Iron overload in polytransfused patients without heart failure is associated with subclinical alterations of systolic left ventricular function using cardiovascular magnetic resonance tagging

BACKGROUND: It remains incompletely understood whether patients with transfusion related cardiac iron overload without signs of heart failure exhibit already subclinical alterations of systolic left ventricular (LV) dysfunction. Therefore we performed a comprehensive evaluation of systolic and diastolic cardiac function in such patients using tagged and phase-contrast CMR. METHODS: 19 patients requiring regular blood transfusions for chronic anemia and 8 healthy volunteers were investigated using cine, tagged, and phase-contrast and T2* CMR. LV ejection fraction, peak filling rate, end-systolic global midventricular systolic Eulerian radial thickening and shortening strains as well as left ventricular rotation and twist, mitral E and A wave velocity, and tissue e' wave and E/e' wave velocity ratio, as well as isovolumic relaxation time and E wave deceleration time were computed and compared to cardiac T2*. RESULTS: Patients without significant iron overload (T2* > 20 ms, n = 9) had similar parameters of systolic and diastolic function as normal controls, whereas patients with severe iron overload (T2* 20 ms) or normal controls. Patients with moderate iron overload (T2* 10-20 ms, n = 5), had preserved ejection fraction (59 ± 6%, p = NS vs. pts. with T2* > 20 ms and controls), but showed reduced maximal LV rotational twist (1.8 ± 0.4 degrees). The magnitude of reduction of LV twist (r = 0.64, p < 0.001), of LV ejection fraction (r = 0.44, p < 0.001), of peak radial thickening (r = 0.58, p < 0.001) and of systolic (r = 0.50, p < 0.05) and diastolic twist and untwist rate (r = -0.53, p < 0.001) in patients were directly correlated to the logarithm of cardiac T2*. CONCLUSION: Multiple transfused patients with normal ejection fraction and without heart failure have subclinical alterations of systolic and diastolic LV function in direct relation to the severity of cardiac iron overload. Among all parameters, left ventricular twist is affected earliest, and has the highest correlation to log (T2*), suggesting that this parameter might be used to follow systolic left ventricular function in patients with iron overload

The coronavirus disease pandemic among adult congenital heart disease patients and the lessons learnt - results of a prospective multicenter european registry.

BACKGROUND At the beginning of the COVID-19 pandemic, professionals in charge of particularly vulnerable populations, such as adult congenital heart disease (ACHD) patients, were confronted with difficult decision-making. We aimed to assess changes in risk stratification and outcomes of ACHD patients suffering from COVID-19 between March 2020 and April 2021. METHODS AND RESULTS Risk stratification among ACHD experts (before and after the first outcome data were available) was assessed by means of questionnaires. In addition, COVID-19 cases and the corresponding patient characteristics were recorded among participating centres. Predictors for the outcome of interest (complicated disease course) were assessed by means of multivariable logistic regression models calculated with cluster-robust standard errors. When assessing the importance of general and ACHD specific risk factors for a complicated disease course, their overall importance and the corresponding risk perception among ACHD experts decreased over time. Overall, 638 patients (n = 168 during the first wave and n = 470 during the subsequent waves) were included (median age 34 years, 52% women). Main independent predictors for a complicated disease course were male sex, increasing age, a BMI >25 kg/m2, having ≥2 comorbidities, suffering from a cyanotic heart disease or having suffered COVID-19 in the first wave vs. subsequent waves. CONCLUSIONS Apart from cyanotic heart disease, general risk factors for poor outcome in case of COVID-19 reported in the general population are equally important among ACHD patients. Risk perception among ACHD experts decreased during the course of the pandemic

Roadmap for cardiovascular education across the European Society of Cardiology: inspiring better knowledge and skills, now and for the future

AIMS: The provision of high-quality education allows the European Society of Cardiology (ESC) to achieve its mission of better cardiovascular practice and provides an essential component of translating new evidence to improve outcomes. METHODS AND RESULTS: The 4th ESC Education Conference, held in Sophia Antipolis (December 2016), brought together ESC education leaders, National Directors of Training of 43 ESC countries, and representatives of the ESC Young Community. Integrating national descriptions of education and cardiology training, we discussed innovative pathways to further improve knowledge and skills across different training programmes and health care systems. We developed an ESC roadmap supporting better cardiology training and continued medical education (CME), noting: (i) The ESC provides an excellent framework for unbiased and up-to-date cardiovascular education in close cooperation with its National Societies. (ii) The ESC should support the harmonization of cardiology training, curriculum development, and professional dialogue and mentorship. (iii) ESC congresses are an essential forum to learn and discuss the latest developments in cardiovascular medicine. (iv) The ESC should create a unified, interactive educational platform for cardiology training and continued cardiovascular education combining Webinars, eLearning Courses, Clinical Cases, and other educational programmes, along with ESC Congress content, Practice Guidelines and the next ESC Textbook of Cardiovascular Medicine. (v) ESC-delivered online education should be integrated into National and regional cardiology training and CME programmes. CONCLUSION: These recommendations support the ESC to deliver excellent and comprehensive cardiovascular education for the next generation of specialists. Teamwork between international, national and local partners is essential to achieve this objective

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

European Society of Cardiology: Cardiovascular Disease Statistics 2019

Aims The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets. Methods and results In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5–23.1%] vs. 15.7% (IQR 14.5–21.1%)}, diabetes [7.7% (IQR 7.1–10.1%) vs. 5.6% (IQR 4.8–7.0%)], and among males smoking [43.8% (IQR 37.4–48.0%) vs. 26.0% (IQR 20.9–31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0–10.8) vs. 16.7% (IQR 13.9–19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655–8115)] compared with high-income [2235 (IQR 1896–3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures. Conclusion A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest

Heterogeneous contributions of change in population distribution of body mass index to change in obesity and underweight NCD Risk Factor Collaboration (NCD-RisC)

From 1985 to 2016, the prevalence of underweight decreased, and that of obesity and severe obesity increased, in most regions, with significant variation in the magnitude of these changes across regions. We investigated how much change in mean body mass index (BMI) explains changes in the prevalence of underweight, obesity, and severe obesity in different regions using data from 2896 population-based studies with 187 million participants. Changes in the prevalence of underweight and total obesity, and to a lesser extent severe obesity, are largely driven by shifts in the distribution of BMI, with smaller contributions from changes in the shape of the distribution. In East and Southeast Asia and sub-Saharan Africa, the underweight tail of the BMI distribution was left behind as the distribution shifted. There is a need for policies that address all forms of malnutrition by making healthy foods accessible and affordable, while restricting unhealthy foods through fiscal and regulatory restrictions

Bisoprolol et perindopril, une nouvelle association originale et utile pour de nombreux patients

Même si la mortalité cardiovasculaire a diminué ces dernières années, le traitement optimal de la maladie coronaire stable reste un défi. Selon les recommandations européennes, il devrait comprendre d’une part un bêta-bloquant pour son rôle dans le traitement et la prévention des épisodes ischémiques ouvert ou occultes, ainsi que dans l’amélioration de la capacité physique. D’autre part, un inhibiteur de l’enzyme de conversion (ACE inhibiteur), chez les patients avec des comorbidités comme l’hypertension, l’insuffisance rénale, le diabète ou encore une insuffisance cardiaque (1)

Myocardial viability : clinical detection and prognostic implications.

L'atteinte coronaire est une des principales cause de morbidité et de mortalité dans les pays développés. L'infarctus du myocarde et l'angor instable représentent les formes les plus courantes d'atteinte cardiaque mais l'ischémie myocardique peut aussi être silencieuse et conduire progressivement à des lésions chroniques. Selon la sévérité et l'importance de l'insulte ischémique, la fonction globale du ventricule gauche peut être soit préservée ou détériorée affectant par la même le pronostic du patient. Pendant de nombreuses années, les régions akinétiques du ventricule gauche ont été considérées comme représentant du myocarde irréversiblement endommagé ou nécrosé. Récemment, des données expérimentales et cliniques ont démontré que sous certaines conditions ce myocarde dysfonctionnel pouvait récupérer sa fonction. Ces régions ont été désignées sous le terme : myocarde hibernant. Le myocarde hibernant est défini comme du myocarde chroniquement dysfonctionnel chez un patient ayant une cardiopathie ischémique chronique et recouvrant partiellement ou totalement sa fonction après revascularisation. Dans la première partie de ce travail, nous avons étudié la relation entre la réponse inotrope à la dobutamine du myocarde dysfonctionnel et sa fonction mécanique. Nous avons démontré que les techniques ultrasonores de caractérisation tissulaires permettaient de mettre en évidence la présence de propriétés mécaniques fondamentales dans le myocarde dysfonctionnel répondant à l'injection de dobutamine. Ces propriétés ne peuvent pas être mises en évidence par imagerie échographique conventionnelle. Contrairement aux autres techniques l'interprétation de l'échographie de stress sous dobutamine (DbE) est largement subjective. Les mesures de strain dérivées des mesures de Doppler tissulaire réfèrent aux propriétés élastiques du muscle. Le strain permet de mesurer l'importance de la réponse inotrope du muscle. La quantification de l'échographie de stress dobutamine est donc possible. Ceci facilitera certainement la lecture des examens et augmentera la précision du diagnostic. En fonction des différents stades de dysfonction myocardique, certains segments avec une dysfonction réversible ne sont pas ou mal identifiés par l'échographie dobutamine il était alors important d'analyser l'efficacité diagnostique de l'échographie dobutamine pour prédire la récupération fonctionnelle du myocarde dysfonctionnel. La seconde partie de ce travail compare la performance relative de la tomographie par émissions de positron (PET) et DbE pour prédire la récupération fonctionnelle du myocarde dysfonctionnel. Nos données indiquent que PET et l'échographie dobutamine ont une efficacité diagnostique comparable. Nous avons également démontré que DbE n'identifiait pas seulement la dysfonction régionale réversible mais pouvait également prédire l'amélioration de la fonction globale du ventricule gauche après chirurgie. Donc, l'échographie dobutamine est un outil valable pour évaluer à la fois la réversibilité régionale et globale de la dysfonction myocardique. Finalement, l'amélioration la fonction ventriculaire après revascularisation n'est utile que si elle modifie le pronostic des patients. Dans la troisième partie de ce travail, nous avons établi que les patients avec du myocarde viable qui étaient revascularisé, avaient un meilleur pronostic que ceux sans myocarde viable ou traités médicalement. Ceci était particulièrement vrai pour les patients avec une maladie tritronculaire ou diabétiques. Chez les patients avec insuffisance cardiaque et fonction ventriculaire gauche fortement altérée (fraction d'éjection <25%), la possibilité d'une transplantation cardiaque est souvent évoquée. Nos données suggèrent que chez ces patients, l'identification du myocarde viable par DbE permet d'identifier ceux dont le pronostic sera amélioré par une revascularisation myocardique. A l'opposé, les patients sans myocarde viable ont un mauvais pronostic malgré une revascularisation chirurgicaleCoronary artery disease is one of the leading causes of morbidity and mortality in developed countries. Although myocardial infarction and unstable angina are the most common forms of "heart attacks", the consequence of myocardial ischemia may also be silent and lead progressively to chronic ischemic damage. Depending on the extent and severity of chronic injury, global LV function may be either preserved or globally impaired, affecting thereby the outcomes of the patients. For many years, it was considered that non-contracting areas of the LV represented irreversibly injured myocardium. Clinical and experimental data have demonstrated that under certain conditions, dysfunctional myocardium could be "waken up" and eventually recover function. These regions were coined as hibernating myocardium. The "hibernating myocardium" is defined as chronic LV dysfunction in patients with chronic coronary artery disease in whom complete or partial functional recovery occured after revascularization. In the first part of this work, we have assessed the relationship between the inotropic response of dysfunctional myocardium to dobutamine and its mechanical function. We demonstrated that ultrasonic tissue characterization permits to reveal the presence of basic mechanical properties in dysfunctional myocardium responsive to dobutamine infusion, that cannot be detected using conventional wall motion imaging. Contrary to the other techniques, interpretation of dobutamine stress echocardiography is largely subjective. Strain is a tissue Doppler derived measurement, which refers to the elastic properties of the muscle. It allows us to "measure" the magnitude of the inotropic response. Thus, quantification of dobutamine stress echocardiography is feasible and this will certainly facilitate the reading of dobutamine stress echocardiography and improve its accuracy. According to the various states of dysfunctional myocardium, some segments with reversible dysfunction are poorly or not identified by dobutamine echocardiography. It was thus important to investigate the accuracy of dobutamine stress echocardiography in predicting functional recovery in dysfunctional myocardium. The second part of this work compared the relative performance of PET and dobutamine stress echocardiography (DbE). In this respect, the data indicate that DbE and PET have a comparable diagnostic performance. We have also demonstrated that DbE could not only identify regional reversibility but also could predict global functional improvement. Thus, dobutamine stress echocardiography is a suitable tool to assess the reversibility of both regional and global ventricular dysfunction. Finally, the presence of reversible myocardial dysfunction and global improvement in ventricular function will only be clinically meaningful if they modify the prognosis of the patients. In the third part of this work, we have established that patients with viable myocardium who underwent revascularization have a better prognosis than these without viable myocardium or these treated medically. This was particularly true for patient with multivessel disease and diabetes. In patients with heart failure and severely depressed left ventricular function (< 25% ejection fraction), those in whom heart transplantation is frequently contemplated, the usefulness of revascularization remains an open question. Our data suggest that in these patients identification of viable myocardium by DbE allows the identification of those in whom prognosis will be improved by revascularization. At the opposite, patients without viable myocardium have a poor prognosis despite revascularization.Thèse de doctorat en sciences médicales (cardiologie) (MED 3) -- UCL, 200