Silent myocardial ischemia

Oral mitochondrial transplantation using nanomotors to treat ischaemic heart disease

Mitochondrial transplantation is an important therapeutic strategy for restoring energy supply in patients with ischaemic heart disease (IHD); however, it is limited by the invasiveness of the transplantation method and loss of mitochondrial activity. Here we report successful mitochondrial transplantation by oral administration for IHD therapy. A nitric-oxide-releasing nanomotor is modified on the mitochondria surface to obtain nanomotorized mitochondria with chemotactic targeting ability towards damaged heart tissue due to nanomotor action. The nanomotorized mitochondria are packaged in enteric capsules to protect them from gastric acid erosion. After oral delivery the mitochondria are released in the intestine, where they are quickly absorbed by intestinal cells and secreted into the bloodstream, allowing delivery to the damaged heart tissue. The regulation of disease microenvironment by the nanomotorized mitochondria can not only achieve rapid uptake and high retention of mitochondria by damaged cardiomyocytes but also maintains high activity of the transplanted mitochondria. Furthermore, results from animal models of IHD indicate that the accumulated nanomotorized mitochondria in the damaged heart tissue can regulate cardiac metabolism at the transcriptional level, thus preventing IHD progression. This strategy has the potential to change the therapeutic strategy used to treat IHD.

Silent Myocardial Ischemia: From Pathophysiology to Diagnosis and Treatment

Silent myocardial ischemia (SMI), characterized by a lack of overt symptoms despite an inadequate blood supply to the myocardium, remains a challenging entity in cardiovascular medicine. The pathogenesis involves intricate interactions of vascular, neurohormonal, and metabolic factors, contributing to perfusion deficits without the characteristic chest pain. Understanding these mechanisms is pivotal for recognizing diverse clinical presentations and designing targeted interventions. Diagnostic strategies for SMI have evolved from traditional electrocardiography to advanced imaging modalities, including stress echocardiography, single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (MRI). Treating SMI is a matter of ongoing debate, as the available evidence on the role of invasive versus medical management is controversial. This comprehensive review synthesizes current knowledge of silent myocardial ischemia, addressing its pathophysiology, diagnostic modalities, and therapeutic interventions.

Cardiac Autonomic Dysfunction and Risk of Silent Myocardial Infarction Among Adults With Type 2 Diabetes

Background There is a paucity of large-scale epidemiological studies on the link between cardiac autonomic neuropathy (CAN) and the risk of silent myocardial infarction (SMI) in type 2 diabetes. We evaluated the association between CAN and the risk of SMI in a large sample of adults with type 2 diabetes. Methods and Results Participants with type 2 diabetes from the ACCORD (Action to Control Cardiovascular Risk in Diabetes) study without atherosclerotic cardiovascular disease at baseline were included. CAN was ascertained using heart rate variability indices calculated from 10-s resting electrocardiograms. The heart rate variability indices included standard deviation of all normal-to-normal R-R intervals and root mean square of successive differences between normal-to-normal R-R intervals. CAN was defined as both the standard deviation of all normal-to-normal R-R intervals and root mean square of successive differences between normal-to-normal R-R intervals less than the fifth percentile of the general population. We used Cox proportional hazards regression to generate hazard ratios (HRs) for incident SMI in relation to CAN measures. Among 4842 participants (mean age, 62.5 years; 46.6% women; 60.2% White), there were 73 incident SMI cases over a median follow-up of 4.9 years (incidence rate 3.1 out of 1000 person-years [95% CI, 2.5-3.9]). After adjusting for confounders, low heart rate variability was associated with a higher risk of SMI (HR, 1.67 [95% CI, 1.02-2.72] and HR, 1.56 [95% CI, 0.94-2.58] for low standard deviation of all normal-to-normal R-R intervals and root mean square of successive differences between normal-to-normal R-R intervals, respectively). Participants with CAN had a 1.9-fold greater risk of SMI (HR, 1.91 [95% CI, 1.14-3.20]). Conclusions In a large cohort of adults with type 2 diabetes, CAN was significantly associated with an increased risk of incident SMI.

Vasospastic angina: Past, present, and future

Vasospastic angina (VSA) is characterized by episodes of rest angina that are responsive to short-acting nitrates and are attributable to coronary artery vasospasm. The condition is underdiagnosed as the provocation test is rarely performed. VSA, the most important component of non-obstructive coronary artery disease, can present with angina, be asymptomatic, or can even present with fatal arrhythmias and cardiac arrest. Although most patients with VSA respond well to vasodilating medications, prognosis does not improve as expected in most patients, suggesting the existence elusive prognostic factors and pathogenesis that warrant further exploration. Moreover, patients with either severe or refractory VSA barely respond to conventional treatment and may develop life-threatening arrhythmias or suffer sudden cardiac death during ischemic attacks, which are associated with immune-inflammatory responses and have been shown to achieve remission following glucocorticoid and immunoglobulin treatments. Our recent work revealed that inflammation plays a key role in the initiation and development of coronary spasms, and that inflammatory cytokines have predictive value for diagnosis. In contrast to the existing literature, this review both summarizes the theoretical and clinical aspects of VSA, and also discusses the relationship between inflammation, especially myocarditis and VSA, in order to provide novel insights into the etiology, diagnosis, and treatment of VSA.

Cardiology co-management of rheumatoid arthritis patients with coronary artery disease as an intervention reduces hospitalization rates and adverse event occurrence

INTRODUCTION

Rheumatoid arthritis (RA) is a systemic autoimmune disease with important cardiovascular (CV) implications. CV disease represents over half of RA patient deaths and causes significant morbidity. CV manifestations in RA can be complex, raising concerns for adequate patient management and provider-dependent roles.

METHODS

This is a retrospective study of patients diagnosed with RA and coronary artery disease (CAD). Patients were identified and filtered via EPIC Database search engine. Parameters were set from January 1, 2014, to December 31, 2020. Inclusion criteria consisted of patients who met diagnostic criteria for both RA and CAD. A total of 399 patients met criteria.

RESULTS

Of the 399 identified patients, 272 were female (68.2%) and 127 were male (31.8%) with a median age of 73 (range 26-98). The population was further divided into two groups: those with established cardiology care versus those without. Patients without cardiology follow-up experienced significantly more hospitalizations (RR 1.63 95% CI 1.12, 2.38), higher rates of adverse events including myocardial infarction (MI) (RR 4.82 95% CI 1.94, 11.98), heart failure (HF) (OR 15.81 95% CI 3.54, 70.52), and stroke (RR 2.55 95% CI 1.29, 5.03). Patients not followed by cardiology also had numerical increases in CV death (4 deaths compared to none in those with cardiology follow) and all-cause mortality (HR 1.03 95% CI 0.63, 1.67).

CONCLUSION

Patients with regular cardiology follow-up demonstrated fewer cardiac-related adverse events. This suggests that co-management may have a role in adverse cardiac event risk reduction and should therefore be an early consideration. Key Points • Rheumatoid arthritis patients demonstrate higher rates of coronary disease compared to the general population. Traditional cardiac risk factors may not be entirely responsible for this phenomenon • Hospitalization rates and adverse event occurrence are significantly higher in patients with single-provider care (rheumatology only) compared to dual provider care (rheumatology and cardiology) • Cardiology co-management should be an early consideration in the management of RA patients • Early screening, risk stratification of coronary disease, and utilization of appropriate treatment algorithms are important to decrease morbidity and mortality.

Abdominal and Pelvic Computed Tomography for the Diagnosis of ST-Elevation Myocardial Infarction: The Challenges of Acute Coronary Syndrome in Diabetic Patients

Diabetes mellitus (DM) is a major independent risk factor for cardiovascular disease. Patients who present with the metabolic emergency of diabetic ketoacidosis (DKA) have similar symptoms of diaphoresis, nausea, emesis, and abdominal pain, which can conceal acute coronary syndrome (ACS). We present a unique case where computed tomography (CT) of the abdomen and pelvis with IV contrast played an integral role in diagnosing an acute myocardial infarction in a patient with no typical ischemic symptoms. A 56-year-old female presented to the emergency department with abdominal pain, nausea, and vomiting. She was suspected of having DKA. Aggressive management was started, including weight-based appropriate IV regular insulin. A CT abdomen and pelvis with IV contrast was performed due to persistent abdomen pain. This demonstrated severe hypoattenuation of the posteroinferior aspect of the left ventricular wall. An EKG was immediately performed and was consistent with an inferior STEMI. The patient was taken to the interventional cardiology suite where they found the culprit lesion to be mid-circumflex with 100% stenosis. This case highlights many important lessons in approaching diabetic patients who are presenting with DKA. DM is associated with cardiac autonomic neuropathy (CAN), a condition that greatly influences perceived chest pain. While little is known about this condition, some manifestations include resting tachycardia, exercise intolerance, orthostatic hypotension, and an increased risk of silent myocardial infarction. Critically, providers must maintain a low threshold to assess for cardiac ischemia in diabetic patients and more readily obtain EKGs in triage as well as during the patient's course in the ED to prevent complications from delayed ACS care.

Large vessel occlusions requiring repeated mechanical thrombectomy caused by silent myocardial infarction in a young adult

OBJECTIVES

Silent myocardial ischemia, defined as objective evidence of myocardial ischemia without symptoms, is associated with ischemic stroke. Nevertheless, silent myocardial infarction is a rare cause of ischemic stroke, especially in young adults with no medical history.

MATERIALS AND METHODS

Herein, we report a young adult patient with acute ischemic stroke treated with repeated mechanical thrombectomy for recurrent large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction.

RESULTS

A 40-year-old man was transferred by ambulance to our hospital because of a generalized seizure. He was diagnosed with cerebral infarction and left middle cerebral artery occlusion. We performed intravenous thrombolysis and mechanical thrombectomy. Recanalization was achieved and his symptoms gradually improved. However, the day after treatment he developed bilateral cerebellar infarction and basilar artery occlusion. We performed a second mechanical thrombectomy and recanalization was achieved. Transthoracic echocardiography revealed a mobile left ventricular thrombus. Although he had no previous chest symptomatic episodes, cardiac examination confirmed myocardial infarction of unknown onset. He was diagnosed with acute ischemic stroke with large vessel occlusions caused by left ventricular thrombus following a silent myocardial infarction. Anticoagulation therapy reduced the amount of thrombus. At 1-year follow-up, he had not experienced any recurrences or symptoms.

CONCLUSIONS

Silent myocardial infarction should be considered a cause of ischemic stroke in young adults, even without any vascular risk factors. Recurrent large vessel occlusion may occur in patients with left ventricular thrombus, and repeated mechanical thrombectomy should be considered for treatment.

The long-term prognostic value of E/e' in patients with ST segment elevation myocardial infarction

Objectives

This study aimed to evaluate the long-term prognostic value of E/e’ ratio in patients with ST-segment elevation myocardial infarction (STEMI).

Methods

We retrospectively assessed 314 patients who underwent primary coronary interventions between January 2010 and December 2015. The included patients were classified into two groups according to the E/e’ ratios: E/e’<15 (n = 245) and E/e’≥15 (n = 69). We investigated the incidence of major adverse cardiac events (MACEs) from the event to the final follow-up period of at least three years.

Results

A total of 55 cases of MACEs occurred during the follow-up. The E/e’≥15 group showed a significantly higher rate of MACEs than the E/e’<15 group (34.8% vs. 12.7%, p < 0.001). Among the MACE, the percentage of cardiac deaths (17.4% vs. 0.4%, p < 0.001) was higher in the E/e’≥15 group than in the E/e’<15 group. In the multivariable model, E/e’≥15 was demonstrated as the strongest prognostic factor for MACEs (hazard ratio [HR], 2.597; 95% confidence interval [CI], 1.294–5.211; p = 0.007) and cardiac death (HR, 27.537; 95% CI, 3.287–230.689; p = 0.002), while left ventricular ejection fraction (LVEF) was not. Neither the discrepancy of systolic nor diastolic function between initial and follow-up echocardiography affected the overall prevalence of MACEs. A disparity was observed between the two groups, with a significant increase in the rate of MACEs in the E/e’≥15 group (log-rank test, p < 0.001).

Conclusion

The baseline E/e’≥15 in patients with STEMI after successful reperfusion is the strongest predictor of poor long-term clinical outcomes among those analyzed.

Long-term mortality in asymptomatic patients with stable ischemic heart disease undergoing percutaneous coronary intervention

OBJECTIVES

Patients with stable ischemic heart disease (SIHD) may present with a variety of symptoms including typical angina, angina equivalents such as dyspnea or no symptoms. We sought to determine whether symptom status affects periprocedural safety and long-term mortality in patients undergoing PCI.

METHODS

Prospectively enrolled consecutive patients undergoing PCI for SIHD at six hospitals in Australia between 2005 to 2018 as part of the Melbourne Interventional Group registry. Symptom status was recorded at the time of PCI and patients undergoing staged PCI were excluded.

RESULTS

Overall, 11,730 patients with SIHD were followed up for a median period of 5 years (maximum 14.0 years, interquartile range 2.2-9.0 years) with 1,317 (11.2%) being asymptomatic. Asymptomatic patients were older, and more likely to be male, have triple-vessel disease, with multiple comorbidities including renal failure, diabetes and heart failure (all P < .01). These patients had significantly higher rates of periprocedural complications and major adverse cardiovascular events at 30-days. Long-term mortality was significantly higher in asymptomatic patients (27.2% vs 18.0%, P < .001). On cox regression for long-term mortality, after adjustment for more important clinical variables, asymptomatic status was an independent predictor (Hazard ratio (HR) 1.39 95% CI 1.16-1.66, P < .001).

CONCLUSIONS

In a real-world cohort of patients undergoing revascularization for SIHD, absence of symptoms was associated with higher rates of periprocedural complications and, after adjustment for more important clinical variables, was an independent predictor of long-term mortality. As the primary goal of revascularization in SIHD remains angina relief, the appropriateness of PCI in the absence of symptoms warrants justification.

OUP accepted manuscript

Interventricular septal aneurysm of muscular type is uncommon in adult, to say nothing of membranous type. Acute or subacute left-to-right shunt (LR shunt) in a ventricular septum is mostly critical and usually shows severe symptoms. Therefore, ruptured muscular ventricular septal aneurysm (VSA) with LR shunt of unknown onset in adult is highly rare. A 70-year-old man was suffered from mild dyspnea and chest oppression. A muscular VSA was detected at the center of the ventricular septum and LR shunt of unknown onset in it had induced congestive heart failure. The sandwich patch technique through a right ventricular approach was simultaneously performed with coronary artery bypass grafting and the postoperative course was uneventful. In addition, concomitant myocardial biopsy of VSA wall during the surgery could reveal histopathologic evidence of acute or subacute myocardial infarction with old myocardial infarction as silent myocardial ischemia.

Assessing the prevalence and predicting factors of an abnormal gated myocardial perfusion SPECT in asymptomatic patients with type 2 diabetes

Considering the significant prevalence of silent myocardial ischemia and its related morbidity and mortality in asymptomatic type 2 diabetic patients, it is not well known whether early screening with MPI is cost-effective and predicting factors are not well elucidated. This was a cross-sectional study including 63 asymptomatic patients with type 2 diabetes mellitus (T2DM), with normal ECG and ejection fraction. Patients with any history of documented valvular, congestive or ischemic heart disease, renal or hepatic failure were excluded. At first all patients were interviewed and checked for risk factors and then patients underwent a two-day rest/stress 99mTc-MIBI gated MPI SPECT. Data was assessed by QPS/QGS and 4DM software and evaluated by a nuclear medicine specialist with summed stress score (SSS) of more than 4 defined as CAD. There were 42 females (67%) and 21 males (33%), with a mean age of 61.33 ± 6.98 years and 7.97 ± 4.86 years history of T2DM. CAD was detected in 26 (41.3%) patients and was significantly associated with male gender, smoking and requiring insulin therapy (P-value = 0.019, 0.046, 0.05, respectively). A significant association was found between the duration of diabetes, especially when > 15 years, and the probability of having CAD. Multivariable logistic regression revealed that smoking; male gender and diabetes duration were the strongest independent predictors of abnormal MPI results. We found a high (46%) prevalence of abnormal stress MPI SPECT in patients with type 2 diabetes mellitus, despite being asymptomatic. Asymptomatic patients with a history of smoking, long duration of diabetes, being under insulin treatment and male gender might benefit from MPI for early detection of silent ischemia.

Manual der Arbeitsgruppe Interventionelle Kardiologie (AGIK) der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e. V. (DGK)

Dieses Manual zur diagnostischen Herzkatheteruntersuchung (Teil 1) ist eine Anwendungsempfehlung für interventionell tätige Ärzte, die den gegenwärtigen Kenntnisstand unter Berücksichtigung neuester Studienergebnisse wiedergibt. Hierzu wurde in den einzelnen Kapiteln speziell auf die Alltagstauglichkeit der Empfehlungen geachtet, sodass dieses Manual jedem interventionell tätigen Kardiologen als Entscheidungshilfe im Herzkatheterlabor dienen soll. Trotz der von vielen Experten eingebrachten praktischen Hinweise kann dieses Manual dennoch nicht die ärztliche Evaluation des individuellen Patienten ersetzen und damit eine Anpassung der Diagnostik bzw. Therapie ersetzen.

Silent coronary artery disease in asymptomatic patients with severe aortic stenosis and normal exercise testing

OBJECTIVE

There are no data about the prevalence of silent coronary artery disease in asymptomatic severe aortic stenosis patients with normal exercise testing. Importantly, unmasking significant coronary artery disease in patients with aortic stenosis could influence the choice/timing of treatment in these patients.

METHOD

Exercise testing was performed on semi-supine ergobicycle. Cardiopulmonary analysis during exercise testing, echocardiography, and laboratory analysis at rest was done. Standard clinical/electrocardiography criteria were assessed for symptoms/signs of ischemia during/after exercise testing. In patients with normal exercise testing coronary angiography was performed using standard femoral/radial percutaneous approach. Coronary stenosis was considered significant if >70% of vessel diameter or 50%-70% with fractional flow reserve ≤0.8.

RESULTS

Total of 96 patients with normal exercise testing were included (67.6 years, 50.6% males). No patient had any complication or adverse event. The Pmean was 52.7 mmHg, mean indexed aortic valve area was 0.36 cm/m and left ventricular ejection fraction, 69.5%. 19/96 patients (19.8%) had significant coronary artery disease on coronary angiography. Multivariate logistic regression analysis revealed brain natriuretic peptide and blood glucose as independent predictors of silent coronary artery disease. Brain natriuretic peptide value of 118 pg/ml had sensitivity/specificity of 63%/73% for predicting coronary artery disease (area under the curve 0.727, P = 0.006).

CONCLUSION

Our results are the first to show that in patients with severe aortic stenosis, normal left ventricular ejection fraction,, and normal exercise testing, significant coronary artery disease is present in as many as 1/5 patients. In such patients, further prospective studies are warranted to address the diagnostic value of brain natriuretic peptide in detecting silent coronary artery disease.

Comparison of Incidence of Myocardial Infarction in Patients With Rheumatoid Arthritis and Diabetes Mellitus

Introduction Patients with rheumatoid arthritis (RA) have a higher risk of cardiovascular diseases (CVDs) when compared to the general population, with most deaths attributed to myocardial infarctions (MI). However, patients with RA do not get the same attention in terms of cardiovascular screening as compared to other diseases, like diabetes mellitus (DM). Therefore, this study aims to compare the risk of CVD among patients with RA and DM. Methods This prospective study was carried out in Pakistan's two tertiary care hospitals. A total of 750 participants were enrolled in three groups with a 1:1:1 ratio; patients with RA, type 2 DM, and the control group. Patients were observed for 12 months or until the development of a major adverse cardiovascular event (MACE), whichever occurred first. Results Both fatal (12.66% vs. 13.48%; p-value: 0.79) and non-fatal (3.93% vs. 4.35%; p-value: 0.82) MI was comparable between both RA and DM group. However, compared to the control group, non-fatal MI (12.66% vs. 5.58%; p-value: 0.01) was significantly higher in the RA group. Conclusion Our study shows that RA and DM have an equal risk of cardiovascular (CV) events. It is important that RA should be considered as a prominent risk factor for CV events. The management of these patients should be multidisciplinary, including cardiologists.

Myocardial Ischemia Induced by 5-Fluorouracil: A Prospective Electrocardiographic and Cardiac Biomarker Study

BACKGROUND

Cardiotoxicity induced by 5-fluorouracil (5-FU) is well known but poorly understood. In this study, we undertook ECG recording (Holter) and analyses of the biomarkers troponin and copeptin in patients receiving 5-FU to increase our understanding of the cardiotoxicity.

SUBJECTS, MATERIALS, AND METHODS

Patients with colorectal or anal cancer that received first-time treatment with 5-FU-based chemotherapy were prospectively included. Holter recording, clinical evaluation, 12-lead electrocardiogram, and assessment of plasma concentrations of troponin I and copeptin were performed before (control) and during 5-FU treatment (intervention).

RESULTS

A total of 108 patients were included, 82 with colorectal and 26 with anal cancer. The proportion of patients with myocardial ischemia on Holter recording was significantly higher during the first 5-FU infusion (14.1%) than before (3.7%; p = .001). The ischemic burden per day (p = .001), the number of ST depression episodes per day (p = .003), and the total duration of ischemic episodes per day (p = .003) were higher during the first 5-FU infusion than before, as was plasma copeptin (p < .001), whereas plasma troponin I was similar (p > 0.999). Six patients (5.6%) developed acute coronary syndromes and two (1.8%) developed symptomatic arrhythmias during 5-FU treatment.

CONCLUSION

5-FU infusion is associated with an increase in the number of patients with myocardial ischemia on Holter recording. According to biomarker analyses, 5-FU is associated with an increase in copeptin, but rarely with increases in cardiac troponin I. However, 5%-6% of the patients developed acute coronary syndromes during treatment with 5-FU.

IMPLICATIONS FOR PRACTICE

Symptomatic 5-fluorouracil (5-FU) cardiotoxicity occurs in 0.6%-19% of patients treated with this drug, but a small electrocardiographic (Holter) study has revealed silent myocardial ischemia in asymptomatic patients, suggesting a more prevalent subclinical cardiac influence. This study demonstrated a significant increase in the number of patients with myocardial ischemia on Holter recording during 5-FU treatment and an increase in ischemic burden. Cardiac biomarker analyses suggested that 5-FU infusion results in endogenous stress (increased copeptin) but rarely induces myocyte injury (no change in troponin). These findings suggest a more prevalent cardiac influence from 5-FU and that Holter recording is an important tool in the evaluation of patients with suspected cardiotoxicity from 5-FU.

Silent coronary artery disease in type 2 diabetes: a narrative review on epidemiology, risk factors, and clinical studies

Silent coronary artery disease (CAD) is one of the manifestations of heart disease that particularly affects subjects with type 2 diabetes mellitus (T2DM). From a clinical point of view, silent CAD represents a constant challenge for the diabetologist, who has to decide whether a patient could or could not be screened for this disease. In the present narrative review, several aspects of silent CAD are considered: the epidemiology of the disease, the associated risk factors, and main studies conducted, in the last 20 years, especially aimed to demonstrate the usefulness of the screening of silent CAD, to improve cardiovascular outcomes in type 2 diabetes.

[Diagnosis, Prevention and Treatment of Cardiovascular Disease in People with Diabetes and Prediabetes]

Diagnosis, Prevention and Treatment of Cardiovascular Disease in People with Diabetes and Prediabetes Abstract. Diabetes is associated with an increased cardiovascular risk. In addition to optimizing glycemia, timely diagnosis and stringent control of cardiovascular risk factors is essential for individuals with diabetes. Therapeutic options include lifestyle-optimization, individualized drug therapy and targeted treatment of concomitant or secondary cardiovascular disease. Cardiovascular disease occurs more often in individuals with diabetes and includes heart failure, atrial fibrillation, coronary heart disease and sudden cardiac death. The correct choice of antidiabetic drugs and interventions can control cardiovascular risk factors, reduce cardiovascular risk and treat concomitant or secondary diseases in a targeted manner. This review is intended to provide guidance on diagnosis, treatment and choice of therapy for individuals with type 2 diabetes without and with concomitant or secondary cardiovascular disease.

Ambulatory and silent myocardial ischemia in women with coronary microvascular dysfunction: Results from the Cardiac Autonomic Nervous System study (CANS)

BACKGROUND

Up to two-thirds of patients with obstructive coronary artery disease (CAD) have silent ischemia (SI), which predicts an adverse prognosis and can be a treatment target in obstructive CAD. Over 50% of women with ischemia and no obstructive CAD have coronary microvascular dysfunction (CMD), which is associated with adverse cardiovascular outcomes. We aimed to investigate the prevalence of SI in CMD in order to consider it as a potential treatment target.

METHODS

36 women with CMD by coronary reactivity testing and 16 age matched reference subjects underwent 24-h 12-lead ambulatory ECG monitoring (Mortara Instruments) after anti-ischemia medication withdrawal. Ambulatory ECG recordings were reviewed by two-physician consensus masked to subject status for SI measured by evidence of ≥1 minute horizontal or downsloping ST segment depression ≥1.0 mm, measured 80 ms from the J point.

RESULTS

Demographics, resting heart rate, and systolic blood pressure were similar between CMD and reference subjects. Thirty-nine percent of CMD women had a total of 26 SI episodes vs. 0 episodes in the reference group (p = 0.002). Among these women 13/14 (93%) had SI, and few episodes (3/26, 12%) were symptomatic. Mean HR at the onset of SI was 96 ± 13 bpm and increased to 117 ± 16 bpm during the ischemic episodes. 87% reported symptoms that were not associated with ST depressions.

CONCLUSIONS

Ambulatory ischemia is prevalent in women with CMD, with a majority being SI, while most reported symptoms were not accompanied by ambulatory ischemia. Clinical trials evaluating anti-ischemic medications should be considered in the CMD population.

Ambulatory electrocardiographic monitoring as a diagnostic tool for ischemic heart disease in women

Introduction. Ischemic heart disease(IHD) is currently the leading cause of mortality in women. In this study we aimed to evaluate ambulatory electrocardiographic monitoring(AECGm) as a diagnostic test for IHD in women. Material and method. The study included 225 female who underwent AECGm divided into 2 groups: 136 previously diagnosed with IHD(IHD+) and 89 controls(IHD-). The IHD+ group was subdivided into AECGm ischemia subgroup(I+) and AECGm non-ischemia subgroup(I-). AECGm was assessed for presence of myocardial ischemia (ST segment depression >5mm), duration and ischemic load (the percentage that episodes of myocardial ischemia accounted throughout the recording). Results and discussions. Patients mean age was 62.31±12.51years. The IHD+ and IHD- groups were similar regarding associated risk factors (hypertension, obesity, dyslipidemia, diabetes mellitus), echocardiographic parameters (left ventricular size, ejection fraction, kinetic disorders), minimum and maximum heart rates(MaxHR) on AECGm. Statistically significant differences were identified regarding presence of atrial fibrillation episodes(AFibE) (IHD+:21.3% vs IHD-:8.9%), myocardial ischemia (IHD+:55.14% vs IHD-:42.69%), ischemic load (IHD+:15.23±30.54% vs IHD-:4.7±15.65%), duration of ischemia (IHD+:174.16±380.75 minutes vs IHD-:59.44 ± 209.02 minutes). In multivariate analysis, ischemia episodes, ischemic load and duration of ischemia were predicted by obesity, MaxHR and AFibE. Statistically significant differences were also identified regarding presence of AFibE (I+:30% vs I-:8.9%), MaxHR (I+:120 vs I-:111beats/minute), obesity (I+:20% vs I-:41%), diabetes mellitus (I+:16% vs I-:69%), hypertension (I+:76% vs I-:90%). Conclusions. Although myocardial ischemia was also present in IHD- group, our study demonstrated that the diagnosis of IHD can be established by AECGm using the threshold values of ischemic load (> 27%) and ischemic duration (> 315minutes).

Noninvasive Testing for Diagnosis of Stable Coronary Artery Disease in the Elderly

Efficient diagnostic approaches to detect coronary artery disease (CAD) in elderly patients are necessary to ensure optimal and timely treatment. The population of suspected CAD patients older than 70 years is especially vulnerable and constantly growing. Finding the optimal diagnostic approach is challenging due to certain features of this population, such as high prevalence of comorbidities, existing contraindications to exercise tests or cognitive decline, which hinders correct assessment of the patient's situation. Moreover, some symptoms of CAD can have variable significance in the elderly compared to younger adult groups. In this review, we present current recommendations of the United States (US) and European cardiologists' associations and discuss their applicability for diagnostics in the elderly population. Exercise electrocardiogram (ECG) and exercise stress echocardiography (SE) tests are not feasible for a substantial proportion of elderly patients. Coronary computed tomography angiography (CTA) appears to be an attractive alternative for such patients, but is not universally applicable; for instance, it is problematic in patients with significant calcification of the vessels. Moreover, more studies are needed to compare the results delivered by CTA to those of other diagnostic methods. Future efforts should be focused on comparative studies to better understand the limits and advantages of different diagnostic methods and their combinations. It is possible that some of the currently used diagnostic criteria could be improved to better accommodate the needs of the elderly population.

Differential role of specific cardiovascular neuropeptides in pain regulation: Relevance to cardiovascular diseases

In many instances, the perception of pain is disproportionate to the strength of the algesic stimulus. Excessive or inadequate pain sensation is frequently observed in cardiovascular diseases, especially in coronary ischemia. The mechanisms responsible for individual differences in the perception of cardiovascular pain are not well recognized. Cardiovascular disorders may provoke pain in multiple ways engaging molecules released locally in the heart due to tissue ischemia, inflammation or cellular stress, and through neurogenic and endocrine mechanisms brought into action by hemodynamic disturbances. Cardiovascular neuropeptides, namely angiotensin II (Ang II), angiotensin-(1-7) [Ang-(1-7)], vasopressin, oxytocin, and orexins belong to this group. Although participation of these peptides in the regulation of circulation and pain has been firmly established, their mutual interaction in the regulation of pain in cardiovascular diseases has not been profoundly analyzed. In the present review we discuss the regulation of the release, and mechanisms of the central and systemic actions of these peptides on the cardiovascular system in the context of their central and peripheral nociceptive (Ang II) and antinociceptive [Ang-(1-7), vasopressin, oxytocin, orexins] properties. We also consider the possibility that they may play a significant role in the modulation of pain in cardiovascular diseases. The rationale for focusing attention on these very compounds was based on the following premises (1) cardiovascular disturbances influence the release of these peptides (2) they regulate vascular tone and cardiac function and can influence the intensity of ischemia - the factor initiating pain signals in the cardiovascular system, (3) they differentially modulate nociception through peripheral and central mechanisms, and their effect strongly depends on specific receptors and site of action. Accordingly, an altered release of these peptides and/or pharmacological blockade of their receptors may have a significant but different impact on individual sensation of pain and comfort of an individual patient.

Treating Dyslipidemias in the Primary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults with Diabetes Mellitus

People with diabetes mellitus (DM), especially those who are older, are at higher risk for premature morbidity and mortality related to atherosclerotic cardiovascular disease (ASCVD). Clinical practice guidelines recommend statin therapy for people with DM ages 40 to 75 years. The evidence for those greater than 75 years of age is relatively limited at present. Other health problems should be considered when planning ASCVD primary prevention in adults ages greater than 75 years with DM. Clinicians should discuss the risks and benefits of each plan with these patients and their caregivers.

Monte Carlo modeling of photon migration in realistic human thoracic tissues for noninvasive monitoring of cardiac hemodynamics

Noninvasive monitoring of cardiac hemodynamics remains challenging in cardiovascular medicine. The possibility of noninvasive optical monitoring of cardiac hemodynamics was theoretically investigated in this study. By utilizing the Monte Carlo simulation method for voxelized media (MCVM) and Visible Chinese Human dataset, we quantified and visualized the photon migration in human thoracic region. The light fluence distribution was showed to reach heart tissue (∼3 cm depth underbody surface) and 12% of the total fluence was absorbed by the myocardium. The proportion of spatial sensitivity distribution (SSD) in cardiac tissue to the total SSD reached 0.0195%. The portion of SSD increased following with cardiac diastole and diffuse reflectance deceased linearly with increasing cardiac volume. The optimal separation between the light source and detector was provided to be 3.5 to 4.0 cm for future development of noninvasive cardiac hemodynamics monitoring. A pilot experimental study was conducted to measure the diffuse reflectance light and fingertip photoplethysmography. These data suggest that the fluctuation period of near-infrared (NIR) diffuse reflectance was consistent with the cardiac cycle, while the fluctuation features of the NIR signal was not consistent with that of photoplethysmography. All results indicate the great potential of noninvasive optical monitoring of myocardial hemodynamics.

Unrecognised cardiovascular disease in type 2 diabetes: is it time to act earlier?

Cardiovascular disease (CVD) is the most significant prognostic factor in individuals with type 2 diabetes (T2D). However, a significant number of individuals may develop CVD that does not present with the classic angina-related or heart failure symptoms. In these cases, CVD may seem to be ‘silent’ or ‘asymptomatic’, but may be more accurately characterised as unrecognised diabetic cardiac impairment. An initial step to raise awareness of unrecognised CVD in individuals with T2D would be to reach a consensus regarding the terminology used to describe this phenomenon. By standardising the terminologies, and agreeing on the implementation of an efficient screening program, it is anticipated that patients will receive an earlier diagnosis and appropriate and timely treatment. Given the availability of anti-diabetic medications that have been shown to concomitantly reduce CV risk and mortality, it is imperative to improve early identification and initiate treatment as soon as possible in order to enable as many patients with T2D as possible to benefit.

Association of serum thyrotropin levels with coronary artery disease documented by quantitative coronary angiography: a transversal study

OBJECTIVE

The association between coronary artery disease (CAD) and thyroid function remains controversial. We evaluated the thyroid function and graduated well-defined CAD as confirmed by quantitative coronary angiography (CA).

SUBJECTS AND METHODS

We evaluated the serum TSH, free thyroxine, free triiodothyronine and thyroid antibody levels in 300 consecutive patients (age 61.6 ± 9.9 years and 54% were male) undergoing CAD diagnosis as confirmed by CA. Plaques with ≥ 50% stenosis being indicative of obstructive CAD, and patients were divided into groups according to main epicardial coronary arteries with plaques (0, 1, 2, 3). Lipid profiles and a homeostasis model assessment (HOMA-IR) were determined.

RESULTS

Serum median (25% and 75% percentile) TSH levels in patients with group 2 and 3 (2.25; 1.66-3.12 mU/L and 4.99; 4.38-23.60 mU/L, respectively) had significantly higher TSH concentrations (p < 0.0001) than the group 0 (1.82; 1.35-2.51 mU/L). Furthermore, patients of group 3 had higher TSH concentration (p < 0.0001) than those of group 1 (1.60; 0.89-2.68 mU/L). Group 3 were older (64 ± 8.5 vs. 59 ± 9.5, p = 0.001), had more patients with dyslipidemia (84% versus 58%, p < 0.001), male (54% versus 44%, p = 0.01), hypertension (100% versus 86%, p < 0.001), and smoking (61% versus 33%, p < 0.001) than group 0. Multivariate stepwise logistic analysis showed TSH, age, HbA1c, and HOMA-IR were the CAD associated variables.

CONCLUSIONS

In this cohort, elevated TSH levels in the high normal range or above are associated with the presence and severity of CAD besides may represent a weak CAD risk factor.

Effects of Diesel Exhaust on Cardiovascular Function and Oxidative Stress

SIGNIFICANCE

Air pollution is a major global health concern with particulate matter (PM) being especially associated with increases in cardiovascular morbidity and mortality. Diesel exhaust emissions are a particularly rich source of the smallest sizes of PM ("fine" and "ultrafine") in urban environments, and it is these particles that are believed to be the most detrimental to cardiovascular health. Recent Advances: Controlled exposure studies to diesel exhaust in animals and man demonstrate alterations in blood pressure, heart rate, vascular tone, endothelial function, myocardial perfusion, thrombosis, atherogenesis, and plaque stability. Oxidative stress has emerged as a highly plausible pathobiological mechanism by which inhalation of diesel exhaust PM leads to multiple facets of cardiovascular dysfunction.

CRITICAL ISSUES

Diesel exhaust inhalation promotes oxidative stress in several biological compartments that can be directly associated with adverse cardiovascular effects.

FUTURE DIRECTIONS

Further studies with more sensitive and specific in vivo human markers of oxidative stress are required to determine if targeting oxidative stress pathways involved in the actions of diesel exhaust PM could be of therapeutic value. Antioxid. Redox Signal. 28, 819-836.

Post hoc support vector machine learning for impedimetric biosensors based on weak protein–ligand interactions

We develop a simple, open source machine learning algorithm for analyzing impedimetric biosensor data using a mobile phone.

Positive and Negative Affect Is Related to Experiencing Chest Pain During Exercise-Induced Myocardial Ischemia

OBJECTIVE

Silent myocardial ischemia is thought to be associated with worse cardiovascular outcomes due to a lack of perception of pain cues that initiate treatment seeking. Negative affect (NA) has been associated with increased pain reporting and positive affect (PA) with decreased pain reporting, but these psychological factors have not been examined within the context of myocardial ischemia. This study evaluated the associations between PA, NA, and chest pain reporting in patients with and without ischemia during exercise testing.

METHODS

A total of 246 patients referred for myocardial perfusion single-photon emission computed tomography exercise stress testing completed the positive and negative affect schedule-expanded version, a measure of PA and NA. Presence of chest pain and myocardial ischemia were evaluated using standardized protocols.

RESULTS

Logistic regression analyses revealed that for every 1-point increase in NA, there was a 13% higher chance for ischemic patients (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.02 to 1.26) and an 11% higher chance in nonischemic patients (OR = 1.11; 95% CI = 1.03 to 1.19) to report chest pain. A significant interaction of PA and NA on chest pain reporting (β = 0.02; 95% CI = 0.002 to 0.031) was also observed; nonischemic patients with high NA and PA reported more chest pain (57%) versus patients with low NA and low PA (13%), with high NA and low PA (17%), and with high PA and low NA (7%).

CONCLUSIONS

Patients who experience higher NA are more likely to report experiencing chest pain. In patients without ischemia, high NA and PA was also associated with a higher likelihood of reporting chest pain. Results suggest that high levels of PA as well as NA may increase the experience and/or reporting of chest pain.

Risk factors for silent myocardial ischemia in patients with well-controlled essential hypertension

Silent myocardial ischemia (SMI) is frequently observed in patients with essential hypertension (EH). The major risk factor for SMI is uncontrolled blood pressure (BP), but SMI is also observed in patients with well-controlled BP. To evaluate the prevalence of SMI and the factors associated with SMI in EH patients with well-controlled BP. The medical records of 859 EH patients who underwent simultaneous 24-h ambulatory blood pressure monitoring (ABPM) and 24-h ambulatory electrocardiogram recording (AECG) were retrospectively evaluated. Each SMI episode was characterized by: (a) ST segment depression ≥0.5 mm; (b) duration of ST segment depression >60 s; and (c) reversibility of the ST segment depression. Overall 126 EH patients (14.7 %) had at least one episode of SMI. The SMI events were more frequent among patients with poorly controlled compared to those with well-controlled BP [86/479 (17.95 %) vs. 40/380 (10.52 %), p < 0.01]. Among EH patients with well-controlled BP, current and past smoking as well as the presence of an additional metabolic syndrome (MetS) constitutive element (obesity, impaired fasting glucose level or dyslipidemia) were significantly associated with the occurrence of SMI. In all EH patients with well-controlled BP and AECG evidence of SMI, there were one or more coronary artery stenotic lesions greater than 50 % found at coronary angiography. In EH patients who are current smokers, or have one or more additional components of a MetS there is markedly reduced benefit associated with good BP control with regard to the occurrence of myocardial ischemia: in this patient category, an AECG may help detect this condition.

Troponin T release is associated with silent myocardial ischaemia in black men: The SABPA Study

Background High sensitivity cardiac troponin T (hs-cTnT) is a validated marker of myocardial damage and may reflect the degree of silent myocardial ischaemia (SMI) and ventricular strain. Our aim was to compare hs-cTnT levels in black and white South Africans taking SMI into consideration. We further explored the capability of hs-cTnT to predict the presence of compensatory systolic hypertension in this South African cohort. Methods A bi-ethnic sex cohort ( n = 404) with similar socioeconomic status (198 black participants and 206 white participants, aged 20-65 years) participated in this target population study where 24 h ambulatory blood pressure, electrocardiogram and overnight fasting cardiometabolic variables were measured. Results Hypertension, higher glycated haemoglobin levels and more frequent and longer SMI events were observed more often in the black participants. Multivariate linear regression analysis showed positive associations between SMI events [Adj. R²= 0.19; β 0.35 (0.08-0.62); p < 0.01], SMI event maximum duration [Adj. R²= 0.17, β 0.43 (0.16-0.70), p < 0.01], SMI total duration [Adj. R²= 0.12; β 0.37 (0.10; 0.65), p = 0.05] and hs-cTnT in black males only.] A lower hs-cTnT cut-point ≥4.2 pg/ml for 24 h systolic hypertension was predicted in the black participants compared with ≥5.6 pg/ml in the white participants (area under the curve 0.66-67 (95% CI: 0.57-0.75), p < 0.001) with a respective sensitivity/specificity of 64/68% and 61/71%. Conclusions hs-cTnT may be a potential marker of SMI in the prediction of systolic blood pressure increases, as well as clusters of risk factors for cardiovascular disease. Ethnic- and possibly sex-specific references values for hs-cTnT should be considered for risk stratification.

Translational bioinformatics in the era of real-time biomedical, health care and wellness data streams

Monitoring and modeling biomedical, health care and wellness data from individuals and converging data on a population scale have tremendous potential to improve understanding of the transition to the healthy state of human physiology to disease setting. Wellness monitoring devices and companion software applications capable of generating alerts and sharing data with health care providers or social networks are now available. The accessibility and clinical utility of such data for disease or wellness research are currently limited. Designing methods for streaming data capture, real-time data aggregation, machine learning, predictive analytics and visualization solutions to integrate wellness or health monitoring data elements with the electronic medical records (EMRs) maintained by health care providers permits better utilization. Integration of population-scale biomedical, health care and wellness data would help to stratify patients for active health management and to understand clinically asymptomatic patients and underlying illness trajectories. In this article, we discuss various health-monitoring devices, their ability to capture the unique state of health represented in a patient and their application in individualized diagnostics, prognosis, clinical or wellness intervention. We also discuss examples of translational bioinformatics approaches to integrating patient-generated data with existing EMRs, personal health records, patient portals and clinical data repositories. Briefly, translational bioinformatics methods, tools and resources are at the center of these advances in implementing real-time biomedical and health care analytics in the clinical setting. Furthermore, these advances are poised to play a significant role in clinical decision-making and implementation of data-driven medicine and wellness care.

The Value of Detecting Asymptomatic Signs of Myocardial Ischemia in Patients With Coronary Artery Disease in Outpatient Cardiac Rehabilitation

BACKGROUND

Electrocardiographic (ECG) monitored outpatient cardiac rehabilitation (OP-CR) is routinely performed following a variety of cardiovascular procedures and conditions.

OBJECTIVE

The aim of this study is to determine if diagnostic-quality ECG monitoring in patients with coronary artery disease (CAD) during OP-CR is useful in identifying asymptomatic myocardial ischemia, resulting in change(s) in care or medical management.

METHODS

A retrospective analysis of ECG monitoring was done on all OP-CR patients diagnosed with CAD (n = 1213) from January 2000 through June 2013.

RESULTS

Nearly a quarter of the patients (24%; n = 288) displayed at least 1 mm of asymptomatic ST-segment depression at 80 milliseconds after the J-point during at least 1 session of OP-CR. Of these patients, 57% had medical management change(s) compared with 24% for those who did not show ECG changes suggesting ischemia (P < .0001). In patients with asymptomatic ischemia having medical management change(s), 84% resulted directly from OP-CR staff detection. Fewer patients diagnosed with myocardial infarction and coronary artery bypass graft surgery demonstrated ECG signs of ischemia, whereas more patients diagnosed with stable angina and percutaneous coronary interventions demonstrated ECG signs of ischemia.

CONCLUSION

This study demonstrates that most patients with CAD showing asymptomatic ECG signs suggesting ischemia undergo medical management change(s) as a result of the finding. Diagnostic-quality ECG monitoring during OP-CR appears warranted in this population.

Ambulatory monitoring of myocardial ischemia in the 21st century-an opportunity for high frequency QRS analysis

Ambulatory monitoring represents an effective tool for the assessment of silent and transient myocardial ischemia during routine daily activities. Incidence of silent ischemia can provide important prognostic information about patients with coronary artery disease or acute coronary syndrome, as well as about post-myocardial infarction patients. The current technological progress enables development of powerful and miniaturized wearable devices for Holter monitoring. Higher sampling rates, dynamic range, and extended computational and storage capacity allow for considering of more complex methodological solutions such as high-frequency QRS analysis for diagnosing myocardial ischemia. Implementation of suitable methodologies for advanced detection of myocardial ischemia into modern ambulatory monitoring devices creates the potential of making the ambulatory myocardial ischemia monitoring a valuable diagnostic tool in clinical practice.

Incidence of sudden cardiac death in adults with end-stage renal disease: a systematic review and meta-analysis

BACKGROUND

Although sudden cardiac death (SCD) is recognized as a distinct cause of death in patients with end stage renal disease (ESRD), its incidence has not been well summarized.

METHODS

We performed a systematic review and meta-analysis of the literature based on a protocol developed a priori. We searched MEDLINE and EMBASE (inception to March 2015) for randomized controlled trials and cohort studies reporting the incidence of SCD in adult patients with ESRD on hemodialysis or peritoneal dialysis. We collected data on number of SCD as well as the definition of SCD for each individual study. A random-effects model was used to summarize the incidence of SCD. We conducted subgroup analyses to explore sources of heterogeneity.

RESULTS

Forty two studies (n = 80,382 patients) were included in the meta-analysis. The incidence of SCD among adults with ESRD ranged from 0.4 to 10.04 deaths per 100 person-years. The definitions and assessment of SCD varied across the included studies. There was evidence of significant heterogeneity (I(2) = 98; p < 0.001), which was not explained by subgroup analyses stratified by mean age, proportion of hypertensive or diabetic patients, follow-up time, study size, or type of cohort studied.

CONCLUSION

Current estimates of the incidence of SCD among adults with ESRD vary widely. There is a need for further studies to more accurately estimate the incidence of SCD in patients with ESRD.

The long-term risk of recognized and unrecognized myocardial infarction for depression in older men

BACKGROUND

The association between myocardial infarction (MI) and depression is well described. Yet, the underlying mechanisms are unclear and the contribution of psychological factors is uncertain. We aimed to determine the risk of recognized (RMI) and unrecognized (UMI) myocardial infections on depression, as both have a similar impact on cardiovascular health but differ in psychological epiphenomena.

METHOD

Participants of the Rotterdam Study, 1823 men aged ⩾55 years, were followed for the occurrence of depression. RMI and UMI were ascertained using electrocardiography and medical history at baseline. We determined the strength of the association of RMI and UMI with mortality, and we studied the relationship of RMI and UMI with depressive symptoms and the occurrence of major depression.

RESULTS

The risk of mortality was similar in men with RMI [adjusted hazard ratio (aHR) 1.71, 95% confidence interval (CI) 1.45-2.03] and UMI (aHR 1.58, 95% CI 1.27-1.97). Men with RMI had on average [unstandardized regression coefficient (B) 1.14, 95% CI 0.07-2.21] higher scores for depressive symptoms. By contrast, we found no clear association between UMI and depressive symptoms (B 0.55, 95% CI -0.51 to 1.62) in men. Analysis including occurrence of major depression as the outcome were consistent with the pattern of association.

CONCLUSION

The discrepant association of RMI and UMI with mortality compared to depression suggests that the psychological burden of having experienced an MI contributes to the long-term risk of depression.

[Silent myocardial ischemia in acute coronary syndrome]

The given review considers the pathogenesis, diagnosis, and clinical significance of silent myocardial ischemia (SMI) in individual patient groups. It discusses the problem of SMI in acute coronary syndrome (ACS), the possible causes of SMI and the specific features of its diagnosis. It also indicates that there is a need for 12-lead ECG telemonitoring in intensive care unit patients with ACS to intraoperatively correct patient management and treatment policy.