Application of recommended therapies among patients with heart failure during the Syrian conflict : reality and barriers

Aims Lower socio-economic status may delay and even prevent the application of guideline-directed heart failure (HF) therapy for most patients. This study aims to evaluate the feasibility and possible difficulties facing the application of this treatment during the current Syrian conflict. Methods and results A questionnaire on HF management and feasibility of recommended HF therapy was addressed to physicians practising cardiology in Syria. The questionnaire consisted of 30 questions and focused on the quality of HF management and awareness of recommended drug and device therapy for HF among physicians practising cardiology in Syria. A total of 228 physicians participated in the survey. Awareness of recommended medical and device therapy of HF was very high among participants (98% and 95%, respectively). The majority of participants (>75%) believe that more than half of HF patients do not receive optimal medical HF therapy. Ninety per cent of participants believe that <10% of patients with an appropriate indication for device therapy receive it. More than 75% of participants believe that the cost of medications, alone or in combination with other medical causes, represents the major problem facing the application of optimal HF medical therapy. More than 95% of participants reported that cost alone, or in combination with unavailability, is the primary reason why patients with appropriate indications are not offered device therapy. Conclusions Despite the high level of awareness of recommended HF therapies among Syrian cardiologists, the majority of HF patients are still undertreated. Financial difficulties and lack of resources are the main causes of this problem

Inclusion in the World Health Organization Model List of Essential Medicines of Non-Vitamin K Anticoagulants for Treatment of Non-Valvular Atrial Fibrillation: A Step Towards Reducing the Burden of Cardiovascular Morbidity and Mortality.

Non-vitamin K antagonist oral anticoagulants (NOACs) represent a paradigm shift in the treatment of non-valvular atrial fibrillation (AF) with major practice guidelines around the world recommending NOACs over vitamin K antagonist oral anticoagulants for initial treatment of AF for stroke prevention. Here we describe the evidence collated and the process followed for the successful inclusion of NOACs into the 21st WHO Model List of Essential Medicines (EML). Individual NOACs have been reported to be non-inferior or superior to warfarin in preventing stroke and systemic embolism in eligible AF patients with a reduction in the risk of stroke and systemic embolism and a lower risk of major bleeding in patients with non-valvular AF compared with warfarin in both RCTs and real-world data. The successful inclusion of NOACs in the WHO EML is an important step forward in the global fight against cardiovascular morbidity and mortality, especially in low- and middle-income countries, where the burden of disease is high and limited access to diagnosis and treatment translates into a higher burden of morbidity, mortality, and economic costs

Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume–pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference

Echocardiography Markers Of myocardial tissue Deformation as Independent predictors of rhythm outcome after catheter ablation for Atrial Fibrillation

AF recurrence is common post catheter ablation. AF recurrence is associated with symptomatic deterioration, thromboembolic events, hospital admissions and worse prognosis. Therefore, definition of an accurate and easily obtainable predictor of AF recurrence is of crucial importance. AF is associated with left atrial (LA) structural remodeling and functional deterioration due to a variable degree of myocardial hypertrophy, disarray, apoptosis and fibrosis. In clinical practice, M mode and B mode echocardiography-derived indices of LA size are routinely used to assess left atrium (LA). However, these parameters have important limitations to describe complex myocardial changes associated with AF. Speckle tracking is an echocardiographic technique which has gradually gained relevance in the last decade. Quantification of myocardial deformation based on SLE overcomes most of the limitations of classic echocardiography and provides an early detection of myocardial funticonal impairment. Today, its feasibility and usefulness to measure LA function are highly supported by literature and several studies demonstrated that STE could provide additional prognostic information beyond conventional echocardiographic parameters. Recent advances in echocardiography equipment and image post-processing allow an assessment of LA strain and strain rate. The speckle-tracking echocardiography (STE)-derived LA longitudinal strain has been shown to be an accurate and reproducible parameter to evaluate LA longitudinal shortening. Furthermore, LA strain has significantly correlated with underlying LA fibrosis. A recent standardization of speckle tracking analysis regarding all cardiac chambers supported the integration of STE in diagnostic and prognostic protocols in daily practice. This suggests that LA strain provides a comprehensive and quantitative assessment of LA structure and function. Hence, it is tempting to speculate that the analysis of LA strain will show high accuracy to predict AF recurrence post catheter ablation. However, LA strain can be affected by several factors not related to LA structural damage such as loading conditions or arrhythmias. Moreover, in the real-world setting, the value of LA strain to predict AF recurrence following catheter ablation is not known. Therefore, the aim of the present study is fourfold: (1. To evaluate feasibility of STE-derived strain assessment in patients undergoing catheter ablation for paroxysmal or persistent AF. (2. To determine the acute effect of catheter ablation on LA structure and function. (3. To define echocardiographic predictors of AF recurrence during long-term follow-up. (4. To define the role of LA strain in the diagnosis of HFpEF in patients with history of AF

Imaging of Myocardial Fibrosis and Its Functional Correlates in Aortic Stenosis: A Review and Clinical Potential

Patients with severe aortic stenosis (AS) show progressive fibrotic changes in the myocardium, which may impair cardiac function and patient outcomes even after successful aortic valve replacement. Detection of patients who need an early operation remains a diagnostic challenge as myocardial functional changes may be subtle. In recent years, speckle tracking echocardiography (STE) and cardiac magnetic resonance mapping have been shown to provide complementary information for the assessment of left ventricular mechanics and identification of subtle damage by focal or diffuse myocardial fibrosis, respectively. Little is known, however, about how focal and diffuse myocardial fibrosis occurring in severe AS are related to measurable functional changes by echocardiography and to which extent both parameters have prognostic and diagnostic value. The aims of this review are to discuss the occurrence of focal and diffuse myocardial fibrosis in patients with severe AS and to explore their relation with myocardial function, determined by STE, as well as the prognostic and diagnostic potential of both parameters

P6469Catheter ablation during sinus rhythm is associated with acute loss of left atrial contractile function in paroxysmal atrial fibrillation: a strain study

Background: Catheter ablation is the recommended treatment in patients with paroxysmal atrial fibrillation (AF). However, the data on acute effects of catheter ablation on left atrial (LA) contractile function are scarce. Therefore, the purpose of the study was twofold:Purpose: Firstly, to describe acute effects of catheter ablation on LA contractile function in patients with paroxysmal AF and in sinus rhythm at the time of ablation. Secondly, to assess potential value of different indices of LA morphology and function.Background: Catheter ablation is the recommended treatment in patients with paroxysmal atrial fibrillation (AF). However, the data on acute effects of catheter ablation on left atrial (LA) contractile function are scarce. Therefore, the purpose of the study was twofold:Purpose: Firstly, to describe acute effects of catheter ablation on LA contractile function in patients with paroxysmal AF and in sinus rhythm at the time of ablation. Secondly, to assess potential value of different indices of LA morphology and function.status: Published onlin

Fractional flow reserve in patients with reduced ejection fraction

Fractional flow reserve (FFR) has never been investigated in patients with reduced ejection fraction and associated coronary artery disease (CAD). We evaluated the impact of FFR on the management strategies of these patients and related outcomes

Inter‐center reproducibility of standard and advanced echocardiographic parameters in the EACVI‐AFib echo registry

International audienceAim: we sought to test the inter-center reproducibility of 16 echo laboratories involved in the EACVI-Afib Echo Europe.Methods: This was done on a dedicated setting of 10 patients with sinus rhythm (SR) and 10 with persistent atrial fibrillation (AF), collected by the Principal Investigator. Images and loops of echo-exams were stored and made available for labs. The tested measurements included main echo-Doppler parameters, global longitudinal strain (GLS) and peak atrial longitudinal strain (PALS).Results: Single measures interclass correlation coefficients (ICCs) of left ventricular mass and ejection fraction were suboptimal in both patients with SR and AF. Among diastolic parameters, ICCs of deceleration time were poor, in particular in AF (=.50). ICCs of left atrial size and function, besides optimal in AF, showed an acceptable despite moderate concordance in SR. ICC of GLS was .81 and .78 in SR and AF respectively. ICCs of PALS were suitable but lower in 4-chamber than in 2-chamber view. By depicting the boxplot of the 16 laboratories, GLS distribution was completely homogeneous in SR, whereas GLS of AF and PALS of both SR and AF presented a limited number of outliers. GLS mean ± SE of the 16 labs was 19.7 ± .36 (95% CI: 18.8-20.4) in SR and 16.5 ± .29 (95% CI: 15.9-17.1) in AF, whereas PALS mean ± SE was 43.8 ± .70 (95% CI: 42.3-45.3) and 10.2 ± .32 (95% CI: 9.5-10.9) respectively.Conclusion: While the utilization of some standard-echo variables should be discouraged in registries, the application of GLS and PALS could be largely promoted because their superior reproducibility, even in AF