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

Revascularization methods in patients with carotid stenosis and concomitant coronary heart disease

A major feature of the atherosclerotic process is its systemic and progressive character. The plaque pathogenetic mechanisms, morphology, evolution, and predilection site (bifurcation zones) determine the frequent coincidence of carotid and coronary atherosclerosis in the same patient. The present overview chronologically traces the history, effectiveness, and benefit of surgical and continuously improving interventional carotid revascularization. It thereby analyzes the indications, results, and complications based on a number of randomized clinical trials, industry-sponsored registries, and large single-center series in the last 3 decades. Carotid endarterectomy (CEA) and percutaneous carotid angioplasty (CAS) have evolved from ‘dubious’ procedures to a modern strategy resulting in a significantly lower incidence of stroke and death compared to medical treatment only. Although almost every second patient with carotid stenosis and indications for CAS has coronary atherosclerosis, studies on therapeutic modeling in such a combination are few, showing controversial results. Having both CHD and CS doubles the risk of myocardial infarction, stroke, HF, and death. An isolated revascularization approach compromises the results of therapeutic strategies and worsens patient survival. The high risk associated with coronary heart disease in CAS and CEA is a fact and minimization requires both an individualized and uniform stepwise revascularization strategy

An Incidental Finding of Heart Echinococcosis in a Patient with Infective Endocarditis: a Case Report

Echinococcosis is a cosmopolitan zoonotic parasitic disease caused by infection with the larval stage of tapeworms from the Echinococcus genus, most commonly Echinococcus granulosus. According to WHO, more than 1 million people are affected by hydatid disease at any time.1 About 10% of the annual cases are not officially diagnosed.2 In humans, the disease is characterized by development of three-layered cysts. The cysts develop primarily in the liver and the lungs, but can also affect any other organ due to the spreading of the oncospheres. Cardiac involvement is very uncommon - only about 0.01-2% of all cases.4,5 In most cases, the cysts develop asymptomatically, but heart cysts could manifest with chest pain, dyspnea, cough, hemophtisis and can complicate with rupture. Diagnosis is based on a number of imaging techniques and positive serological tests. Treatment for cardiac localization is almost exclusively surgical

Diagnostic benefits of 18F-FDG PET/CT in cases of prosthetic infective endocarditis

Infective endocarditis (IE) is a difficult-to-diagnose provocative disease that causes significant morbidity and mortality. The first-line imaging test for the diagnosis of IE is echocardiography. However, in cases of prosthetic IE or IE associated with intracardiac devices, its sensitivity is limited. A new diagnostic tool, 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT), improves diagnosis in these difficult cases. The most recent European guidelines for IE (2015) include this imaging modality as a primary diagnostic criterion. We present a case of culture-negative prosthetic IE diagnosed with 18F-FDG PET/CT

A case of acute infective endocarditis and septic shock

Инфекциозният ендокардит (ИЕ) бележи нарастваща заболяемост и непроменяща се смъртност въпреки напредъка в диагностиката и лечението му. При около 20% от случаите ИЕ протича остро, с признаци на сепсис и септичен шок, който влошава драматично прогнозата и е независим предиктор за вътреболнична смърт. Навременното диагностициране и спешната хирургична интервенция могат да подобрят преживяемостта при тези пациенти. Представяме случай на 47-годишен мъж, без анамнеза за минали или съпътстващи заболявания, постъпил по спешност в Интензивно кардиологично отделение, по време на COVID-19 пандемията, с изразен фебрилно-интоксикационен синдром, задух, прекордиален дискомфорт и болка, кашлица, хемоптое. От лабораторните изследвания има данни за изразена възпалителна констелация, също така увеличени тропонин I и D-димери. Този случай показва трудностите в диагностиката на острия ИЕ, спецификите в клиничния ход на болестта, както и значението на спешната хирургична интервенция за подобряване на преживяемостта. Infective endocarditis (IE) marks an increasing morbidity and unchanged mortality despite advances in its diagnosis and treatment. In about 20% of IE cases are acute, with signs of sepsis and septic shock. Septic shock dramatically worsens prognosis and is an independent predictor of in – hospital death. Timely diagnosis and urgent surgical intervention can improve survival in these patients. We present a case of a 47-year-old man, with no history of past or concomitant diseases, who was admitted as an emergency to the Cardiology Intensive Care Unit, during the COVID-19 pandemic, with pronounced febrile-intoxication syndrome, shortness of breath, precordial discomfort and pain, cough, haemoptysis. From laboratory studies with a pronounced infl ammatory constellation, troponin I and D-dimers are also increased. This case shows the diffi culties in the diagnosis of acute IE, the specifi cs in the clinical course of the disease, as well as the importance of urgent surgical intervention to improve survival

Acute neurological symptoms as a debut of infective endocarditis

Инфекциозният ендокардит (ИЕ) е възпалително заболяване на ендокарда на сърцето, засягащо сърдечните клапи (нативни или протезни), а в последните няколко десетилетия и налични вътресърдечни постоянни устройства или катетри. Въпреки технологичния прогрес и натрупания опит, тази болест не спира да бъде огромно предизвикателство за лекарите по отношение на диагностика, лечение и подобряване на преживяемостта. Клиничната картина е нетипична и разнородна, с различни клинични „маски“ на други заболявания – инфекциозни, онкологични, хематологични, ревматологични, неврологични и др. Емболичните усложнения често са първа изява на болестта, като най-често са мозъчни. Представяме клиничен случай на 29 г. жена, с остра неврологична симптоматика като първа проява на ИЕ. Този случай отразява нетипичната клинична презентация на заболяването, значението на новите образни модалности в прецизната диагностика на неврологичнте усложнения, както и решението за времето на оперативната интервенция, когато е покзана. Остава отворен въпросът за профилактиката на ИЕ при умеренорисковите пациенти, каквито са тези с митрален клапен пролапс и бикуспидна аортна клапа. Infective endocarditis (IE) is an infl ammatory disease of the endocardium of the heart affecting heart valves (native or prosthetic) and, in the last few decades, also available intracardiac permanent devices or catheters. Despite technological progress and accumulated experience, this disease continues to be a huge challenge for doctors in terms of diagnosis, treatment and improvement of survival. The clinical picture is atypical and heterogeneous, with different clinical "masks" of other diseases – infectious, oncological, hematological, rheumatological, neurological, etc. Embolic complications are often the fi rst manifestation of the disease and are most often cerebral. We present a clinical case of a 29-year-old woman with acute neurological symptoms as a fi rst manifestation of IE. This case refl ects the atypical clinical presentation of the disease, the importance of new imaging modalities for the precise diagnosis of neurological complications, and the decision on the timing of operative intervention when indicated. The question of IE prophylaxis in moderate-risk patients, such as those with mitral valve prolapse and bicuspid aortic valve, remains open

Characteristics of infective endocarditis according to the mode of acquisition – a single-center, retrospective analysis

Според начина на придобиване инфекциозният ендокардит (ИЕ) се класифицира като обществено придобит – CAIE (Community acquired IE), свързан със здравни грижи – HAIE (Health care–associated infective endocarditis) и ИЕ, резултат на интравенозна наркомания – IDUIE (intravenous drug use–related IE). На този етап липсват данни за България за тези три групи пациенти. Цел: Поставихме си за цел да изследваме ИЕ според начина на придобиване и да направим клинико-инструментална характеристика на групите. Материал и методи: Проучването е едноцентрово, ретроспективно и включва 270 пациенти, лекувани в УМБАЛ “Св. Георги“ – Пловдив, за периода 01.2005-12.2021 г. Резултати: Пациенти със CAIE са 64.8% (175), с HAIE 26,7% (72) и с IDUIE 8,5% (23). Пациентите с IDUIE са по-млади спрямо останалите две групи – 33 (8) г. (р = 0.000), с ниска коморбидност (CCI – 1, IQR 1; p = 0.000), с най-често десностранно засягане (p < 0.001), с често усложнение септичен шок – 21.7% (р = 0.017) и с най-чест причинител Staphylococcus aureus (р < 0.01). Пациентите с HAIE са най-възрастни (69; 18 г.), с най-голяма коморбидност (CCI 4, IQR 3), без сигнификантна разлика със CAIE (66; 20 г. и CCI 3 IQR 3). Големият дял входна врата при тях са манипулации/процедури (62.5%) и хемодиализа (18.1%), с най-чест причинител Enterococci (19.5%, р = 0.001). CAIE се причинява най-често от Staphylococci (29.6%) и Streptococci (12%). Вътреболничната смъртност и ранната хирургична интервенция са без сигнификантна разлика в трите групи. Заключение: Познаването на трите групи ИЕ според начина на придобиване – CAIE, HAIE и IDUIE, и техните характеристики, е важно за избора на начално емпирично антибиотично лечение и подобряване на превенцията. According to the mode of acquisition, infective endocarditis (IE) is classifi ed as community-acquired (CAIE), healthcareassociated (HAIE), and injection drug use–related IE (IDUIE). At this stage, there are no data for Bulgaria for these three groups of patients. Objective: We set ourselves the goal of investigating IE according to the mode of acquisition and to make a clinical-instrumental characterization of the groups. Material and methods: The study is single-center, retrospective and includes 270 patients treated at the UMHAT “Sveti Georgi” – Plovdiv for the period 01.2005-12. 2021. Results: Patients with CAIE were 64.8% (175), with HAIE 26.7% (72) and with IDUIE 8.5% (23). Patients with IDUIE are younger compared to the other two groups (33; 8 years) (p = 0.000), with low comorbidity (CCI – 1, IQR – 1; p = 0.000), with most frequent right-sided involvement (p < 0.001) and with the most common causative agent being Staphylococcus aureus (p < 0.01). Patients with HAIE were the oldest (69; 18 years;), with the most comorbidity (CCI – 4; IQR – 3), with no signifi cant difference with CAIE (66; 20 years; and CCI – 3; IQR – 3). The large proportion of portal of entry for them were manipulations/ procedures (62.5%) and hemodialysis (18.1%), with Enterococci being the most common causative agent (19.5%, p = 0.001). In-hospital mortality and early surgical intervention were without signifi cant difference in the three groups. Conclusion: Knowledge of the three groups of IE according to the mode of acquisition – CAIE, HAIE and IDUIE and their characteristics is important for the choice of initial empiric antibiotic treatment and for improvement of prevention

Management of High and Very High-Risk Subjects with Familial Hypercholesterolemia: Results from an Observational Study in Bulgaria

Background: Familial hypercholesterolaemia (FH) is a genetic disorder causing accelerated atherosclerosis and premature cardiovascular disease (CVD). This retrospective observational study examined the clinical characteristics and management of FH subjects in Bulgaria over a 12-month period

Diagnostic algorithm in transthyretin amyloidosis with cardiomyopathy

Транстиретиновата сърдечна амилоидоза е рестриктивна кардиомиопатия (ATTR-КМП), резултат от извънклетъчно натрупване на неразтворими транстиретинови амилоидни фибрили в миокарда, има прогресиращ ход и е възможен летален изход в рамките на 2-6 години от поставяне на диагнозата. Бива два вида – наследствена и див тип. Данни от последните години показват, че дивият тип АТТР-КМП е относително честа причина за сърдечна недостатъчност със запазена фракция на изтласкване, особено при по-възрастни мъже. В същото време в България, наследствената транстиретинова амилоидоза не е толкова рядка. Диагностицирни са пет различни патологични мутации. Най-разпространена е р.Glu89Gln, като по данни от юни 2019 г има установени 62 несвързани семейства с 117 пациенти и 72 носители. Диагнозата АТТР-КМП често се поставя със закъснение или се пропуска, а нейното ранно диагностициране е изключително важно, тъй като има одобрен медикамент (стабилизатор на транстиретина), който е по-ефикасен приложен в начален стадий на заболяването. Други медикаменти са в клинични изпитания. Диагностицирането на АТТР-КМП е процес, който изисква мултидисциплинарен подход с участието на подготвени специалисти, мултимодална образна диагностика, добре оборудвани хистопатологична и генетична лаборатории. Изграждането на експертни центрове на функционален принцип би могло да допринесе за по-ранното откриване, своевременното лечение и проследяването на пациентите с АТТР-КМП, което съответно да подобри тяхната прогноза. Transthyretin cardiac amyloidosis is a restrictive cardiomyopathy ((ATTR-CM), caused by an extracellular deposition of insoluble amyloid fibrils in the myocardium. It is a life threatening disease with life expectancy of 2 to 6 years after diagnosis. There are two types – hereditary and wild type. Recent data reveal that the wild type ATTR-CM is a common cause of heart failure with preserved ejection fraction, especially in elderly men. Hereditary ATTR amyloidosis is not so rare in Bulgaria. Five different mutations have been diagnosed, the most common being p.Glu89Gln, identified in 62 unrelated families with 117 patients and 72 mutation carriers. ATTR-CM diagnosis is often delayed or even missed, however its early recognition has become very important as a new drug, which is a transthyretin stabilizer is now available and other drugs are under development. Updated knowledge about the clinical presentation, diagnostic algorithm, available and future therapeutic options for ATTR-CM are a prerequisite for an early identification, timely treatment and better prognosis of the affected patients. The diagnosis requires a multidisciplinary approach with the participation of experienced specialists, multimodality imaging, well equipped histopathological and genetic laboratories. Establishing centres of expertise could improve the management of the patients with ATTR-CM

Community Noise Exposure and its Effect on Blood Pressure and Renal Function in Patients with Hypertension and Cardiovascular Disease

Background: Road traffic noise (RTN) is a risk factor for cardiovascular disease (CVD) and hypertension; however, few studies have looked into its association with blood pressure (BP) and renal function in patients with prior CVD