significant MR/TR was associated with preoperative atrial fibrillation/flutter, symptomatic heart failure, and above-mild MR/TR as well as concomitant composite graft use, but not with baseline echocardiographic measures of biventricular function and dimensions, aortic valve morphology, or procedural aspects. In conclusion, among patients undergoing SAVR for AR, significant MR/TR developed in one fifth by six years, correlated with more adverse course, and was anticipated by baseline clinical and echocardiographic variables.

Effect of Telehealth Services on Mitral and Tricuspid Regurgitation Progression: Retrospective Study

BACKGROUND

Mitral regurgitation (MR) and tricuspid regurgitation (TR) are common cardiac conditions with high mortality risks, which can be improved through early intervention. Telehealth services, which allow for remote monitoring of patient conditions, have been proven to improve the health management of chronic diseases, but the effects on MR and TR progression are unknown.

OBJECTIVE

This study aimed to explore whether patients receiving telehealth services have less MR and TR progression compared with a control group. We also aimed to identify the determinants of MR and TR progression.

METHODS

This single-center retrospective study conducted at the National Taiwan University Hospital compared MR and TR progression (defined as either progression to moderate or greater MR and TR or MR and TR progression by ≥2 grades during the study period) between the telehealth and control groups. Patients had a minimum of 2 transthoracic echocardiograms at least 6 months apart; baseline mild-moderate MR and TR or lower; and no prior surgeries on the mitral or tricuspid valve. Telehealth patients were defined as those who received telehealth services for at least 28 days within 3 months of baseline. Basic demographics, baseline blood pressure measurements, prescribed medication, and Charlson Comorbidity Index components were obtained for all patients.

RESULTS

A total of 1081 patients (n=226 in the telehealth group and n=855 in the control group) were included in the study analyses. The telehealth group showed significantly lower baseline systolic blood pressure (P<.001), higher Charlson Comorbidity Index (P=.02), higher prevalence of prior myocardial infarction (P=.01) and heart failure (P<.001), higher beta-blocker (P=.03) and diuretic (P=.04) use, and lower nitrate use (P=.04). Both groups showed similar cardiac remodeling conditions at baseline. Telehealth was found to be neutral for both MR (hazard ratio 1.10, 95% CI 0.80-1.52; P=.52) and TR (hazard ratio 1.27, 95% CI 0.92-1.74; P=.14) progression. Determinants for moderate or greater MR progression included older age, female sex, diuretic use, larger left atrial dimension, left ventricular end-diastolic dimension, left ventricular end-systolic dimension, and lower left ventricular ejection fraction. Determinants of moderate or greater TR progression included older age, female sex, diuretic use, presence of atrial fibrillation, LA dimension, left ventricular end-systolic dimension, and lower left ventricular ejection fraction; statin use was found to be protective.

CONCLUSIONS

This is the first study to assess the association between telehealth services and the progression of MR and TR. Telehealth patients, who had more comorbidities, displayed similar MR and TR progression versus control patients, indicating that telehealth may slow MR and TR progression. Determinants of MR and TR progression included easy-to-measure traditional echo parameters of cardiac function, older age, female sex, and atrial fibrillation, which can be incorporated into a telehealth platform and advanced alert system, improving patient outcomes through personalized care.

Association between the triglyceride-glucose index and calcified aortic stenosis in elderly patients: a cross-sectional study

Insulin resistance (IR) is associated with a variety of cardiovascular diseases, but there are few studies on the correlation between IR and calcified aortic stenosis (CAS). In this study, the triglyceride-glucose (TyG) index, which reflects IR, was used to investigate the correlation between IR and CAS. The study included 183 elderly patients who were diagnosed with CAS by transthoracic echocardiography. The patients were matched 1:1 according to age and sex, and elderly patients who were hospitalized during the same period and underwent transthoracic echocardiography without aortic stenosis were included as the control group. The relationship between the TyG index and CAS was analyzed by a multivariable logistic regression model, curve fitting and trend test. Multivariate logistic regression analysis showed that the TyG index as a continuous variable was negatively associated with CAS (P < 0.001); trend tests and curve fitting further supported this association. Our study showed that the TyG index was negatively associated with CAS in elderly patients, which may be related to the impairment of insulin receptors and signaling pathways in IR.

Changes in Left Ventricular Global Longitudinal Strain in Patients With Heart Failure and Secondary Mitral Regurgitation: The COAPT Trial

Background Left ventricular (LV) global longitudinal strain (GLS) provides incremental prognostic information over LV ejection fraction in patients with heart failure (HF) and secondary mitral regurgitation. We examined the prognostic impact of LV GLS improvement in this population. Methods and Results The COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial randomized symptomatic patients with HF with severe (3+/4+) mitral regurgitation to transcatheter edge-to-edge repair with the MitraClip device plus maximally tolerated guideline-directed medical therapy (GDMT) versus GDMT alone. LV GLS was measured at baseline and 6-month follow-up. The relationship between the improvement in LV GLS from baseline to 6 months and the composite of all-cause death or HF hospitalization between 6- and 24-month follow-up were assessed. Among 383 patients, 174 (45.4%) had improved LV GLS at 6-month follow-up (83/195 [42.6%] with transcatheter edge-to-edge repair+GDMT and 91/188 [48.4%] with GDMT alone; P=0.25). Improvement in LV GLS was strongly associated with reduced death or HF hospitalization between 6 and 24 months (P<0.009), with similar risk reduction in both treatment arms (Pinteraction=0.40). By multivariable analysis, LV GLS improvement at 6 months was independently associated with a lower risk of death or HF hospitalization (hazard ratio [HR], 0.55 [95% CI, 0.36-0.83]; P=0.009), death (HR, 0.48 [95% CI, 0.29-0.81]; P=0.006), and HF hospitalization (HR, 0.50 [95% CI, 0.31-0.81]; P=0.005) between 6 and 24 months. Conclusions Among patients with HF and severe mitral regurgitation in the COAPT trial, improvement in LV GLS at 6-month follow-up was associated with improved outcomes after both transcatheter edge-to-edge repair and GDMT alone between 6 and 24 months. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.

Acquired Ventricular Septal Defect in Panton-Valentine Leukocidin-Positive Staphylococcus aureus Infective Endocarditis

Infective endocarditis (IE) is life-threatening and can lead to complications if left untreated. A 56-year-old gentleman presented with acute delirium, fever and rigor. Panton-Valentine leukocidin (PVL)-positive Staphylococcus aureus (S. aureus) was isolated in the blood culture and the PR interval was prolonged on the electrocardiogram (ECG). However, the transthoracic echocardiogram (TTE) and transoesophageal echocardiogram (TOE) at presentation were unremarkable with no evidence of intracardiac vegetations. Despite expedient intravenous antibiotics, an acquired ventricular septal defect (VSD) developed, which required urgent cardiothoracic surgical repair. It is imperative to consider early surgical interventions and the use of anti-toxin antibiotics in PVL-positive S. aureus IE.

Dyslipidemia Update

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States. The development and progression of atherosclerotic CVD are largely dependent on a multitude of modifiable and nonmodifiable risk factors. Current therapeutic strategies involve risk factor modification, especially dyslipidemia. The treatment of dyslipidemia continues to be dynamic, and in this paper, we review the current strategies for risk assessment, diagnosis, and treatment. As treatments for the management of dyslipidemia continue to evolve with ever-increasing options for therapeutic targets, an understanding of lipid-lowering therapies remains an essential topic of understanding for all health care providers.

Asymptomatic Severe and Moderate Aortic Stenosis: Time for Appraisal of Treatment Indications

Over the last decades, we have witnessed considerable improvements in diagnostics and risk stratification of patients with significant aortic stenosis (AS), paralleled by advances in operative and anesthetic techniques. In addition, accumulating evidence points to the potential benefit of early valve replacement in such patients prior to the onset of symptoms. In parallel, interventional randomized trials have proven the benefit of transcatheter aortic valve replacement in comparison to a surgical approach to valve replacement over a broad risk spectrum in symptomatic patients with AS. This article reviews contemporary management approaches and scrutinizes open questions regarding timing and mode of intervention in asymptomatic patients with severe AS. We also discuss the challenges surrounding the management of symptomatic patients with moderate AS as well as emerging dilemmas related to the concept of a life-long treatment strategy for patients with AS.