Initiating a New Era of Cardiovascular Diagnosis and Therapy in Acute Aortic Syndromes: The Mainz–Essen Experience (Part I)—Imaging and Biomarkers

Acute aortic syndromes (AAS) encompass a group of life-threatening medical conditions (acute aortic dissection [AAD], intramural hematoma, and penetrating aortic ulcer) with a common pathophysiological pathway. Due to overlapping symptoms and signs with other cardiovascular emergencies, the diagnosis remains challenging resulting in time delays and related increased in-hospital and long-term morbidity and mortality. The Cardiovascular Department of Johannes Gutenberg University in Mainz at West-German Heart Centre in Essen (Germany) first described (in 1984) AAD by transesophageal echocardiography, AAD diagnostic features, and furtherly explored the implementation of “invasive” imaging techniques, namely, intravascular ultrasound and intraluminal phased-array imaging. Furthermore, pioneer studies were undertaken on the biomarker and imaging interplay, namely, D-dimer and F-fluorodeoxyglucose positron emission tomography/computed tomography. We discuss the unique 35-year-long Mainz–Essen experience on the diagnostic and prognostic role of serological and imaging biomarkers in AAS.

Clinical Profile and Outcome of COVID 19 Patients at Tertiary Cardiovascular Center of Nepal.

Background and Aims: Cardiovascular comorbidities are common in patients with COVID-19 and these patients are at higher risk of morbidity and mortality. It is not known if the presence of cardiovascular co-morbid conditions poses independent risk or whether this is mediated by other factors. Methods: This is a retrospective follow up study done at Shahid Gangalal National Heart Centre (SGNHC). The main objective of this study was to study the clinical profile, baseline comorbidities, and outcome of cardiac patients and health care worker diagnosed with COVID 19. This study retrospectively evaluated case records of all cardiovascular disease (CVD) patients admitted at SGNHC with COVID 19 cases from 1st case diagnosed on July at SGNHC till September 2020. Results: During this study period, 90 patients with COVID 19 with cardiovascular disease were admitted. The mean age of the study population was 52.3±19 years with 65.6% being male. Among the study population 52 (57.8%) had past history of cardiovascular disease, hypertension in 18 (20%) cases, diabetes in 8 (8.9%) cases. Among the patients with cardiovascular diagnosis, acute coronary syndrome was most common cardiovascular diagnosis in 23 (25.6% cases) followed by rheumatic heart disease in 21 (23.4%) cases, dilated cardiomyopathy in 7 (7.8% cases), ischemic cardiomyopathy with reduced ejection fraction (EF) in 7 (7.8%) cases, post coronary artery bypass graft (CABG) in 8 (8.9%), post valve replacement in 5 (5.5%), congenital heart disease in 3.3% cases and complete heart block in 3.3% cases. Most of the cases were symptomatic with moderate illness in 46.7% cases, mild illness in 41.4% cases and severe/critical illness in 11.1% cases. Among COVID patients with cardiovascular disease, the mortality was 11.1%. Conclusion: Patients with cardiovascular disease with COVID 19 have more severe COVID 19 symptoms and has higher COVID 19 related death, so strict vigilance and early intervention is needed to improve its outcome.

A virtual-hybrid approach to launching a cardio-oncology clinic during a pandemic

Background As cardiovascular disease is a leading cause of death in cancer survivors, the new subspecialty of Cardio-Oncology has emerged to address prevention, monitoring, and management of cardiovascular toxicities to cancer therapies. During the coronavirus disease of 2019 (COVID-19) pandemic, we developed a Virtual-Hybrid Approach to build a de novo Cardio-Oncology Clinic. Methods We conceptualized a Virtual-Hybrid Approach including three arms: information seeking in locations with existing Cardio-Oncology clinics, information gathering at the location for a new clinic, and information sharing to report clinic-building outcomes. A retrospective review of outcomes included collection and synthesis of data from our first 3 months (at pandemic peak) on types of appointments, cancers, drugs, and cardiotoxicities. Data were presented using descriptive statistics. Results A de-novo Cardio-Oncology clinic was developed structured from the ground up to integrate virtual and in-person care in a hybrid and innovative model, using the three arms of the Virtual-Hybrid Approach. First, we garnered in-person and virtual preparation through hands-on experiences, training, and discussions in existing Cardio-Oncology Clinics and conferences. Next, we gleaned information through virtual inquiry and niche-building. With partners throughout the institution, a virtual referral process was established for outpatient referrals and inpatient e-consult referrals to actualize a hybrid care spectrum for our patients administered by a multidisciplinary hybrid care team of clinicians, ancillary support staff, and clinical pharmacists. Among the multi-subspecialty clinic sessions, approximately 50% were in Cardio-Oncology, 20% in Preventive Cardiology, and 30% in General Cardiology. In the hybrid model, the Heart & Vascular Center had started to re-open, allowing for 65% of our visits to be in person. In additional analyses, the most frequent cardiovascular diagnosis was cardiomyopathy (34%), the most common cancer drug leading to referral was trastuzumab (29%), and the most prevalent cancer type was breast cancer (42%). Conclusion This Virtual-Hybrid Approach and retrospective review provides guidance and information regarding initiating a brand-new Cardio-Oncology Clinic during the pandemic for cancer patients/survivors. This report also furnishes virtual resources for patients, virtual tools for oncologists, cardiologists, and administrators tasked with starting new clinics during the pandemic, and innovative future directions for this digital pandemic to post-pandemic era.

Quality indicators of a cardiac rehabilitation program in women with coronary heart disease

Introduction Cardiac rehabilitation programs (CRP) are well known to improve functional status and prognosis after a cardiovascular event. This programs are class IA recommendation. However, many studies have demonstrated that women are less likely to stick to a CRP. Purpose To compare baseline characteristics between men and women participating in a cardiac rehabilitation program and to determine whether there are gender differences in the benefits obtained after the program. Methods Using data from our Department of CRP, we analysed a total of 1091 patients referred between 2015 and 2018 to our center CRP after a cardiovascular diagnosis. Clinical, analytical and echocardiographic outcomes were collected. We defined benefit as the achievement of the target levels established for each cardiovascular risk factor (CVRF) as well as improvement in the exercise capacity. This capacity was evaluated with exercise tests and maximum O2 uptake at the beginning and at the end of the CPR. Results Between 2015 and 2018, 189 (17.3%) of them women with a mean age of 62 years were enrolled in the CRP. There were no significant gender differences in mean age or incidence of CVRF. Likewise, there weren't differences in cardiovascular diagnosis, risk stratification, left ventricular ejection fraction or exercise test performed before the program. In the results after CRP there were no important gender differences in the percentage of patients who achieved the quality indicators described as HbA1c <7.0%, systolic arterial pressure <140 mmHg, diastolic arterial pressure <90 mmHg. Percentage of LDL cholesterol <70 mg/dl was significantly higher in male patients. Both in men and women an improvement of the second exercise test result was observed. Conclusions 1. Men and women who suffer from a coronary heart disease have similar clinical characteristics. 2. Among patients with coronary heart disease who attended a cardiac rehabilitation program there were no significant gender differences in the benefits obtained after the program. Funding Acknowledgement Type of funding source: None

Clinical evaluation and diagnostic yield following evaluation of abnormal pulse detected using Apple Watch

Objective The study sought to characterize the evaluation of patients who present following detection of an abnormal pulse using Apple Watch. Materials and Methods We conducted a retrospective review of patients evaluated for abnormal pulse detected using Apple Watch over a 4-month period. Results Among 264 included patients, clinical documentation for 41 (15.5%) explicitly noted an abnormal pulse alert. Preexisting atrial fibrillation was noted in 58 (22.0%). Most commonly performed testing included 12-lead echocardiography (n = 158; 59.8%), Holter monitor (n = 77; 29.2%), and chest x-ray (n = 64; 24.2%). A clinically actionable cardiovascular diagnosis of interest was established in only 30 (11.4%) patients, including 6 of 41 (15%) patients who received an explicit alert. Discussion False positive screening results may lead to overutilization of healthcare resources. Conclusions The Food and Drug Administration and Apple should consider the unintended consequences of widespread screening for asymptomatic (“silent”) atrial fibrillation and use of the Apple Watch abnormal pulse detection functionality by populations in whom the device has not been adequately studied.

Psychophysiological Models to Identify and Monitor Elderly with a Cardiovascular Condition: The Added Value of Psychosocial Parameters to Routinely Applied Physiological Assessments

The steadily growing elderly population calls for efficient, reliable and preferably ambulant health supervision. Since cardiovascular risk factors interact with psychosocial strain (e.g., depression), we investigated the potential contribution of psychosocial factors in discriminating generally healthy elderly from those with a cardiovascular condition, on and above routinely applied physiological assessments. Fifteen elderly (aged 60 to 88) with a cardiovascular diagnosis were compared to fifteen age and gender matched healthy peers. Six sequential standardized lab assessments were conducted (one every two weeks), including an autonomic test battery, a 6-min step test and questionnaires covering perceived psychological state and experiences over the previous two weeks. Specific combinations of physiological and psychological factors (most prominently symptoms of depression) effectively predicted (clinical) cardiovascular markers. Additionally, a highly significant prognostic model was found, including depressive symptoms, recently experienced negative events and social isolation. It appeared slightly superior in identifying elderly with or without a cardiovascular condition compared to a model that only included physiological parameters. Adding psychosocial parameters to cardiovascular assessments in elderly may consequently provide protocols that are significantly more efficient, relatively comfortable and technologically feasible in ambulant settings, without necessarily compromising prognostic accuracy.