Exercise and cardiac rehabilitation in hypertensive patients with heart failure with preserved ejection fraction: A position statement on behalf of the Working Group of Arterial Hypertension of the Hellenic Society of Cardiology

Arterial hypertension is a major cause of cardiovascular morbidity and mortality and the most common cause of comorbidity in heart failure (HF) with preserved ejection fraction (HFpEF). As an adjunct to medication, healthy lifestyle modifications with emphasis on regular exercise are strongly recommended by both the hypertension and the HF guidelines of the European Society of Cardiology. Several long-term studies have shown that exercise is associated with a reduction in all-cause mortality, a favorable cardiac and metabolic risk profile, mental health, and other non-cardiovascular benefits, as well as an improvement in overall quality of life. However, the instructions for the prescriptive or recommended exercise in hypertensive patients and, more specifically, in those with HFpEF are not well defined. Moreover, the evidence is based on observational or small randomized studies, while well-designed clinical trials are lacking. Despite the proven benefit and the guidelines' recommendations, exercise programs and cardiac rehabilitation in patients with hypertensive heart disease and HFpEF are grossly underutilized. This position statement provides a general framework for exercise and exercise-based rehabilitation in patients with hypertension and HFpEF, guides clinicians' rehabilitation strategies, and facilitates clinical practice. It has been endorsed by the Working Group of Arterial Hypertension of the Hellenic Society of Cardiology and is focused on the Health Care System in Greece.

A new approach of statin therapy in carotid atherosclerosis: Targeting indices of plaque vulnerability on the top of lipid-lowering. A narrative review

Novel imaging techniques and biomarkers have emerged as surrogate markers of carotid plaque vulnerability. In parallel, statin administration in patients with established carotid atherosclerosis not requiring revascularization has reduced the number of consequent cerebrovascular events. This reduction is not only attributed to the lipid-lowering properties of statins but also to their pleiotropic actions. The present literature review aimed to summarize the stabilizing effects of statins on carotid plaques based on imaging modalities and biomarkers and propose an alternative approach to their implementation. Moreover, we assessed the perioperative use of statins in patients undergoing carotid revascularization and the impact of aggressive vs. conventional statin therapy. Recent studies using: (1) ultrasound indices of plaque echogenicity; (2) fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scans for plaque inflammation assessment; or (3)magnetic resonance imaging (MRI) scans quantifying intraplaque hemorrhage, and lipid-rich necrotic core (LRNC) have shown quite promising results in evaluation of carotid plaque vulnerability. Based on those imaging modalities, a growing number of studies have demonstrated a very modest carotid plaque regression due to/induced by statins, while their stabilizing impact is disproportionally higher. Other studies assaying several biomarkers (e.g. inflammation, etc.) have confirmed a statin-induced carotid plaque stabilization. All the aforementioned benefits followed a dose-dependent pattern of statins, on top of the low-density lipoprotein cholesterol (LDL-C) target in current guidelines. In the case of symptomatic patients with carotid atherosclerosis suitable for revascularization, robust evidence implicates a significant statin-related reduction of perioperative cardiovascular risk only in patients undergoing endarterectomy.

A new approach of statin therapy in carotid atherosclerosis: Targeting indices of plaque vulnerability on the top of lipid-lowering. A narrative review

Novel imaging techniques and biomarkers have emerged as surrogate markers of carotid plaque vulnerability. In parallel, statins' administration in patients with established carotid atherosclerosis not requiring revascularization have reduced the consequent cerebrovascular events. This is not only attributed to the lipid-lowering properties of statins, but to their pleiotropic actions as well. The aim of the present literature review was to summarize the stabilizing effects of statins on carotid plaques based on imaging modalities and biomarkers proposing an alternative approach of their implementation. Moreover, we assessed the perioperative use of statins in patients undergoing carotid revascularization and the impact of aggressive vs. conventional statin therapy. Recent studies using: 1) ultrasound indices of plaque echogenicity, 2) fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) scan for plaque inflammation assessment or 3) magnetic resonance imaging (MRI) scan quantifying intraplaque hemorrhage, and lipid rich necrotic core (LRNC) have shown quite promising results for the objective evaluation of carotid plaque vulnerability. Based on those imaging modalities a growing number of studies have demonstrated a very modest carotid plaque regression of statins, while their stabilizing impact is disproportionally higher. Other studies assaying several biomarkers (e.g. inflammation, etc.) have confirmed a statin-induced carotid plaque stabilization. All the aforementioned benefits followed a dose-dependent pattern of statins, on the top of the low-density lipoprotein cholesterol (LDL-C) target in current guidelines. In case of symptomatic patients with carotid atherosclerosis suitable for revascularization, robust evidence implicates a significant statin-related reduction of perioperative cardiovascular risk only in patients undergoing endarterectomy.

Left ventricular mass index unveils differences in sympathetic nervous system activity between patients with MINOCA and Takotsubo syndrome

Background/Introduction

Left ventricular mass index (LVMI) has been long established as an index of target organ damage. It has demonstrated a prognostic role in cardiovascular morbidity and mortality assessed using either echocardiography or cardiac magnetic resonance (CMR) under the prism of coronary artery disease, hypertension, diabetes mellitus, chronic kidney disease. On the other hand, it has shown a strong association with indices of sympathetic nervous system (SNS) activity.

Purpose

The aim of our study is to investigate for potential associations between LVMI and indices of SNS among patients with a working diagnosis of MINOCA.

Methods

Our study population consists of 50 patients [32% male; mean age: 61±12 years old; 50% hypertensives (HTN), 16% with history of diabetes mellitus (DM), 22% smokers] admitted with acute coronary syndrome (ACS) fulfilling the diagnostic criteria of MINOCA. A subsequent CMR demonstrated an ischemic pattern of late gadolinium enhancement (LGE) in 15 cases (27.8%), findings indicative of Takotsubo syndrome (TTS) in 19 patients (35.2%), whereas failed to reveal any abnormalities in 16 cases (29.8%). LVMI was estimated using left ventricular mass per body surface area (LV mass/BSA) as derived from CMR. SNS activity was assessed using muscle sympathetic nerve activity (MSNA) during the first 30 days of patient discharge.

Results

Univariate analysis failed to demonstrate an association between LVMI and indices of SNS in the total population. This was found to be driven by the TTS group. However, for all other MINOCA cases (n=31; including both LGE CMR and clear CMR cases) LVMI demonstrated a significant positive association with MSNA measured as bursts/min (OR, 0.558; CI 95%, 0.200–0.915; p=0.004). A multivariate analysis was conducted in the same group in which LVMI retained its statistical significance independently of age, gender, ejection fraction derived from CMR, history of HTN and DM (OR, 0.518; CI 95%, 0.030 - 0.952; p=0.038). TTS group did not show any association between LVMI and MSNA.

Conclusions

These preliminary results may imply an underlying mechanism of reverse negative feedback on systematic SNS activity after the acute phase of sympathetic overdrive during a TTS event. Further investigation is warranted to confirm our research findings.

Funding Acknowledgement

Type of funding sources: None.

Superiority of cardiac magnetic resonance derived left-ventricular ejection fraction in the identification of true acute myocardial infarction among MINOCA patients

Background/Introduction

MINOCA constitutes a clinical entity characterized by heterogeneous and poorly understood pathophysiological substrate, whereas current knowledge leaves significant gaps regarding the identification, risk stratification and therapeutical approach of these patients.

Purpose

The aim of our study is to investigate the potential role of clinical, hemodynamic, laboratory and imaging parameters in the early identification of true acute myocardial infarction (AMI) among patients with a working diagnosis of MINOCA.

Methods

Our study population included 62 patients admitted with acute coronary syndrome (ACS) fulfilling the diagnostic criteria of MINOCA. A subsequent cardiac magnetic resonance (CMR) performed at 54 patients demonstrated an ischemic pattern of late gadolinium enhancement (LGE) confirming the diagnosis of true AMI in 15 cases (27.8%). Other findings included Takotsubo syndrome (n=19; 35.2%) and myocarditis (n=4; 7.4%), whereas CMR failed to reveal abnormal findings at 16 cases (29.8%).

Results

Focusing on the combined population of true AMI and clear CMR groups (n=31; 51.6% male; mean age: 58±12 years old; 42% hypertensives (HTN), 16% with history of diabetes mellitus (DM), 28.6% smokers) no significant difference was observed regarding classic cardiovascular risk factors (HTN, DM, smoking, age, dyslipidemia) except for a tendency of overrepresentation of female sex (r=0.354; p=0.051) in the true AMI group. Coronary angiographic (CA) findings did not differ between the two groups: clear vessels: 16/31 (51.6%); lesions causing ≤50% stenosis: 7/31 (22.6%); bridges: 4/31 (12.9%); spontaneous coronary artery dissection (SCAD): 2/31 (6.5%); slow flow phenomenon or spontaneous epicardial spasm: 2/31 (6.5%). No difference was observed in treatment approach with beta-blockers, renin-angiotensin system blockers, statins or the selection of no, single or dual antiplatelet strategy. Univariate regression analysis demonstrated that CMR derived left-ventricular ejection fraction (CMR-LVEF) (OR, 0.846; CI 95%: 0.742–0.965; p=0.012), as well as admission ECG abnormalities (OR, 0.154; CI 95%: 0.026–0.914; p=0.04), admission (OR, 5.689; CI 95%: 1.374–23.553; p=0.016) and peak troponin levels (OR, 15.874; CI 95%: 2.486–101.367; p=0.003) were the only parameters significantly related to a true AMI. Statistical significance was retained in multivariate models adjusted for age, gender, history of HTN and DM. On the contrary echocardiography derived LVEF failed to predict true AMI.

Conclusions

These preliminary results further highlight the need of an early CMR evaluation of MINOCA patients. A timely identification of true AMI is expected to improve patient outcomes by guiding the treatment approach.

Funding Acknowledgement

Type of funding sources: None.

The interplay between statins and adipokines. Is this another explanation of statins' 'pleiotropic' effects?

Statin therapy comprises an integral part of secondary and to a lesser extent of primary cardiovascular disease prevention. This is attributed not only to their lipid-lowering properties, but as well to a plethora of pleiotropic actions. Recently, the cytokines secreted by adipose tissue, the so-called adipokines, have been proved to play a critical role in various pathophysiological functions, among which inflammation and atherosclerosis development and vulnerability. The aim of this literature review was to summarize the effects of statins and the underlying mechanisms on the circulating levels of the most common adipokines regulating atherosclerosis process, as a part of their pleiotropic function. Up to now, robust evidence implicates a significant statin-induced reduction of pro-inflammatory adipokines IL-6, TNF-a and visfatin. Weak evidence from limited, small and mostly non-randomized studies suggest increased levels of anti-inflammatory adipokines apelin, vaspin and omentin-1 after statin therapy. In the rest of most known adipokines, statins have shown either controversial (adiponectin, retinol binding protein-4 and fetuin-A) or negligible effects (leptin and resistin) on their circulating levels. Therefore, statins may favourably alter the balance of inflammatory/anti-inflammatory adipokines, implicating a novel atheroprotective mechanism. However, the interplay between statins and adipokines is still not fully elucidated and its potential clinical relevance is warranted.

Plasma nesfatin-1 and DDP-4 levels in patients with coronary artery disease: Kozani study

Background

Nesfatin-1, a novel adipokine and dipeptidyl peptidase-4 (DPP4), a mam malian serine protease, are potent factors of atherosclerosis. In the present cross-sectional study, we investigated whether the plasma nesfatin-1 and DPP4 is associated with the prevalence and severity of coronary artery disease (CAD) with and without diabetes mellitus (DM).

Methods

We consecutively enrolled a total of 240 patients with significant CAD (previous revascularization or angiographically-proven coronary artery stenosis > 50%) presented with either unstable angina (UA, N = 76) or stable chronic CAD (SCAD, N = 165). 85 patients with at least 2 classical cardiovascular risk factors but without significant CAD served as controls. The severity of CAD was assessed using coronary angiography by the Gensini score. Clinical parameters, glycemic and lipid profile, high-sensitivity CRP (hsCRP), nesfatin-1 and DPP4 levels were assayed.

Results

No differences were found for age, sex, hypertension and diabetes distribution between groups. Low nesfatin-1 levels were found in both CAD groups (UA & SCAD) with respect to controls. The difference between UA and SCAD groups was marginally non-significant. There was a significant increase of DPP4 along UA to SCAD and control groups. Differences between groups remained unchanged in non-diabetic participants. Nesfatin-1 significantly correlated to hsCRP (r = − 0.287, p = 0.036), HOMA-IR (r = − 0.587, p = 0.007) and hyperlipidemia (r = − 0.331, p = 0.034). DPP4 was significantly associated with hs-CRP (r = 0.353 p < 0.001) and FPG (r = 0.202, p = 0.020) in univariate analysis, but those correlations were lost in multiple regression analysis. There was a negative correlation between nesfatin-1 and the severity of CAD, quantified by the Gensini score (r = − 0.511, p < 0.001), but no association was found for DPP4.

Conclusions

Serum DPP4 levels are increased in patients with CAD, while serum nesfatin-1 levels have a negative association with both the incidence and the severity of CAD. These results are independent of the presence of diabetes mellitus. In addition, both peptides have a strong association with hsCRP.

Trial registration ClinicalTrials.gov Identifier: NCT00306176

Omentin-1 and vaspin serum levels in patients with pre-clinical carotid atherosclerosis and the effect of statin therapy on them

BACKGROUND

Omentin-1 and vaspin are novel adipokines, and their association with atherosclerosis is still under investigation. The present study aimed to assess the relationship of those adipokines with preclinical, non-significant carotid atherosclerosis and the impact of statin therapy on their levels, suggesting a link between adiposity and atherosclerosis.

METHODS

Eighty-four statin-free subjects with non-significant, preclinical carotid atherosclerosis and elevated LDL- cholesterol levels (>130 mg/dl) were recruited to receive atorvastatin (from 10 to 80 mg per day) (atorvastatin group - AG group). Forty-six age- and gender-matched healthy individuals, without any chronic disease served as controls (control group - CG). Clinical parameters, metabolic profile, serum omentin-1, vaspin concentrations and ultrasound measurements of carotid thickening were obtained at the beginning and after 12 months.

RESULTS

At baseline, AG showed lower omentin-1 and vaspin serum levels than CG (p ≤ 0.001). Along the entire study population at baseline, omentin-1 levels were independently related to LDL-cholesterol, while vaspin levels were independently associated with hsCRP and the presence of carotid atherosclerosis (p < 0.05). Within AG, 12-months atorvastatin treatment significantly increased omentin-1 (from 202.79 ± 91.41 ng/ml to 262.56 ± 101 ng/ml, p < 0.001) and vaspin concentrations (from 1.29 ± 0.51 ng/ml to 1.70 ± 0.5 ng/ml, p = 0.002). In standard multiple regression analysis, the presence of carotid atherosclerosis related to baseline vaspin levels (β = -0.232, p < 0.001), while the atorvastatin-induced increase of vaspin was independently associated with hsCRP reduction (β = -0.198, p = 0.045).

CONCLUSION

Low omentin-1 and vaspin serum levels associated with preclinical, non-significant carotid atherosclerosis. Notably, atorvastatin administration significantly increased both adipokines, but the underlying mechanisms and the clinical impact of those changes requires further investigation.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Prevention of Radial Artery Occlusions Following Coronary Procedures: Forward and Backward Steps in Improving Radial Artery Patency Rates

Radial artery (RA) occlusion (RAO) remains the Achilles heel of transradial coronary procedures. Although of silent nature, RAO is relatively frequent, results in graft shortage for future coronary artery bypass surgery, and may occur even after short-lasting, 5F coronary angiography (CAG). The most frequent predictors of RAO are RA size, body size, female gender, and periprocedural anticoagulation intensity. Methods to detect RAO are variable, of which the Barbeau test and ultrasonography have similar diagnostic accuracy. Data indicate that late RAO recanalization may occur. Meticulous handling of RA and the use of appropriate hemostatic devices and techniques along with sufficient heparin dose appear important measures to reduce RAO rates. Recent contradictory studies indicate that the decreasing incidence of RAO overtime is not as uniform as previously thought. In 2 meta-analyses, the benefit of higher over lower anticoagulation intensity became evident. As “it may all be appropriate anticoagulation” for a simplified approach against RAO, the results of an ongoing trial comparing 100 with 50 IU/kg body weight in transradial CAG are eagerly awaited.