The Importance of Being Aware of Intrinsic Methods' Limitation in Low-Density Lipoprotein Cholesterol Determination to Correctly Identify Cardiovascular Risk: Is Direct Determination Obtained with the Roche System Systematically Overestimating LDL in Very High-Risk Patients with Triglycerides Concentration of Less than 2.25 mmol/L?

BACKGROUND

low-density lipoprotein cholesterol (LDL-C) is a strong cardiovascular risk factor, but the methods used to correctly determine it are is still questioned. The aim of this study was to compare the direct determination of LDL-C levels, obtained with the Roche cobas c system, with LDL-C values calculated through Sampson's and Friedewald's equations in very high-risk patients with triglycerides concentrations of less than 2.25 mmol/L (<200 mg/dL).

METHODS

in 127 consecutive patients with a recent diagnosis of acute coronary syndrome and triglycerides of less than 2.25 mmol/L, plasma LDL-C was measured directly and calculated with Sampson's and Friedewald's equations before hospital discharge, and the data were compared.

RESULTS

median LDL values obtained with the Friedenwald and Sampson equations and with direct determination were 2.31 (IQR 1.59-3.21), 2.36 (IQR 1.66-3.26) and 2.64 (IQR 1.97-3.65) mmol/L, respectively. Direct measurements were higher by 0.35 and 0.40 mmol/L when compared to the levels calculated with Sampson's or Friedewald's equations, respectively (p < 0.01). The correlation between the two equations was almost perfect (rho 0.997) but decreased when the directly determined data were compared to those calculated with Sampson's equation (rho 0.954) or Friedewald's method (rho 0.939).

CONCLUSION

direct determination generated higher values of LDL-C concentration through a probable systematic overestimation.

Reverse Remodeling and Functional Improvement of Left Ventricle in Patients with Chronic Heart Failure Treated with Sacubitril/Valsartan: Comparison between Non-Ischemic and Ischemic Etiology

Sacubitril/valsartan (SV) has been demonstrated to reduce cardiovascular mortality, hospitalization for heart failure and to induce reverse ventricular remodeling. The present study was designed to confirm the effects of SV in a selected population of patients with HFrEF and to evaluate the different responses between patients with an ischemic or a non-ischemic etiology. A total of 79 patients with indication of SV were recruited prospectively during a timelapse of 4 years. SV was overall associated to a reduction of end-diastolic and end-systolic volume, of NT-proBNP levels, furosemide dosage and NYHA functional class, together with an increase in EF. These changes were more evident in patients with non-ischemic dilated cardiomyopathy, who showed a significant improvement in ventricular volumes, ejection fraction, TAPSE and blood levels of NT-proBNP. Kaplan-Meier curves confirmed a greater benefit in terms of ejection-fraction improvement in non-ischemic patients compared to the ischemic group. The results of the present study confirm the positive effect of SV on NYHA functional class, NT- proBNP, left ventricular volumes and EF in HFrEF patients, showing evidence of association of SV with ventricular remodeling in patients with dilated cardiomyopathy of non-ischemic etiology compared to the ischemic group.

Multi-Modality Imaging Approach to a rare form of Biventricular Ring-Shaped Constrictive Pericarditis

A 48-year-old man with AIDS/HIV and a previous history of tuberculous pericarditis 25 years earlier was admitted to our department of infectious diseases because of P. carinii pneumonia. A CT (computed tomography) scan described diffuse pericardial thickening with extensive pericardial calcifications on both ventricles. A transthoracic echocardiogram showed all the typical hemodynamic features of pericardial constriction. A review of the CT with 3D reconstruction revealed the presence of ring-shaped pericardial calcification at the basal segments of right and left ventricles extending over the inferior atrioventricular groove, the inferior interventricular groove and the cranial wall of the right atrium. Only a few cases of ring-shaped constrictive pericarditis have been reported and both global ventricular constriction and localized segmental constriction have been described. Our case wants to underline how important a comprehensive multi-modality imaging approach is to this rare form of constrictive pericarditis.

240 A PEDIATRIC CASE OF BIVENTRICULAR END-STAGE ARRHYTHMOGENIC CARDIOMYOPATHY

Background

Arrhythmogenic cardiomyopathy (ACM) is a rare heart muscle disease characterized by cardiomyocyte necrosis and fibro-adipose substitution which contribute both to the genesis of malignant ventricular arrhythmias and the morpho-functional alterations of the ventricles. ACM has always been considered a right ventricular disease with secondary involvement of the left ventricle, but recently a left dominant phenotype has been also described.

Case report

A 14-year-old patient was admitted to our hospital after out-of-hospital cardiac arrest due to ventricular fibrillation, which occurred when she was at rest. A family history of sudden death and dilated cardiomyopathy was retrieved (her brother died at the age of 18 with a dilated heart), but other family members had never been screened to date. Cardiac magnetic resonance imaging (cMRI) appearance was consistent with biventricular dilatation along with severe systolic dysfunction (left ventricular ejection fraction 20%; right ventricular ejection fraction 25%). It showed also thinning and bulging of the basal free wall of the right ventricle proximal to the outflow tract (up to 4 mm) and multiple foci of subepicardial, mid-wall and transmural late gadolinium enhancement (LGE) in both ventricles. Signs of acute decompensated heart failure and a high arrhythmic burden were present. After cardiopulmonary stabilization, she underwent the implantation of a cardioverter-defibrillator (ICD).

Conclusion

We herein report an uncommon case of biventricular AC (‘definite diagnosis’ according to both Task force criteria 2010 and Padua criteria) with advanced morpho-functional dysfunction occurring already in pediatric age, without any alerting symptom until the cardiac arrest (the typical onset of the ACM in children). It shows how severe biventricular involvement may affect young patients with a rapid progression of the disease. It also stresses the need for a strict follow-up of the family members of a proband since his first diagnosis, highlighting the pivotal role of cMRI in the diagnosis of pediatric disease. This has not been thoroughly studied and lacks sensitive and specific diagnostic criteria.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Large Serpiginous Thrombus Crossing a Patent Foramen Ovale

Transesophageal iconic image of a large serpiginous thrombus crossing a patent foramen ovale.

Role of three-dimensional echocardiography in structural complications after acute myocardial infarction

Three-dimensional echocardiography (3DE) is a unique cardiovascular imaging modality in terms of: ability to provide realistic anatomical views of cardiac structures in the beating heart and possibility to visualize cardiac structures from any desired perspective. Therefore, 3DE is emerging as an accurate imaging modality for a prompt diagnosis and detailed anatomical description of structural complications (SC) of acute myocardial infarction (AMI). We report 3 emblematic cases which show how both the transthoracic (TTE) and transesophageal (TEE) 3D imaging can provide precise anatomic information useful to address management of SC in AMI patients: (1) detailed assessment of size, location, and morphology of an apical ventricular septal defect (VSD) obtained with 3DTTE was pivotal in referring the patient to percutaneous closure of it; (2) size and location of a complex inferior VSD with irregular margins advised against percutaneous closure; and (3) 3DTEE assisted surgeons to choose between reparative or replacement surgery for an acute mitral regurgitation due to complete papillary muscle rupture.