Analysing electrocardiographic traits and predicting cardiac risk in UK biobank

The electrocardiogram (ECG) is a commonly used clinical tool that reflects cardiac excitability and disease. Many parameters are can be measured and with the improvement of methodology can now be quantified in an automated fashion, with accuracy and at scale. Furthermore, these measurements can be heritable and thus genome wide association studies inform the underpinning biological mechanisms. In this review we describe how we have used the resources in UK Biobank to undertake such work. In particular, we focus on a substudy uniquely describing the response to exercise performed at scale with accompanying genetic information.

Contemporary approaches to bifurcation stenting

Bifurcation lesions are common and associated with higher risks of major cardiac events and restenosis after percutaneous coronary intervention (PCI). Treatment requires understanding of lesion characteristics, stent design and therapeutic options. We review the evidence for provisional vs 2-stent techniques. We conclude that provisional stenting is suitable for most bifurcation lesions. We detail situations where a 2-stent technique should be considered and the steps for performing each of the 2-step techniques. We review the importance of lesion preparation, intracoronary imaging, proximal optimization (POT) and kissing balloon inflation

Right ventricular ejection fraction as predictor of outcome in acute heart failure using RV ellipsoid model: A retrospective analysis of a prospective cross-sectional study

Objectives The right ventricular (RV) function is an important prognostic factor in acute and chronic heart failure (HF). Echocardiography is an essential imaging modality with established parameters for RV function which are useful and easy to perform. However, these fail to reflect global RV volumes due to reliability on one acoustic window. It is therefore attractive to calculate RV volumes and ejection fraction (RVEF/E) using an ellipsoid geometric model which has been validated against MRI in healthy adults but not in the HF patients. Design This is a retrospective analysis of a prospective cross-sectional study enrolling 418 consecutive patients with symptoms of HF according to a predefined study protocol. All patients underwent echocardiographic assessment of RV function using Tricuspid Annular Plane Systolic Excursion (TAPSE) and RV fractional area change (RVFAC) and RVEF/E. Setting Single centre study with multiple locations for acute in-patients including high dependency units. Participants Patients with acute or exacerbation of chronic HF older than 18 y.o. Main outcome measures Ability of RVEF/E to predict patient outcomes compared with two established parameters of RV function over two-year follow-up period. Primary outcome measure was all-cause mortality. Results RVEF/E is equal to TAPSE & RVFAC in predicting outcome (p ≤ 0.01 vs p ≤ 0.01) and provides additional benefit of RV volume estimation based on standard 2D echo measurements. Conclusions In this study we have shown that RVEF/E derived from ellipsoid model is not inferior to well established measures of RV function as a prognostic indicator of outcome in the acute HF.

Retrospective cohort study of statin prescribing for primary prevention among people living with HIV

Objective To compare statin prescribing rates between intermediate-risk people living with human immunodeficiency virus (HIV; PLWH) and intermediate-risk patients without a diagnosis of HIV for primary prevention of atherosclerotic cardiovascular disease (ASCVD). Methods Retrospective cohort study . Electronic health record data were used to identify a cohort of PLWH aged 40–75 years with a calculated 10-year ASCVD risk between 7.5%-19.9% as determined by the Pooled Cohort Equation (PCE). A matched cohort of primary prevention non-HIV patients was identified. The primary outcome was the proportion of PLWH who were prescribed statin therapy compared to patients who were not living with HIV and were prescribed statin therapy Results 81 patients meeting study criteria in the PLWH cohort were matched to 81 non-HIV patients. The proportion of patients prescribed statins was 33.0% and 30.9% in the PLWH and non-HIV cohorts, respectively (p = 0.74). Conclusion and relevance: This study evaluated statin prescribing in PLWH for primary prevention of ASCVD as described in the 2018 AHA/ACC/Multisociety guideline. Rates of statin prescribing were similar, yet overall low, among intermediate-risk primary prevention PLWH compared to those not diagnosed with HIV.

Reduced physical activity and weight gain are associated with an increase of depressive symptoms during the COVID-19 pandemic. A general practitioners’ prospective observational study

Objectives We aimed to assess associations between depressive symptoms, lifestyle, and somatic symptoms during the COVID-19 pandemic. Design A prospective, observational study using a self-designed questionnaire. Setting Three general practitioners’ (GP) offices in rural Germany. Participants 271 adult patients without manifest cardiovascular or pulmonary disease with (n = 82) and without (n = 189) hypertension reporting to our GP offices. Main outcome measures The reported increase of depressive symptoms (loneliness, sleeplessness, joylessness, listlessness) prior to the first documented case in Germany on 27.01.2020 (t0) as opposed to patients’ health perception during the Corona pandemic (t1) was the primary outcome measure. The secondary outcome measures were changes in physical activity (PA), dyspnea and angina in the two groups. Results Out of 271 patients (50.8 ± 16.8 years, 55.1% females), 1.5% were tested positive for COVID-19. Overall, listlessness (8.5%, p = 0.001), sleeplessness (5.2%, p = 0.001) and joylessness (4.2%, p = 0.003) were increased. Dyspnea significantly increased (9.2%, p < 0.001) and employment status worsened (6.5%, p < 0.001). There were significant associations between the increase of depressive symptoms, weight increase (p = 0.017), and reduction in physical activity (p = 0.046). However, after adjusting for age, hypertensive patients did not show more depressive symptoms (p = 0.704), dyspnea (p = 0.063) or angina (p = 0.432), nor was there any difference in PA (p = 0.906) compared to healthy individuals. Conclusions We demonstrate an association between the deterioration of depressive symptoms, weight gain, and reduced physical activity during COVID-19, both in hypertensives and healthy controls. Hypertension is no driver of symptom deterioration during the pandemic. The trial was registered in the German Clinical Trials Registry (DRKS00022157).

How to select patients requiring coronary revascularisation using coronary physiology

The coronary angiogram is an indicator of flow limiting coronary artery disease but coronary physiology at the time of angiography is vital in assessing the true functional significance of coronary artery disease. With advances in guidewire technology and the greater use of physiology within the catheter laboratory, there is now a slow evolution of physiological indices in being able to reliably assess the functional significance of individual lesions and also the adequacy of revascularization in a growing range of clinical scenarios. As co-registration of physiology with the angiogram and intravascular imaging will become easier, we will find ourselves increasingly in an era of ‘Precision PCI’.

Improved low-risk criteria scores for combination therapy of sildenafil and generic bosentan in patients with congenital heart disease with severe pulmonary hypertension: A prospective open label study

Objective We evaluated the efficacy and safety of the bosentan as a sequential add-on therapy with sildenafil in pulmonary arterial hypertension with congenital heart disease (PAH-CHD) patients. Material and method Twenty patients who were receiving sildenafil were given generic bosentan for up to a year. Hemodynamic data was collected from cardiac catheterization at pretreatment and at three months. Comparisons were made between the total scores of the four, low-risk criteria adapted from the 2015 ESC/ERS pulmonary hypertension guidelines, which are: 1) WHO functional class of I or II, 2) 6MWD of more than 440 m, 3) right atrial pressure of less than 8 mm Hg, and 4) cardiac index ≥2.5 L/min/m2, performed at the beginning of therapy, 3-months, 6-months, and 1 year. Results Patients’ average age was 27 ± 11 years old (12–53). PVRi decreased from 16.7 ± 9.5 to 12.7 ± 10.3 Wood unit (WU) m2 (p = 0.025) and PVRi/SVRi decreased from 0.69 ± 0.33 to 0.49 ± 0.32 (p = 0.001). During the follow-up, the composite scoring of the low risk scores for 19 patients was increased significantly from 1.8 ± 1.0 at baseline to 2.3 ± 0.9 at 3 months, to 2.9 ± 0.8 at 6 months, and 3 ± 0.7 at 1 year (p = 0.001). Conclusion We demonstrated intermediate term benefits for generic bosentan as an add-on therapy to sildenafil in patients with PAH-CHD by improving PVRi, and PVRi/SVRi at three months. A significant improvement was also seen in the combined scores of the low-risk criteria from below 2 to 3 at one year (p = 0.001). Thai Clinical Trials Registry (TCTR): TCTR identification number is TCTR20200506006.

Pulmonary embolism after discharge for COVID-19: A report of two cases

Previous studies have found critically ill patients with COVID-19 to have an increased risk of thromboembolic complications. In this case report of two patients admitted with symptomatic COVID-19, both patients developed pulmonary embolism within a few days after hospital discharge. Both patients received thromboprophylaxis and had an increasing fibrin D-dimer during their hospital stay. Continued thromboprophylaxis after hospital discharge may be indicated for patients with COVID-19, especially for patients at high risk of thrombosis with elevated levels of fibrin D-dimer.

Health promotion interventions post-stroke for improving self-management: A systematic review

Background It is well-documented that women tend to be worse off post-stroke. They are often frailer, have less independence, lower functionality, increased rates of depression, and overall a lower quality of life. People who have had strokes benefit from rehabilitative support to increase their independence and reduce the risk of stroke reoccurrence. Despite the gender differences in the effects of stroke, interventions explicitly aimed at helping women have not been identified. Purpose This systematic review aimed to summarize the effectiveness of the health promoting behavioural interventions for reducing risk factors and improved self-management in women post-stroke, compared to usual care. Method Seven databases, Medline (Ovid), CINAHL, PsychInfo, Embase, PubMed, Scopus, and Google Scholar, were reviewed for randomized controlled trials covering post-stroke interventions. The following keywords were used: health promotion, secondary prevention, woman, women, female, sex difference, gender difference, after stroke, and post-stroke. Results Ten randomised controlled trials were found. These demonstrated common successful approaches for rehabilitation, but none specifically described health promotion strategies for women. Core components of successful programs appeared to be a structured approach, tailored to clientele and formalised support systems through their carer, family networks, or community engagement. Comprehensive reminder systems were successful for stroke risk reduction. Conclusion Women are disproportionately affected by stroke and are often in the frail category. Tailored structured health promotion programs with family and caregiver support combined with a comprehensive reminder system would appear to enable women post-stroke.

Characterising the incidence and mode of visceral stent failure after fenestrated endovascular aneurysm repair (FEVAR)

Background In FEVAR, visceral stents provide continuity and maintain perfusion between the main body of the stent and the respective visceral artery. The aim of this study was to characterise the incidence and mode of visceral stent failure (type Ic endoleak, type IIIa endoleak, stenosis/kink, fracture, crush and occlusion) after FEVAR in a large cohort of patients at a high-volume centre. Methods A retrospective review of visceral stents placed during FEVAR over 15 years (February 2003-December 2018) was performed. Kaplan-Meier analyses of freedom from visceral stent-related complications were performed. The outcomes between graft configurations of varying complexity were compared, as were the outcomes of different stent types and different visceral vessels. Results Visceral stent complications occurred in 47/236 patients (19.9%) and 54/653 stents (8.3%). Median follow up was 3.7 years (IQR 1.7–5.3 years). There was no difference in visceral stent complication rate between renal, SMA and coeliac arteries. Visceral stent complications were more frequent in more complex grafts compared to less complex grafts. Visceral stent complications were more frequent in uncovered stents compared to covered stents. Visceral stent-related endoleaks (type Ic and type IIIa) occurred exclusively around renal artery stents. The most common modes of failure with SMA stents were kinking and fracture, whereas with coeliac artery stents it was external crush. Conclusion Visceral stent complications after FEVAR are common and merit continued and close long-term surveillance. The mode of visceral stent failure varies across the vessels in which the stents are located.