Pacing stress echocardiography: an alternative to pharmacologic stress testing

AbstractOBJECTIVESWe sought to evaluate the diagnostic accuracy and feasibility of bedside pacing stress echocardiography (PASE) as a potential substitute for pharmacologic stress echocardiography in patients admitted to the hospital with new-onset chest pain or worsening angina pectoris.BACKGROUNDAccurate and rapid noninvasive identification and evaluation of the extent of coronary artery disease (CAD) is essential for optimal management of these patients.METHODSBedside transthoracic stress echocardiography was performed in 54 consecutive patients admitted to a community hospital with new-onset chest pain, after acute myocardial infarction had been excluded. We used 10F transesophageal pacing catheters and a rapid and modified pacing protocol. The PASE results were validated in all patients by coronary angiography performed within 24 h of the test. Significant CAD was defined as ≥75% stenosis in at least one major epicardial coronary artery.RESULTSThe sensitivity of PASE for identifying patients with significant CAD was 95%, specificity was 87% and accuracy was 92%. The extent of significant CAD (single- or multivessel disease) was highly concordant with coronary angiography (kappa = 0.73, p < 0.001). Pacing stress echocardiography was well tolerated, and only 4% of the patients had minor adverse events. The mean rate–pressure product at peak pacing was 22,313 ± 5,357 beats/min per mm Hg, and heart rate >85% of the age-predicted target was achieved in 94% of patients. The average duration of the bedside PASE test, including image interpretation, was 38 ± 6 min.CONCLUSIONSBedside PASE is rapid, tolerable and accurate for identification of significant CAD in patients admitted to the hospital with new-onset chest pain or worsening angina pectoris

A Linear Finite Element Acoustic Fluid-Structure Model of Ultrasonic Angioplasty in Vivo

The delivery of high-power ultrasonic energy via small diameter wire waveguides represents a new alternative therapy for the treatment of chronic totally occluded arteries (CTOs). This type of energy manifests itself as a mechanical vibration at the distal-tip of the waveguide with amplitudes of vibration up to 60 µm and at frequencies of 20- 50 kHz. Disruption of diseased tissue is reported to be a result of direct mechanical ablation, cavitation, pressure components and acoustic streaming and that ablation was only evident above the cavitation threshold. This work presents a linear finite element acoustic fluid-structure model of an ultrasonic angioplasty waveguide in vivo. The model was first verified against a reported analytical solution for an oscillating sphere. It was determined that 140 elements per wavelength (EPW) were required to predict the pressure profile generated by the wire waveguide distal-tip. Implementing this EPW count, the pressure field surrounding a range of distal-tip geometries was modelled. For validation, a model was developed with parameters based on a bench-top experiment from the literature of an ultrasonic wire waveguide in a phantom leg. This model showed good correlation with the experimental measurements. These models may aid in the further development of this technology

Design and baseline characteristics of the finerenone in reducing cardiovascular mortality and morbidity in diabetic kidney disease trial

Background: Among people with diabetes, those with kidney disease have exceptionally high rates of cardiovascular (CV) morbidity and mortality and progression of their underlying kidney disease. Finerenone is a novel, nonsteroidal, selective mineralocorticoid receptor antagonist that has shown to reduce albuminuria in type 2 diabetes (T2D) patients with chronic kidney disease (CKD) while revealing only a low risk of hyperkalemia. However, the effect of finerenone on CV and renal outcomes has not yet been investigated in long-term trials. Patients and Methods: The Finerenone in Reducing CV Mortality and Morbidity in Diabetic Kidney Disease (FIGARO-DKD) trial aims to assess the efficacy and safety of finerenone compared to placebo at reducing clinically important CV and renal outcomes in T2D patients with CKD. FIGARO-DKD is a randomized, double-blind, placebo-controlled, parallel-group, event-driven trial running in 47 countries with an expected duration of approximately 6 years. FIGARO-DKD randomized 7,437 patients with an estimated glomerular filtration rate >= 25 mL/min/1.73 m(2) and albuminuria (urinary albumin-to-creatinine ratio >= 30 to <= 5,000 mg/g). The study has at least 90% power to detect a 20% reduction in the risk of the primary outcome (overall two-sided significance level alpha = 0.05), the composite of time to first occurrence of CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. Conclusions: FIGARO-DKD will determine whether an optimally treated cohort of T2D patients with CKD at high risk of CV and renal events will experience cardiorenal benefits with the addition of finerenone to their treatment regimen. Trial Registration: EudraCT number: 2015-000950-39; ClinicalTrials.gov identifier: NCT02545049

Cardiopoietic cell therapy for advanced ischemic heart failure: results at 39 weeks of the prospective, randomized, double blind, sham-controlled CHART-1 clinical trial

Cardiopoietic cells, produced through cardiogenic conditioning of patients' mesenchymal stem cells, have shown preliminary efficacy. The Congestive Heart Failure Cardiopoietic Regenerative Therapy (CHART-1) trial aimed to validate cardiopoiesis-based biotherapy in a larger heart failure cohort

Stress-Induced Cardiomyopathy&mdash;Considerations for Diagnosis and Management during the COVID-19 Pandemic

The novel coronavirus disease 2019 (COVID-19) is associated with several cardiovascular manifestations including myocardial injury, myocarditis, arrhythmia, and pulmonary embolism. Rare cases of stress-induced cardiomyopathy, or takotsubo syndrome have also been reported during the acute infection, and secondary to stress following lockdown and self-isolation. Diagnosis in the setting of the acute infection is challenging since conventional imaging modalities such as transthoracic echocardiography and coronary angiography should be restricted to minimize physician-patient contact until the patients is tested negative for COVID-19. The use of point of care hand-held ultrasound is appropriate for this purpose. The overall course of the disease seems to be similar to takotsubo in the general population. Physicians should be familiar with the clinical presentation, possible complications, and management of takotsubo during COVID-19 outbreak. Here, we review the special considerations in the diagnosis and management of takotsubo syndrome during the current pandemic

The Prognostic Value of Natriuretic Peptides in Stable Patients with Suspected Acute Myocarditis: A Retrospective Study

Risk stratification in acute myocarditis is based on the clinical signs of heart failure, the degree of cardiac dysfunction, and the findings in cardiac magnetic resonance (CMR). The aim of the current study is to examine the prognostic yield of the natriuretic peptide N-terminal-pro hormone Brain Natriuretic Peptide (NT-proBNP) and C-reactive protein (CRP) in acute myocarditis among patients with preserved/mildly reduced left ventricular ejection fraction (LVEF). We retrospectively analyzed 59 patients (median age 28 years, 76% males) with ICD-9 discharge diagnosis of acute myocarditis. Basic characteristics, echocardiographic, and laboratory parameters were obtained from computerized files. The median length of stay was 3, (IQR 2&ndash;5) days, and the median LVEF was 48% (IQR, 54&ndash;62%). High levels of NT-proBNP and CRP were associated with increased length of stay (r = 0.57, p &lt; 0.001; r = 0.4 p = 0.001, respectively), while troponin level was not (r = 0.068, p = 0.61). During the index hospitalization, complications occurred in 14 (23.7%) patients. High NT-proBNP and CRP levels were associated with complications (p &lt; 0.001, and p = 0.001, respectively), while troponin level was not (p = 0.452). In conclusion, routine measurement of NT-proBNP and CRP are preferred over troponin for risk stratification in hemodynamically stable myocarditis

Sodium-Glucose Co-Transporter 2 Inhibitors in Heart Failure—Current Evidence in Special Populations

Sodium-glucose co-transporter 2 (SGLT2) inhibitors, originally used for diabetes mellitus, are gaining more popularity for other indications, owing to their positive cardiovascular and renal effects. SGLT2 inhibitors reduce heart failure (HF) hospitalization and improve cardiovascular outcomes in patients with type 2 diabetes. Later, SGLT2 inhibitors were evaluated in patients with HF with reduced ejection fraction (HFREF) and had beneficial effects independent of the presence of diabetes. Recently, reductions in cardiovascular outcomes were also observed in patients with HF with preserved ejection fraction (HFPEF). SGLT2 inhibitors also reduced renal outcomes in patients with chronic kidney disease. Overall, these drugs have an excellent safety profile with a negligible risk of genitourinary tract infections and ketoacidosis. In this review, we discuss the current data on SGLT2 inhibitors in special populations, including patients with acute myocardial infarction, acute HF, right ventricular (RV) failure, left ventricular assist device (LVAD), and type 1 diabetes. We also discuss the potential mechanisms behind the cardiovascular benefits of these medications

Management of Patients with Left Ventricular Assist Device during the COVID-19 Pandemic

The novel coronavirus disease 2019 (COVID-19) is an infectious disease with multi-organ involvement, including the cardiovascular system. The disease may cause several cardiovascular complications, and may increase morbidity and mortality among patients with background cardiovascular disease. Patients with advanced heart failure are often treated with left ventricular assist device (LVAD), and represent a unique population mandating multi-disciplinary approach. Several aspects of COVID-19 should be taken into account in LVAD implants, including right ventricular involvement, hemodynamic alterations, thromboembolic and haemorrhagic complications, and the psychological effects of social isolation. Patients with VAD and suspected COVID-19 should be transferred to specialized centers for better management of complications. Here, we review the implications of COVID-19 pandemic on LVAD patients with our recommendations for appropriate management

The Role of Stress in Stable Patients with Takotsubo Syndrome&mdash;Does the Trigger Matter?

Background: Takotsubo syndrome (TTS) is a unique type of reversible cardiomyopathy that predominantly affects elderly women. The role of physical and emotional stress in the pathophysiology of TTS is well established. However, the association between preceding emotional triggers and clinical outcomes in stable patients has not yet been fully investigated. We aimed to investigate the association between emotional triggers before symptom onset and clinical outcomes in stable patients with TTS. Methods: This is a retrospective cohort study based on the data of patients with ICD-9 discharge diagnosis of TTS between 2017 and 2022. Patients were divided into two groups: with and without obvious emotional trigger before symptom onset. Demographic, laboratory, echocardiographic, and clinical outcomes were obtained and compared between the two groups. Results: We included 86 patients (93% were women, mean age 68.8 &plusmn; 12.3 years). Of them, 64 (74.4%) reported an emotional trigger before symptom onset. Patients with a previous emotional trigger had a longer hospital stay (4.3 + 2.0 days vs. 3.0 + 1.4, p = 0.002) with no difference in in-hospital complications (32.8% vs. 13.6%, p = 0.069), with no difference in 30-day mortality, readmissions, or recurrence rate between the groups. Conclusions: Patients with TTS related to an emotional trigger may represent a different population from patients without a preceding trigger by having more symptomatic disease and longer hospital stay, yet with no difference in the 30-day outcomes