Artificial Intelligence in Patients with Congenital Heart Disease: Where Do We Stand?

Life expectancy of patients with congenital heart disease (CHD) has increased in recent decades; however, late complications remain frequent and difficult to predict. Progress in data science has spurred the development of decision support systems and could aid physicians in predicting clinical deterioration and in the management of CHD patients. Newly developed artificial intelligence (AI) algorithms have shown performances comparable to humans in clinical diagnostics using statistical and computational algorithms and are expected to partly surpass human intelligence in the near future. Although much research on AI has been performed in patients with acquired heart disease, little data is available with respect to research on AI in patients with CHD. Learning algorithms in patients with CHD have shown to be promising in the interpretation of ECG, cardiac imaging, and the prediction of surgical outcome. However, current learning algorithms are not accurate enough to be implemented into daily clinical practice. Data on AI possibilities remain scarce in patients with CHD, and studies on large data sets are warranted to increase sensitivity, specificity, accuracy, and clinical relevance of these algorithms.

Association Between the Hospital Readmissions Reduction Program and Heart Failure Subtype Readmissions and Mortality in the USA

Background: The Hospital Readmission Reduction Program (HRRP) sought to reduce readmissions by penalising centres with readmissions above the national average, and heart failure (HF) is the leading driver of the readmission penalty. Recent Medicare analyses question the effectiveness of this strategy. This study evaluated the efficacy of HRRP by utilising large national datasets and is the first to analyse based on heart failure subtypes. Methods: Aggregate data was used from the National Inpatient Sample (NIS) to study mortality and the National Readmissions Database (NRD) to study readmissions. Both included all payer-types and were stratified by heart failure subtype and time (pre- and post-HRRP implementation). Results: Patients with HF with preserved ejection fraction (HFpEF) tended to be older females with a higher proportion of comorbidities compared to patients with HF with reduced ejection fraction (HFrEF). In the post-HRRP period, readmission rates decreased for HFrEF (21.4% versus 22.3%, p<0.001) and HFpEF (21.2% versus 22.4%, p<0.001); readmission rates for the two subtypes were not statistically different compared to the other. Post-HRRP, inpatient mortality was consistent for HFrEF (2.8% versus 2.8%, p=0.087), but decreased for HFpEF (2.4% versus 2.5%, p=0.029). There were no significant differences noted in average length of stay. Patients with HFrEF were more frequently discharged to short-term hospitals or home with home healthcare, and patients with HFpEF were discharged to skilled nursing facilities more often. Estimated inpatient costs decreased in both subtypes post-HRRP, but readmission costs were higher for HFrEF. Conclusions: This study suggests that HRRP was associated with minimal change in readmission and inpatient mortality.

2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure

An engaging session on the newly revised European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) was conducted on the first day of the 2021 ESC virtual congress. Chaired by Colin Baigent, Professor of Epidemiology, University of Oxford, UK, the session also explored the classification and management of HF, and addressed questions from the congress audience.

A Case Report on Ischaemic Cardiomyopathy with Severe Left Ventricular Dysfunction

Ischaemic cardiomyopathy is a condition that arises when heart muscle is weakened because of coronary artery disease or a heart attack. Left ventricular (LV) dysfunction occurs when the left ventricle is either defective or damaged, thus disrupting healthy function. Normal LV function can be perturbed because of several causes. Some cardiac defects such as valvular malformations or conditions block the passage of blood into the body. Effective and cost-effective treatment is available for such patients that can reduce both morbidity and mortality. Herein, the authors present the case of a 69-year-old male who was brought to the emergency department with a history of hypertension on medication. Later, the patient was transferred to the cardiology department. The patient was brought to the hospital after midnight and had bleeding gums, and experienced bleeding from the site of needle puncture. Earlier reports showed that the international normalised ratio was >6.0, and the 2D echocardiogram showed large LV blood clots, mild LV dysfunction, mild mitral regurgitation, and aortic valve stenosis. Finally, the patient was diagnosed with ischaemic cardiomyopathy associated with LV dysfunction. During discharge, the patient and patient’s representative were counselled in layman’s language about the conditions and prognosis of the disease, the use and adherence to medications, lifestyle modifications, and were advised to review back to the cardiologist.

A Case Series of Eight Coronary Artery Perforations and a Review of the Up-to-Date Literature

Percutaneous coronary intervention has become a fundamental diagnostic and treatment strategy in coronary artery disease. Much like any procedure, it is not without risk; in fact, a rare but life-threatening complication as a result of percutaneous coronary intervention is coronary artery perforations (CAP). The risk of CAPs correspondingly rises in relation to the difficulty of the procedure, location of lesion, and complexity of anatomy. It follows then that early recognition and instigation of an appropriate treatment strategy is key in reducing the mortality and morbidity associated with CAPs. The authors present eight case reports of varying difficulties, their analogous management, and a literature review of management approaches in treating CAPs in order to provide a review of management strategies and to highlight the importance of immediate recognition of a potentially fatal complication.

Biomarker-Based Guideline-Directed Medical Therapy of Heart Failure: The Gap Between Guidelines and Clinical Practice

Current clinical recommendations provided by the 2016 European Society of Cardiology (ESC) and 2017 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) are substantially distinguished in the use of circulating biomarkers in the management of heart failure (HF). To date, natriuretic peptides continue being the universal biomarkers used in diagnosis, risk stratification, and prediction of cardiovascular death, all-cause mortality, and HF-related outcomes for patients with both phenotypes of HF. However, biomarkers of fibrosis and inflammation, including soluble suppressor of tumourgenicity 2 and galectin-3, were able to increase predictive ability of natriuretic peptides in HF patients regardless of cardiovascular risk-factor presentation and HF phenotypes. Therefore, there are many various biomarkers describing several pathophysiological processes such as fibrosis, inflammation, oxidative stress, neurohumoral activation, extracellular matrix turnover, and vascular reparation, that play a pivotal role in the natural evolution of HF. This review discusses whether multiple biomarker models are more effective than a single biomarker in improving risk stratification strategies in patients with HF. It emphasises how in routine clinical practice, the multiple biomarker approach to elicit response to therapy of HF and predict clinical outcomes is rare, probably because of the relatively high cost, low affordability, lack of clear recommendations for clinical implementation, and significant disagreements in the interpretation of the data obtained.

Hydroxychloroquine- and Azithromycin-Induced Transient Left-Bundle Branch Block in a Patient with COVID-19

Background: COVID-19 has emerged and rapidly spread worldwide due to the high infectivity of the novel coronavirus. A new regimen consisting of a combination of hydroxychloroquine and azithromycin has been under evaluation for efficacy and side effects, especially cardiotoxicity. Case summary: A 58-year-old man was admitted to the hospital for COVID-19 pneumonia. His initial ECG showed sinus tachycardia. He was started on combination therapy of azithromycin and hydroxychloroquine. After the second dose of hydroxychloroquine and initial dose of azithromycin, his ECG showed complete left-bundle branch block (LBBB). The treatment was stopped, and the patient had no cardiac symptoms. On Day 8 of admission, his repeat ECG showed an absence of LBBB. Discussion: The cumulative dose of hydroxychloroquine observed in patients treated for malaria or systemic diseases is cardiotoxic, and few cases of LBBB, have been reported. It is, however, not known whether the use of azithromycin in association with a small dose of hydroxychloroquine induces transient LBBB.

COVID-19 Infection and Myocardial Infarction Pathophysiology and Therapy

The relationship between COVID-19 and cardiovascular disease has been of interest since the beginning of the pandemic, with the focus more recently shifting towards thrombotic complications, including myocardial infarction (MI). While the inflammatory burden of infection has previously been implicated in the pathogenesis of MI, at least early in the pandemic, many hospitals were seeing fewer ST-elevation MI admissions and the delivery of acute coronary syndrome care was disrupted in multiple ways. Furthermore, patients presenting with both COVID-19 infection and MI have been noted in small studies to have unique characteristics that pose clinical challenges, and there is reason to believe that standard therapy for both the prevention and treatment of all thrombotic events, including MI, may not be adequate. The aim of this article is to review the data regarding MI and other thrombotic events during the pandemic, to explore the link between inflammation and thrombosis, and to suggest possible novel therapeutic options for the treatment and prevention of thrombosis in patients with COVID-19.

Acute Severe Mitral Regurgitation Secondary to Haemophilus parainfluenzae Infective Endocarditis

Haemophilus parainfluenzae is an exceedingly rare cause of infective endocarditis, with only a few case reports describing its potential invasiveness. This case reports on a 25-year-old female who was admitted with a fever and was subsequently found to have H. parainfluenzae endocarditis. She was managed with intravenous antibiotics and mitral valve replacement.

2020 ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease

ADVISING individuals with diseases of the heart on what types and intensities of sport to participate in is not a practice cardiologists typically have official guidelines on. A taskforce from ESC has now come together and created guidelines, the first of their kind, on exercise and sports participation in patients with cardiovascular disease. The guidelines were presented at the ESC Congress 2020 in a session chaired by Prof Antonio Pelliccia, Scientific Director of the Institute of Sports Medicine & Science from Rome, Italy. Pelliccia was joined by Prof Martin Halle, President of the European Association of Preventive Cardiology (EAPC), Munich, Germany, and Prof Matthias Wilhem, Head of the Centre for Preventive Cardiology, Sports Medicine, Department of Cardiology at the Inselspital, University Hospital of Bern, Switzerland. The guidelines derived from the need to assist patients who had experienced cardiovascular events and were questioning their limits of sports participation. Prof Halle commented on his experience in the taskforce: “The level of evidence is rather low, so it is very much the personal perspective and the experience of the experts which made us come to that one conclusion in the guidelines. It is something that should be developed in years to come.” A series of videos were shown, presented by specialists who were invited to discuss some of the most relevant topics of the guidelines.