Implantation of the coronary sinus reducer for refractory angina due to coronary microvascular dysfunction in the context of apical hypertrophic cardiomyopathy-a case report

Background: Refractory angina leads to a poor quality of life and increased healthcare resource utilization. In this growing population of patients, multiple mechanism(s) of ischaemia may co-exist, including functional disorders of the coronary microcirculation. There are few evidence-based effective therapies resulting in a large unmet clinical need. Case summary: A 38-year-old woman with refractory angina was referred with daily chest pain despite multiple anti-anginal medications and previous percutaneous coronary intervention. Cardiac magnetic resonance imaging demonstrated apical hypertrophic cardiomyopathy (HCM). Rubidium-82 positron emission tomography (PET) with regadenoson stress confirmed significant myocardial ischaemia in the apex and apical regions (16% of total myocardium) with a global myocardial perfusion reserve (MPR) of 1.23. Coronary angiography confirmed patent stents and no epicardial coronary artery disease. Therefore, the mechanism of ischaemia was thought attributable to coronary microvascular dysfunction (CMD) in the context of HCM. In view of her significant symptoms and large burden of left-sided myocardial ischaemia, a Coronary Sinus Reducer (CSR) was implanted. Repeat PET imaging at 6 months showed a marked reduction in ischaemia (<5% burden), improvement in global MPR (1.58), symptoms, and quality of life. Conclusion: In refractory angina, ischaemia may be due to disorders of both the epicardial and coronary microcirculations. The CSR is a potential therapy for these patients, but its mechanism of action has not been confirmed. This report suggests that CSR implantation may reduce myocardial ischaemia and improve symptoms by acting on the coronary microcirculation. The efficacy of CSR in patients with CMD and its mechanism of action on the coronary microcirculation warrant further investigation

How to develop a national heart failure clinics network: a consensus document of the Hellenic Heart Failure Association

Heart failure (HF) is rapidly growing, conferring considerable mortality, morbidity, and costs. Dedicated HF clinics improve patient outcomes, and the development of a national HF clinics network aims at addressing this need at national level. Such a network should respect the existing health care infrastructures, and according to the capacities of hosting facilities, it can be organized into three levels. Establishing the continuous communication and interaction among the components of the network is crucial, while supportive actions that can enhance its efficiency include involvement of multidisciplinary health care professionals, use of structured HF-specific documents, such as discharge notes, patient information leaflets, and patient booklets, and implementation of an HF-specific electronic health care record and database platform

Effect of blood glucose level on standardized uptake value (SUV) in F-18- FDG PET-scan : a systematic review and meta-analysis of 20,807 individual SUV measurements

Objectives To evaluate the effect of pre-scan blood glucose levels (BGL) on standardized uptake value (SUV) in F-18-FDG-PET scan. Methods A literature review was performed in the MEDLINE, Embase, and Cochrane library databases. Multivariate regression analysis was performed on individual datum to investigate the correlation of BGL with SUVmax and SUVmean adjusting for sex, age, body mass index (BMI), diabetes mellitus diagnosis, F-18-FDG injected dose, and time interval. The ANOVA test was done to evaluate differences in SUVmax or SUVmean among five different BGL groups (200 mg/dl). Results Individual data for a total of 20,807 SUVmax and SUVmean measurements from 29 studies with 8380 patients was included in the analysis. Increased BGL is significantly correlated with decreased SUVmax and SUVmean in brain (p <0.001, p <0.001,) and muscle (p <0.001, p <0.001) and increased SUVmax and SUVmean in liver (p = 0.001, p = 0004) and blood pool (p=0.008, p200 mg/dl had significantly lower SUVmax. Conclusion If BGL is lower than 200mg/dl no interventions are needed for lowering BGL, unless the liver is the organ of interest. Future studies are needed to evaluate sensitivity and specificity of FDG-PET scan in diagnosis of malignant lesions in hyperglycemia.Peer reviewe

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Right ventricular involvement in cancer therapy–related cardiotoxicity: the emerging role of strain echocardiography

The involvement of the right ventricle (RV) in various cardiovascular pathologies is usually explored and demonstrated after thorough research of the left ventricle (LV). This is also true in cardio-oncology, where multimodality imaging with cardiac magnetic resonance and nuclear imaging is essential, but echocardiography plays pivotal role in everyday clinical practice. Chemotherapy and radiotherapy effect on RV has been studied mainly in breast cancer patients and survivors from childhood cancer. Right ventricular geometry and shape limit the ability of classical echocardiographic indices like RV ejection fraction (RVEF), RV fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE) to identify reliably subtle changes in RV systolic function in cancer patients. The assessment of diastolic function of the RV in various timepoints during or after chemotherapy leads to conflicting results too. However, longitudinal strain of the RV (RV LS) seems to detect myocardial injury with consistent results. Remarkably, cardiotoxicity of the RV is identified by RV LS almost simultaneously with LV cardiotoxicity and with similar cutoff percent change suggesting the uniform effect of cancer and its treatments on myocardium. The prognostic value of cardiotoxic effects on the RV needs to be investigated by large prospective studies. © 2020, Springer Science+Business Media, LLC, part of Springer Nature

Right ventricular involvement in hypertrophic cardiomyopathy: Patterns and implications

Although hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy worldwide, the criteria for its definition and most of the literature concern the left ventricle, thus confirming the theory that the right ventricle is the neglected one. Right ventricular (RV) involvement includes structural and functional changes with significant impact on clinical presentation and prognosis. The pattern of RV hypertrophy can be variable with possible dynamic obstruction. Histological findings suggest similar pathogenetic changes in both ventricles supporting the common myopathic process with sarcomeric mutations. Systolic dysfunction of the RV is subtle, and the classical echocardiographic indices are usually within normal limits, while global longitudinal strain is significantly impaired. Diastolic dysfunction of the RV is also evident in patients with HCM possibly due to fibrosis of the RV free wall and/or the obstruction of the RV filling with significant prognostic implications. RV involvement in HCM is associated with increased incidence of supraventricular and ventricular arrhythmias, severe dyspnea, pulmonary thromboembolism, progressive heart failure, and increased risk of sudden cardiac death. Therefore, the RV should be routinely included in the detailed assessment of patients with HCM. © 2018 Hellenic Society of Cardiolog

Cardiogenic shock in cancer

Cardiogenic shock (CS) is increasingly recognized in patients with malignancies, while cancer is independently associated with worse prognosis in CS. A number of conditions may lead to CS in cancer, including acute coronary syndromes, cardiomyopathy, takotsubo syndrome, myocarditis, pulmonary embolism, tamponade, and cardiac herniation. In these conditions, CS may be related to cancer itself or to cancer therapy, including surgery, chemotherapy, or radiotherapy. Given the significantly improved overall survival of patients with malignancies, the early recognition and proper management of CS in cancer become increasingly important. In the present paper, we review the available evidence on CS in patients with malignancies and highlight issues related to its management. © 2019, Springer Science+Business Media, LLC, part of Springer Nature