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Introduction Serum brain-type natriuretic peptide (BNP) levels may be involved in detecting the breakdown of defense mechanisms in pregnant women. BNP and N-terminal pro-BNP (NT-proBNP) levels can be used in emergency settings as a biomarker to rule out or confirm cardiac complications. The present study was conducted as an attempt to evaluate the performance of BNP and NT-proBNP as diagnostic tools for cardiac complications, including heart failure and pre-eclampsia, in pregnant and recently-delivered women. Methods This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. To extract the data, articles meeting the inclusion criteria were directly reviewed by two of the authors. Disputes were resolved through discussion with all authors before data mining. In cases of unresolved disagreement, a third reviewer was consulted to achieve consensus. A quantitative analysis of the total bias of publications was performed using Stata software version 14.0, using funnel plots and Deek’s test. Results Overall, 13 unique studies were included in this review. The pooled sensitivity, specificity and positive and negative predictive values for diagnosing cardiac complications in pregnant women when BNP level was ≤ 100 ng/L, were determined to be 95, 62, 71 and 91%, respectively. The corresponding measures when the BNP levels were 100–500 ng/L were calculated to be 98, 92, 97 and 92%, respectively. The pooled sensitivity, specificity and positive and negative predictive values for diagnosing cardiac complications in pregnant women using NT-proBNP were 78, 74, 20.5 and 97%, respectively. Conclusion Our results suggest that both BNP and NT-proBNP levels can be used as diagnostic tools among pregnant and newly-delivered women to diagnose cardiac complications, including heart failure and pre-eclampsia. While BNP showed a relatively better diagnostic accuracy compared to NT-proBNP, it must be noted that the number of studies evaluating NT-proBNP included in this meta-analysis was low and the studies were inconsistent in terms of cutoff value. Further studies are required to confirm the prospective use of BNP and NT-pro BNP in assessing common symptoms that indicate cardiac complications during labor. Moreover, the clinical use of the NT-proBNP test in this field requires further study.

Growing reports since the beginning of the pandemic and till date describe increased rates of cardiac complications (CC) in the active phase of coronavirus disease 2019 (COVID-19). CC commonly observed include myocarditis/myocardial injury, arrhythmias and heart failure, with an incidence reaching about a quarter of hospitalized patients in some reports. The increased incidence of CC raise questions about the possible heightened susceptibility of patients with cardiac disease to develop severe COVID-19, and whether the virus itself is involved in the pathogenesis of CC. The wide array of CC seems to stem from multiple mechanisms, including the ability of the virus to directly enter cardiomyocytes, and to indirectly damage the heart through systemic hyperinflammatory and hypercoagulable states, endothelial injury of the coronary arteries and hypoxemia. The induced CC seem to dramatically impact the prognosis of COVID-19, with some studies suggesting over 50% mortality rates with myocardial damage, up from ~ 5% overall mortality of COVID-19 alone. Thus, it is particularly important to investigate the relation between COVID-19 and heart disease, given the major effect on morbidity and mortality, aiming at early detection and improving patient care and outcomes. In this article, we review the growing body of published data on the topic to provide the reader with a comprehensive and robust description of the available evidence and its implication for clinical practice.

BACKGROUND Pheochromocytoma is a rare endocrine tumor arising from chromaffin cells and having extensive and profound effects on the cardiovascular system by continuously or intermittently releasing catecholamines. The clinical manifestations of pheochromocytoma are diverse, and the typical triad, including episodic headache, palpitations, and sweating, only occurs in 24% of pheochromocytoma patients, which often misleads clinicians into making an incorrect diagnosis. We herein report the case of a patient with intermittent chest pain and elevated myocardial enzymes for 2 years who was diagnosed with pheochromocytoma. CASE SUMMARY A 49-year-old woman presented with intermittent chest pain for 2 years. Two years ago, the patient experienced chest pain and was diagnosed with acute myocardial infarction, with 25% stenosis in the left circumflex. The patient still had intermittent chest pain after discharge. Two hours before admission to our hospital, the patient experienced chest pain with nausea and vomiting, lasting for 20 min. Troponin I and urinary norepinephrine and catecholamine levels were elevated. An electrocardiogram indicated QT prolongation and ST-segment depression in leads II, III, aVF, and V3-V6. A coronary computed tomography angiogram revealed no evidence of coronary artery disease. Echocardiography showed left ventricular enlargement and a decreased posterior inferior wall motion amplitude. Contrast-enhanced computed tomography demonstrated an inhomogeneous right adrenal mass. The patient successfully underwent laparoscopic right adrenalectomy, and histopathology confirmed adrenal pheochromocytoma. During the first-year follow-up visits, the patient was asymptomatic. The abnormal changes on echocardiography and electrocardiogram disappeared. CONCLUSION Clinicians should be aware of pheochromocytoma. A timely and accurate diagnosis of pheochromocytoma is essential for alleviating serious cardiac complications.

Background Obesity is associated with cardiovascular (CV) risk factors and diseases. Because bariatric surgery is increasingly performed in relatively elderly patients, a risk for pre- and postoperative CV complications exists. Objectives We aimed to assess the value of plasma N-terminal-probrain natriuretic peptide (NT-proBNP) as a CV screening tool. Setting High-volume bariatric center. Methods Between June 2019 and January 2020, all consecutive bariatric patients 50 years and older underwent preoperative NT-proBNP assessment in this cohort study to screen for CV disease. Patients with elevated NT-proBNP (≥125 pg/mL) were referred for further cardiac evaluation, including electrocardiography and echocardiography. Results We included 310 consecutive patients (median age, 56 years; 79% female; body mass index = 43±6.5 kg/m2). A history of CV disease was present in 21% of patients, mainly atrial fibrillation (7%) and coronary artery disease (10%). A total of 72 patients (23%) had elevated NT-proBNP levels, and 67 of them underwent further cardiac workup. Of these 67 patients, electrocardiography (ECG) showed atrial fibrillation in 7 patients (10%). On echocardiography, 3 patients had left ventricular ejection fraction (LVEF), Highlights • This study assessed NT-proBNP as a cardiac screening tool in bariatric patients. • Elevated NT-proBNP levels were present in 23% of patients ≥50 years. • In 37% of them (n=25), echocardiography showed LV dysfunction or heart failure. • NT-proBNP is a non-invasive tool that can detect new CV diseases in bariatric patients

Worldwide, more than 200 million non-cardiac surgeries are performed annually, and this number is constantly increasing; cardiac complications are the leading cause of death in such surgeries. So, in a multicenter study conducted in 27 countries, cardiovascular complications were present in 68% of cases of death in the postoperative period. Registers of recent years have shown that the number of such complications remains high, for example, with a dynamic assessment of troponins, perioperative myocardial damage was detected in 13-18% of cases. This review provides a critical analysis of the step-by-step algorithm for assessing cardiac risk of non-cardiac operations considering the emergence of new publications on this topic. The review discusses new data on risk assessment scales, functional state assessment, the use of non-invasive tests, biomarkers, the role of preventive myocardial revascularization in the preoperative period, and drug therapy. The issues of non-cardiac operations after percutaneous coronary intervention, perioperative myocardial damage are considered separately. The review emphasizes the difficulties in obtaining evidence, conducting randomized clinical trials in this section of medicine, which do not allow obtaining unambiguous conclusions in most cases and lead to inconsistencies and ambiguities in the recommendations of various expert groups. This review will help practitioners navigate this issue and help to use the optimal diagnostic and treatment strategy before performing non-cardiac surgery.

Zijia Liu,1 Guangyan Xu,1 Li Xu,1 Yuelun Zhang,2 Yuguang Huang1 1Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People’s Republic of China; 2Central Research Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, People’s Republic of ChinaCorrespondence: Li Xu Tel +86 10 6915 2020Fax +86 10 6915 5580Email pumchxuli@163.comPurpose: Ever-increasing noncardiac surgeries are performed in patients aged 80 years or over with coronary artery disease (CAD). The objective of the study was to explore the incidence and risk factors of perioperative cardiac complications (PCCs) for the oldest-old patients with CAD undergoing noncardiac surgery, which have not been evaluated previously.Patients and Methods: A total of 547 patients, aged over 80 years, with a history of CAD who underwent noncardiac surgery were enrolled in this retrospective study. Perioperative clinical variables were extracted from the electronic medical records database. The primary outcome was the occurrence of PCCs intraoperatively or within 30 days postoperatively, defined as any of the following complications: acute coronary syndrome, heart failure, new-onset severe arrhythmia, nonfatal cardiac arrest, and cardiac death. Multivariate logistic regression analysis and multivariate Cox regression model were both performed to estimate the risk factors of PCCs. The incidence of PCCs overtime was illustrated by the Kaplan–Meier curve with a stratified Log-rank test.Results: One hundred six (19.4%) patients developed at least one PCC, and 15 (2.7%) patients developed cardiac death. The independent risk factors contributing to PCCs were age ≧85 years; body mass index ≧30 kg/m2; the history of angina within 6 months; metabolic equivalents < 4; hypertension without regular treatment; preoperative ST-T segment abnormality; anesthesia time > 3 h and drainage ≧200 mL within 24 h postoperatively.Conclusion: The incidence of PCCs in elderly patients over 80 years with CAD who underwent noncardiac surgery was high. Comprehensive preoperative evaluation, skilled surgical technique, and regular postoperative monitoring may help to reduce the occurrence of PCCs in this high-risk population.Keywords: oldest-old, coronary artery disease, noncardiac surgery, perioperative, cardiac complications

BACKGROUND: Cardiac complications are still the primary cause of mortality and a major cause of morbidity in thalassemia patients. OBJECTIVES: The aims of this study were to assess the prevalence of cardiac involvement in TDT and NTDT beta thalassemia patients and compare between the different forms and severity in both groups. MATERIALS AND METHODS: In this prospective study, 70 TDT and 50 NTDT β-thalassemia patients were recruited; their cardiac status was evaluated by transthoracic echocardiography as per the standard recommendations. Patients' cardiac status was evaluated against the causal risk factors. RESULTS: The mean serum ferritin level was significantly (P < 0.001) higher in the TDT patients (4940 ± 3643 ng/mL) compared to the NTDT patients (634 ± 520 ng/mL). The mean hemoglobin was significantly (P = 0.004) higher in the TDT group (9.2 ± 0.8 vs. 8.7 ± 1.0 g/dL). The prevalence of dilated cardiomyopathy and left cardiac dysfunction in TDT was 18.6%, whereas pulmonary hypertension (PHT) was found in 30% of NTDT patients. CONCLUSION: Dilated cardiomyopathy was prevailing in the adult TDT patients, whereas PHT was the main cardiac complication in NTDT patients.

Aims/hypothesis Hypoglycaemia is a common side effect of insulin and some other antihyperglycaemic agents used to treat diabetes. Severe hypoglycaemia has been associated with adverse cardiovascular events in trials of intensive glycaemic control in type 2 diabetes. The relationship between non-severe hypoglycaemic episodes (NSHEs) and severe hypoglycaemia in type 2 diabetes has been documented. However, an association between more frequent NSHEs and cardiovascular events has not been verified. This post hoc analysis of the LEADER (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results) trial aimed to confirm whether there is an association between NSHEs and severe hypoglycaemic episodes in individuals with type 2 diabetes. In addition, the possible association between NSHEs and major adverse cardiac events (MACE), cardiovascular death and all-cause mortality was investigated. Methods LEADER was a double-blind, multicentre, placebo-controlled trial that found that liraglutide significantly reduced the risk of MACE compared with the placebo. In this post hoc analysis, we explored, in all LEADER participants, whether the annual rate of NSHEs (defined as self-measured plasma glucose Results We demonstrate that there is an association between NSHEs (2–11 NSHEs per year and ≥12 NSHEs per year) and severe hypoglycaemic episodes (unadjusted HRs 1.98 [95% CI 1.43, 2.75] and 5.01 [95% CI 2.84, 8.84], respectively), which was consistent when baseline characteristics were accounted for. Additionally, while no association was found between participants with 2–11 NSHEs per year and adverse cardiovascular outcomes, higher rates of NSHEs (≥12 episodes per year) were associated with higher risk of MACE (HR 1.50 [95% CI 1.01, 2.23]), cardiovascular death (HR 2.08 [95% CI 1.17, 3.70]) and overall death (HR 1.80 [95% CI 1.11, 2.92]). Conclusions/interpretation The analysis of data from the LEADER trial demonstrated that higher rates of NSHEs were associated with both a higher risk of severe hypoglycaemia and adverse cardiovascular outcomes in individuals with type 2 diabetes. Therefore, irrespective of the cause of this association, it is important that individuals with high rates of hypoglycaemia are identified so that the potentially increased risk of cardiovascular events can be managed and steps can be taken to reduce NSHEs. Trial registration ClinicalTrials.gov (NCT01179048). Graphical abstract

Aims Infection by SARS‐CoV‐2 may result in a systemic disease and a proportion of patients ranging 15%–44% experienced cardiac injury (CI) diagnosed by abnormal troponin levels. The aim of the present study was to analyse the clinical characteristics of a large series of hospitalized patients for COVID‐19 in order to identify predisposing and/or protective factors of CI and the outcome. Methods and results This is an observational, retrospective study on patients hospitalized in two Italian centres (San Raffaele Hospital and Cremona Hospital) for COVID‐19 and at least one high‐sensitivity cardiac troponin (hs‐cTnt) measurement during hospitalization. CI was defined if at least one hs‐cTnt value was above the 99th percentile. The primary end‐point was the occurrence of CI during hospitalization. We included 750 patients (median age 67, IQR 56–77 years; 69% males), of whom 46.9% had history of hypertension, 14.7% of chronic coronary disease and 22.3% of chronic kidney disease (CKD). Abnormal troponin levels (median troponin 74, IQR 34–147 ng/l) were detected in 390 patients (52%) during the hospitalization. At multivariable analysis age, CKD, cancer, C‐reactive protein (CRP) levels were independently associated with CI. Independent predictors of very high troponin levels were chronic kidney disease and CRP levels. Patients with CI showed higher rate of all‐cause mortality (40.0% vs. 9.1%, p = 0.001) compared to those without CI. Conclusion This large, multicentre Italian study confirmed the high prevalence of CI and its prognostic role in hospitalized patients with COVID‐19, highlighting the leading role of systemic inflammation for the occurrence of CI.

Closure of the left atrial appendage is a common procedure for patients with atrial fibrillation undergoing cardiac surgery. The technique of left atrial appendage occlusion (LAAO) by an extracardiac clip (AtriClip) is established as a reliable method. Acute coronary obstruction of the circumflex artery has already been described after minimally invasive LAAO. Here, we report a case of delayed circumflex artery obstruction after open‐heart surgery. A patient who had mitral and tricuspid valve surgery in combination with AtriClip implantation suffered from myocardial infarction 24 h after clip implantation. Cardiac catheterization showed that the circumflex artery was obstructed on the level of the AtriClip device. The stenosis was treated by percutaneous coronary intervention with stent implantation. In conclusion, the surgeon should consider placing the AtriClip device slightly far away from the base of the left atrial appendage to avoid coronary obstruction.

Objectives To determine the viral epidemiology and clinical characteristics of patients with and without clinically apparent respiratory tract infection. Methods This prospective cohort study was conducted during the 2018 winter influenza season. Adult patients with fever/respiratory symptoms (fever/RS group) were age- and sex-matched with patients without fever/RS (non-fever/RS group) in a 1:1 ratio. Respiratory viruses were tested using NxTAG™ Respiratory Pathogen Panel IVD, a commercially-available multiplex PCR panel. Results A total of 214 acutely hospitalized patients were included in the final analysis, consisting of 107 with fever/RS (fever/RS group), and 107 age- and sex-matched patients without fever/RS (non-fever/RS group). Respiratory viruses were detected in 34.1% (73/214) of patients, and co-infection occurred in 7.9% (17/214) of patients. The incidence of respiratory virus was higher in the fever/RS group than in the non-fever/RS group (44.9% (48/107) versus 23.4% (25/107), p 0.001). Influenza B virus, enterovirus/rhinovirus and coronaviruses were detected more frequently in the fever/RS group, whereas parainfluenza virus 4B and adenovirus were detected more frequently in the non-fever/RS group. Among the non-fever/RS group, chest discomfort was more common among patients tested positive for respiratory viruses than those without respiratory virus detected (44% (11/25) versus 22% (18/82), p 0.04). Conclusions Respiratory viruses can be frequently detected among hospitalized patients without typical features of respiratory tract infection. These patients may be a source of nosocomial outbreaks.

Introduction. Refeeding syndrome is a condition underpinned by metabolic disorders emerging as a result of the resumption of feeding in patients after a protracted period of starvation. The real figures of the potentially life threatening refeeding syndrome incidence are unknown. This paper aims to demonstrate the clinical picture and methods of resolving of the refeeding syndrome by presenting a clinical case.Materials and methods. The clinical presentation of the refeeding syndrome with pronounced neurological and cardiological symptoms is demonstrated on the example of a female patient with acute pancreatitis of medium severity at the resumption of enteral feeding. A review of available literature on the subject is also presented.Results and discussion. The range of diagnostic considerations was rather broad as the authors had to eliminate acute coronary and neurological disorders. The auxiliary laboratory examination methods helped form the hypothesis of a developing refeeding syndrome and correct the treatment. Parenteral phosphate-containing preparations and enteral feeding with phosphates were administered. The patient was transferred to the neurology department for further treatment. The patient was discharged home on day 53 with total regression of neurological symptoms.Conclusion. Hypophosphataemia — a very low level of phosphorus in blood — is a key clinical marker of the syndrome. However, low blood levels of potassium, calcium, magnesium and vitamin В1 may also play a role. Chronically undernourished patients and those not having any enteral feed for over 10 days are fall in the high risk group. The feeding should be resumed at a low level energy intake. Vitamins should be prescribed at the resumption and continued for at least 10 days. The electrolyte and fluid balance does not have to be corrected prior to the resumption of feeding; it can be done simultaneously with feeding.

Introduction and aim Sickle cell anemia (SCA) is the most common hemoglobinopathy worldwide, and cardiovascular diseases are the most common causes of death. In these patients, cardiac remodeling begins from childhood and leads to sickle cell cardiomyopathy in the following years. Concentric hypertrophy and eccentric hypertrophy are known to predict early cardiac events. This study aims to reveal the relationship between cardiac remodeling types and survival in patients with SCA and investigate the factors that may affect left ventricular mass. Materials and methods A total of 146 patients with SCA were included in the study, and the left ventricular mass index (LVMI) and relative wall thickness (RWT) of the patients were calculated according to echocardiographic measurements, and the patients were categorized into normal, concentric remodeling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH) groups. Results The median age of the patients is 32 (18-72). In logistic regression analysis, hemoglobin S (HbS) and ferritin levels were independent predictors for LVMI (p = 0.01 and p < 0.001, respectively). It was observed that 56 (38.4%) of the patients had normal left ventricles, 24 (16.4%) had CR, 21 (14.4%) had CH, and 45 (30.8%) had EH. 31 (21.2%) of the patients died. When we look at the survival curves, there was a statistically significant difference between the four groups (log-rank p < 0.001). It was observed that patients with EH were the group with the lowest probability of survival. Conclusion Cardiac death is one of the most common causes of death in patients with SCA. Early detection of cardiac disorders and starting treatment may be important in reducing mortality in these patients.

Highlights • Cardiac complications are associated with poor outcome in COVID-19 patients. • The possible mechanisms of cardiac injury include direct virus invasion, inflammatory storm, hypoxia and instability of coronary plaque. • Special attention should be paid to medicine used in COVID-19 patients, especially those with cardiac side effects., The coronavirus disease-2019 (COVID-19) has become a global pandemic. It has spread to more than 100 countries, and more than 1 million cases have been confirmed. Although coronavirus causes severe respiratory infections in humans, accumulating data have demonstrated cardiac complications and poor outcome in patients with COVID-19. A large percent of patients have underlying cardiovascular disease, and they are at a high risk of developing cardiac complications. The basics of the virus, the clinical manifestations, and the possible mechanisms of cardiac complications in patients with COVID-19 are reviewed. Before an effective vaccine or medicine is available, supportive therapy and identifying patients who are at high risk of cardiac complications are important.

ObjectivesRheumatoid arthritis (RA) is a disabling disease with a high incidence that is regularly accompanied by cardiovascular complications. Several studies have suggested that renin–angiotensin–aldosterone system (RAAS) is closely associated with RA. The aim of this study was to investigate the mechanisms underlying Angiotensin-(1–7) [Ang-(1–7)] and its Mas receptor agonist (AVE0991) on joint inflammation and cardiac complications in a collagen-induced arthritis (CIA) model.MethodsCollagen type II was injected into DBA/1 mice to construct an arthritis model. CIA mice were treated with Ang-(1–7) (2.0 mg/kg intraperitoneally) and AVE0991 (3.0 mg/kg intraperitoneally). The serum levels of inflammatory cytokines [tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1 β, IL-6, and C-reactive protein (CRP)] were determined by ELISA. The mitogen-activated protein kinase (MAPK) and nuclear factor-kappaB (NF-κB) signaling pathways in joint tissues and the transforming growth factor (TGF)-β/Smad pathway and levels of α-Smooth muscle action (SMA) and β-myosin heavy chain (MHC) protein expression in cardiac tissues were assessed by western blots. The levels of TGF-β/Smad pathway, α-SMA, and β-MHC RNA in cardiac tissues were analyzed by real time-PCR. The levels of receptor activator of nuclear factor kappa ligand (RANKL) and promoting matrix metalloproteinase (MMP)-3 expression in the ankle joints were detected by immunohistochemistry and real time-PCR.ResultsAng-(1–7) and AVE0991 reduced the levels of inflammatory cytokines and inhibited the MAPKs and NF-κB signaling pathways in ankle joint tissues, reduced RANKL and MMP3 expression, and ameliorated local joint inflammation and bone destruction compared with the control group. In addition, Ang-(1–7) and AVE0991 attenuated the TGF-β/Smad signaling pathway, reduced the levels of α-SMA and β-MHC expression, and diminished inflammatory cell infiltration into the myocardial interstitium and myocardial interstitial fibrosis in the hearts of CIA mice.ConclusionsAng-(1–7) alleviated joint damage caused by inflammation likely through the attenuation of NF-κB and MAPK pathways and ameliorated inflammation-induced cardiac fibrosis and activation of the TGF-β/Smad pathway. Moreover, Ang-(1–7) was likely mediated through the Mas receptor. This study provides theoretical evidence for exploring novel clinical therapeutic approaches for RA and its cardiac complications.

Background Previous reports have shown various cardiac complications to be associated with COVID-19 including: myocardial infarction, microembolic complications, myocardial injury, arrythmia, heart failure, coronary vasospasm, non-ischemic cardiomyopathy, stress (Takotsubo) cardiomyopathy, pericarditis and myocarditis. These COVID-19 cardiac complications were associated with respiratory symptoms. However, our case illustrates that COVID-19 myopericarditis with cardiac tamponade can present without respiratory symptoms. Case presentation A 58-year-old Caucasian British woman was admitted with fever, diarrhoea and vomiting. She developed cardiogenic shock and Transthoracic echocardiogram (TTE) found a pericardial effusion with evidence of cardiac tamponade. A nasopharyngeal swab showed a COVID-19 positive result, despite no respiratory symptoms on presentation. A pericardial drain was inserted and vasopressor support required on intensive treatment unit (ITU). The drain was removed as she improved, an antibiotic course was given and she was discharged on day 12. Conclusions Our case demonstrates that patients without respiratory symptoms could have COVID-19 and develop cardiac complications. These findings can aid timely diagnosis of potentially life-threatening COVID-19 myopericarditis with cardiac tamponade.

The renin-angiotensin-aldosterone system and its metabolites play an important role in homeostasis of body, especially the cardiovascular system. In this study, we discuss the imbalance of multiple systems during the infection and the importance of therapeutic choice, dosing, and laboratory monitoring of cardiac and anti-coagulant therapies in COVID-19 patients. The crosstalk between angiotensin, kinin-kallikrein system, as well as inflammatory and coagulation systems plays an essential role in COVID-19. Cardiac complications and coagulopathies imply the crosstalks between the mentioned systems. We believe that the blockage of bradykinin can be a good option in the management of COVID-19 and CVD in patients and that supportive treatment of respiratory and cardiologic complications is needed in COVID-19 patients. Ninety-one percent of COVID-19 patients who were admitted to hospital with a prolonged aPTT were positive for lupus anticoagulant, which increases the risk of thrombosis and prolonged aPTT. Therefore, the question that is posed at this juncture is whether it is safe to use the prophylactic dose of heparin particularly in those with elevated D-dimer levels. It should be noted that timing is of high importance in anti-coagulant therapy; therefore, we should consider the level of D-dimer, fibrinogen, drug-drug interactions, and risk factors during thromboprophylaxis administration. Fibrinogen is an independent predictor of resistance to heparin and should be considered before thromboprophylaxis. Alteplase and Futhan might be a good choice to assess the condition of heparin resistance. Finally, the treatment option, dosing, and laboratory monitoring of anticoagulant therapy are critical decisions in COVID-19 patients.

Background This study aimed to evaluate the effect of dipyridamole-thallium scanning (DTS) on the rates of 90-day cardiac complications and 1-year mortality in patients with a femoral neck fracture treated with hemiarthroplasty. Methods Between 2008 and 2015, 844 consecutive patients who underwent cemented or cementless hemiarthroplasty were identified from the database of a single level-one medical center. One-hundred and thirteen patients (13%) underwent DTS prior to surgery, and 731 patients (87%) did not. Patient characteristics, comorbidities, surgical variables, and length of the delay until surgery were recorded. A propensity score-matched cohort was utilized to reduce recruitment bias in a 1:3 ratio of DTS group to control group, and multivariate logistic regression was performed to control confounding variables. Results The incidence of 90-day cardiac complications was 19.5% in the DTS group and 15.6% in the control group (p = 0.343) among 452 patients after propensity score-matching. The 1-year mortality rate (10.6% vs 13.3%, p = 0.462) was similar in the two groups. In the propensity score-matched patients, utilization of DTS was not associated with a reduction in the rate of 90-day cardiac complications (matched cohort, adjusted odds ratio [aOR] = 1.32; 95% confidence interval [CI] 0.75–2.33, p = 0.332) or the 1-year mortality rate (aOR = 0.62; 95% CI 0.27–1.42, p = 0.259). Risk factors for cardiac complications included an American Society of Anesthesiologists grade ≥ 3 (OR 3.19, 95% CI 1.44–7.08, p = 0.004) and pre-existing cardiac comorbidities (OR 5.56, 95% CI 3.35–9.25, p < 0.001). Risk factors for 1-year mortality were a long time to surgery (aOR 1.15, 95% CI 1.06–1.25, p = 0.001), a greater age (aOR 1.05, 95% CI 1.00 to 1.10, p = 0.040), a low body mass index (BMI; aOR 0.89, 95% CI 0.81–0.98, p = 0.015), and the presence of renal disease (aOR 4.43, 95% CI 1.71–11.46, p = 0.002). Discussion Preoperative DTS was not associated with reductions in the rates of 90-day cardiac complications or 1-year mortality in patients with a femoral neck fracture undergoing hemiarthroplasty. The necessity for DTS should be re-evaluated in elderly patients with femoral neck fractures, given that this increases the length of the delay until surgery. Level of evidence Prognostic level III

Reducing mortality due to cardiovascular complications (CVC) after non-cardiac surgery is one of the priority tasks of modern healthcare. According to the literature data, it is the CVC that are leading cause of perioperative mortality in non-cardiac surgery. Atrial fibrillation (AF) is a common complication after surgery. It is believed that in most cases the AF is potentiated by a combination of factors. It is intraoperative triggers, such as deliberate hypotension, anemia, injury, and pain, that can directly contribute to development of arrhythmia. However, heart rate monitoring after non-cardiac surgery is performed in only a small number of patients, so in most cases, arrhythmias remain unreported. The Revised Cardiac Risk Index (RCRI) and theAmericanCollegeof Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator are the current tools for assessing perioperative cardiovascular risk. Postoperative AF is not included in any CVC risk stratification system. The presented review systematizes the data that postoperative AF is closely associated with perioperative complications and in some cases it may be the only marker of these complications. It has been shown that AF detection is of great clinical importance in both high-risk patients and, especially, in patients with a low risk of potential complications in non-cardiac surgery.

Introduction and objective Effective risk stratification is integral to the management of acute coronary syndromes. The Thrombolysis in Myocardial Infarction (TIMI) risk score for ST-segment elevation myocardial infarction (STEMI) is based on eight high-risk parameters that can be used at the bedside for risk stratification of patients presenting with STEMI. This study was designed to determine the frequency of cardiac complications of anterior wall STEMI assessed on TIMI risk score and to compare the rate of cardiac complications according to the TIMI score. Materials and methods An observational case series study was conducted in the Department of Cardiology at Sandeman Provincial Hospital in Quetta, Pakistan. The study duration was six months, from September 22, 2016 to March 23, 2017. A total of 369 patients were selected who had anterior wall myocardial infarction and received thrombolytic therapy, according to the inclusion and exclusion criteria. The TIMI score was calculated by proforma at the time of admission. Patients were divided into three groups: low-risk, moderate-risk, and high-risk TIMI groups. The frequency of complications of anterior wall myocardial infarction at the time of discharge was compared among these groups. Results The study included 285 male patients (77.2%) and 84 (22.8%) female patients. A total of 174 (47.2%) patients were smokers, 79 (21.4%) were obese, and 93 (25.2%) had hyperlipidemia. Of the 369 patients, 205 (55.6%) were included in the low-risk group, 150 (40.7%) in the moderate-risk group, and 14 (3.8%) in the high-risk group. Post-myocardial infarction arrhythmias were noted in 33 (16.09%) patients in the low-risk group and six (4%) patients in the moderate-risk group. Left ventricular dysfunction was noted in 158 (77.07%) patients in the low-risk group, 78 (52%) patients in the moderate-risk group, and seven (50%) patients in the high-risk group. Cardiogenic shock occurred in seven (3.41%) patients in the low-risk group, 47 (31.33%) patients in the moderate-risk group, and 0 (0%) patient in the high-risk group. Death occurred in seven (3.41%) patients in the low-risk group, 19 (12.66%) patients in the moderate-risk group, and seven (50%) patients in the high-risk group. Conclusion TIMI scoring provides a better assessment in terms of complications caused by STEMI. The complications include the mechanical and electrophysiology of the heart.

Background COVID-19 caused by severe acute respiratory syndrome coronavirus 2 most commonly manifests with fever and respiratory illness. The cardiovascular manifestations have become more prevalent but can potentially go unrecognized. We look to describe cardiac manifestations in three patients with COVID-19 using cardiac enzymes, electrocardiograms, and echocardiography. Case summaries The first patient, a 67-year-old Caucasian female with non-ischaemic dilated cardiomyopathy, presented with dyspnoea on exertion and orthopnoea 1 week after testing positive for COVID-19. Echocardiogram revealed large pericardial effusion with findings consistent with tamponade. A pericardial drain was placed, and fluid studies were consistent with viral pericarditis, treated with colchicine, hydroxychloroquine, and methylprednisolone. Follow-up echocardiograms showed apical hypokinesis, that later resolved, consistent with Takotsubo syndrome. The second patient, a 46-year-old African American male with obesity and type 2 diabetes mellitus presented with fevers, cough, and dyspnoea due to COVID-19. Clinical course was complicated with pulseless electrical activity arrest; he was found to have D-dimer and troponin elevation, and inferior wall ST elevation on ECG concerning for STEMI due to microemboli. The patient succumbed to the illness. The third patient, a 76-year-old African American female with hypertension, presented with diarrhoea, fever, and myalgia, and was found to be COVID-19 positive. Clinical course was complicated, with acute troponin elevation, decreased cardiac index, and severe hypokinesis of the basilar wall suggestive of reverse Takotsubo syndrome. The cardiac index improved after pronation and non-STEMI therapy; however, the patient expired due to worsening respiratory status. Discussion These case reports demonstrate cardiovascular manifestations of COVID-19 that required monitoring and urgent intervention.

Background: Kawasaki disease (KD) is an acute febrile illness that largely affects young children before 5 years of age. Younger children with KD are reported to have a higher prevalence of coronary artery abnormalities. Little is known about infants in the first 3 months of age diagnosed with KD. Methods: A retrospective study was conducted at the National Institute of Pediatrics in Mexico City from 1995 to 2019. Clinical features, laboratory results and cardiac outcomes were recorded. Infants in the first 3 months of age were compared with older patients. Wilcoxon-Mann-Whitney analysis was performed for continuous variables and Fisher's exact test for categorical variables. Results: Six hundred and eighty-eight cases of KD were included in this study. Fourteen cases were diagnosed in the first three months of age. Heart failure and KD shock-syndrome was found in five cases (35.7%). Giant coronary artery aneurysms were found in six cases in the younger group (42.9%). Conclusions: Diagnosis of KD in children younger than 3 months of age is rare. In most cases, an incomplete presentation contributed to a delay diagnosis, treatment, and complications. Younger patients with KD have an increased risk of presenting cardiac complications, including giant coronary artery aneurysms, shock, and death.

The success of cardiac surgery over the past 50 years has increased numbers and median age of survivors with congenital heart disease (CHD). Adults now represent two-thirds of patients with CHD; in the USA alone the number is estimated to exceed 1 million. In this population, many affected women reach reproductive age and wish to have children. While in many CHD patients pregnancy can be accomplished successfully, some special situations with complex anatomy, iatrogenic or residual pathology are associated with an increased risk of severe maternal and fetal complications. Pre-conception counselling allows women to come to truly informed choices. Risk stratification tools can also help high-risk women to eventually renounce to pregnancy and to adopt safe contraception options. Once pregnant, women identified as intermediate or high risk should receive multidisciplinary care involving a cardiologist, an obstetrician and an anesthesiologist with specific expertise in managing this peculiar medical challenge. This document is intended to provide cardiologists working in hospitals where an Obstetrics and Gynecology Department is available with a streamlined and practical tool, useful for them to select the best management strategies to deal with a woman affected by CHD who desires to plan pregnancy or is already pregnant.

ObjectivesTo date, no research has investigated the association between cardiac complication and electrical injury; hence, we aimed to assess the consequences and relating factors of cardiac complications from electrical injuries in South Korea.DesignRetrospective single-centre study.Participants721 patients who had electrical injury–related admission during 2007–2017. An electronic medical record system was used to extract records of patients admitted for electrical injury treatment.ResultsCardiac complications included abnormal parameters of myocardial damage, abnormal regional wall motion detected via echocardiogram, dysrhythmia (eg, bradycardia, atrial flutter/fibrillation) and ventricular tachycardia or fibrillation. Overall, 107 patients (14.8%) experienced cardiac complications. The average admission duration and intensive care unit stay duration were significantly longer in patients with cardiac complications than in those without them (75.0±45.3 vs 56.6±48.0 days and 19.3±24.1 vs 10.4±15.5 days, respectively, p=0.01). All deaths occurred within 32 days, and the most common cause of death was septic shock. Total body surface area (TBSA) was only positively related factor to cardiac complications.ConclusionThis study is the first in South Korea to reveal that electrical accident patients with cardiac complications experience poorer in-hospital prognosis, and TBSA was the only risk factor of cardiac complications. And initial treatment for infection and inflammations could be important in electrical injury.

Introduction Hungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcaemia associated with hypophosphatemia and hypomagnesaemia, and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and preoperative high bone turnover. [1] Case report This report concerns a dialysed patient who underwent surgical treatment for secondary refractory hyperparathyroidism. Haemodialysis was carried out pre-operatively, and subsequently, a total parathyroidectomy with auto-transplantation of parathyroid tissue in the sternocleidomastoid muscle (SCM) was performed. Rapid and progressive hypocalcaemia symptoms developed during the second day postoperatively. Acute cardiac symptoms with tachyarrhythmia, haemodynamic instability and finally asystole occurred, which required cardiopulmonary resuscitation (CPR). The ionic calcium level was 2.2 mg/dL being consistent with a diagnosis of HBS. A second cardiac arrest unresponsive to CPR followed an initial period of normal sinus rhythm. Death ensued shortly after. Before death, the ionic calcium was 3.1 mg/dL. Conclusion HBS, after parathyroidectomy in patients with secondary hyperparathyroidism (SHPT), may be severe, prolonged and sometimes fatal. Generally, HBS symptomatology is that of a mild hypocalcaemia. It can, however, include heart rhythm disturbances with haemodynamic alterations requiring intensive care measurements and even cardiopulmonary resuscitation. A close clinical and laboratory post-parathyroidectomy monitoring of dialysed patients is of the utmost importance.

The link between heart disease and infectious pathogens is well known. Despite the high frequency of cardiac pathology in infectious diseases, it is rarely diagnosed because of lack of specific clinical and laboratory symptoms. It is especially difficult to diagnose in children. Airborne infections in the structure of infectious morbidity of children occupy a leading place. The aim of this work was to study the nature of the lesions of the heart in children suffering from acute infection of the respiratory tract. Materials and methods: 341 children with acute respiratory infection of moderate severity were surveyed by a method of ECG dispersion mapping. Cardiac pathology has not previously been determined in these children. Signs of disease of the heart was identified in 76 children (22%). Further study included instrumental (ECG, ECHO-KG, daily monitoring of ECG), biochemical and etiological (ELISA, PCR, immunocytochemical) research methods for determining the nature of the damage to the heart and the etiology of the disease. Results. Myocarditis was diagnosed in 2% of children, a violation of repolarization – in 21%, heart rhythm disorders – in 35% (AV – blockade in 4%). Most often signs of heart disease were detected in children with Epstein-Barr virus (32%), streptococcal (28%), cytomegalovirus (25%), herpesvirus type 6 infection (24%). Pathogens from the group of acute respiratory virus infections were identified in 28%, enterovirus – in 10%, Haemophilus influenzae – in 10%, Mycoplasma pneumonia – in 10%, Pneumococcus – in 9%, Chlamydia – in 9%, Parvovirus B19 – in 6%. Conclusion. Sensitive screening test to detect cardiac pathology is the method of ECG dispersion mapping. Heart damage in children with respiratory diseases in 60% of cases is associated with mixed infections. Timely diagnosis of lesions of the heart in infectious diseases in children allows to adjust the therapy in the early stages and prevent the development of chronic pathology of the heart.

Literature regarding cardiac deaths in hemorrhagic stroke patients is few. The aim of this study was to investigate the incidence and risk factors of cardiac death in hemorrhagic stroke patients. We used the multiple causes of death database from the Centers for Disease Control and Prevention Wide-ranging Online Data of the United States. We identified death certificates from 2006 to 2010 with hemorrhagic stroke (International Classification of Disease, Tenth Revision (ICD-10) code I60-62), or ischemic stroke (ICD-10 code I63), and evaluated the frequency and risk factors of reporting MI (ICD-10 code I20-25) or arrhythmias (ICD-10 code I44-45, I47-49) as the main cause of death in these populations. Over the five-year period, 224,359 death certificates that mentioned hemorrhagic stroke were identified, and the cause of death was MI in 8.95% and arrhythmia in 7.28% patients. With autopsy confirmation, the incidences of MI and arrhythmias in the hemorrhagic stroke group were still lower than the ischemic group. The odds ratio of reporting arrhythmias as a cause of death in hospitalized population was higher. A substantial percentage of hemorrhagic stroke patients had cardiac death. Greater efforts are needed to closely monitor high-risk groups such as females and the elderly.

Study Design: Retrospective cohort study. Objectives: The purpose of this study was to report incidence of cardiopulmonary complications in elective spine surgery, demographic and surgical predictors, and outcomes. Understanding the risks and predictors of these sentinel events is important for risk evaluation, allocation of hospital resources, and counseling patients. Methods: A retrospective review of the National Surgical Quality Improvement Program (NSQIP) was performed on 60 964 patients undergoing elective spine surgery (any region; laminectomy, arthrodesis, discectomy, or laminoplasty) between 2011 and 2013. Incidence of myocardial infarction, cardiac arrest, unplanned reintubation, on ventilator >48 hours, perioperative pneumonia, and pulmonary embolism was measured. Demographic and surgical predictors of cardiopulmonary complications and associated outcomes (length of stay, discharge disposition, and mortality) were measured using binary logistic regression controlling for confounders. Results: Incidence rates per 1000 elective spine patients were 2.1 myocardial infarctions, 1.3 cardiac arrests, 4.3 unplanned intubations, 3.5 on ventilator >48 hours, 6.1 perioperative pneumonia, and 3.7 pulmonary embolisms. In analysis of procedure, diagnosis, and approach risk factors, thoracic cavity (odds ratio = 2.47; confidence interval = 1.95-3.12), scoliosis diagnosis, and combined approach (odds ratio = 1.51; confidence interval = 1.15-1.96) independently added the most risk for cardiopulmonary complication. Cardiac arrest had the highest mortality rate (34.57%). Being on ventilator greater than 48 hours resulted in the greatest increase to length of stay (17.58 days). Conclusions: Expected risk factors seen in the Revised Cardiac Risk Index were applicable in the context of spine surgery. Surgical planning should take into account patients who are at higher risk for cardiopulmonary complications and the implications they have on patient outcome.

Introduction Laparoscopic Nissen operation with mesh reinforcement remains being the most popular operation for large hiatal hernia repair. Complications related to mesh placement have been widely described. Cardiac complications are rare, but have a fatal outcome if they are misdiagnosed. Presentation of cases We sought to outline our institutional experience of three patients who developed cardiac complications following a laparoscopic Nissen operation for large hiatal hernia repair. Discussion Laparoscopic hiatoplasty and Nissen fundoplication are safe and effective procedures for the hiatal hernia repair, but they are not exempt from complications. Fixation technique and material used must be taken into account. We have conducted a review of the literature on complications related to these procedures. Conclusion In the differential diagnosis of hemodynamic instability after laparoscopic hiatal hernia repair, cardiac tamponade and other cardiac complications should be considered., Highlights • Three cases with different clinical expression of cardiac tamponade after laparoscopic large hiatal hernia repair. • We review cardiac complications related to laparoscopic hiatal hernia repair. • It is necessary to consider the risk of injury to the surrounding tissues during the anchorage of the mesh to the diaphragm. • Cardiac complications must be considered in the postoperative period of mesh hiatoplasty.

Prognosis and prevention of cardiac complications of non-cardiac surgery is an important clinical task. Currently quite a lot is known on various scales of myocardial infarction risk prognosis and the death in perioperational period, as on drug treatment and prevention. The issue whether to perform coronary arteriography and preventive coronary revascularization before noncardiac surgical interventions in patients with high cardiological risk score remains controversial. Current review concerns on the perspectives of perioperational myocardial infarction pathogenesis and also analyses in details the results of current retro- and prospective studies of efficacy and safety of various types of preventive coronary revascularization with the aim to reduce the prevalence of extracardiac surgery.

In the Trial Comparing Cardiovascular Safety of Insulin Degludec vs Insulin Glargine in Patients with Type 2 Diabetes at High Risk of Cardiovascular Events (DEVOTE), insulin degludec was non-inferior to insulin glargine in terms of cardiovascular events and mortality. However, there were lower rates of severe hypoglycaemia with insulin degludec. DEVOTE investigators now extend these findings by presenting the results of two observational epidemiological analyses based on trial data. In the first of these analyses (DEVOTE 2), Zinman et al (Diabetologia DOI: 10.1007/s00125-017-4423-z ) demonstrate that, compared with individuals with lower day-to-day fasting glycaemic variability, those with higher day-to-day fasting glycaemic variability had a similar risk of major adverse cardiovascular events (MACE) but a higher risk of severe hypoglycaemia and all-cause mortality. In the second analysis (DEVOTE 3), Pieber et al (Diabetologia DOI: 10.1007/s00125-017-4422-0 ) found that individuals who experienced severe hypoglycaemia had a similar risk of MACE compared with those who never experienced severe hypoglycaemia, but had a more than twofold higher risk of subsequent total mortality and cardiovascular disease (CVD) mortality. The strengths of these studies relate to the availability of high-quality prospective data on adjudicated severe hypoglycaemia, MACE and mortality events in a large number of high-risk insulin-treated individuals with type 2 diabetes. Limitations include the observational nature of the data and thus residual confounding remains possible. Furthermore, the short duration of the trial resulted in limited statistical power for some analyses. Therefore, whilst DEVOTE 2 and DEVOTE 3 raise awareness of the mortality risks associated with glucose variability and severe hypoglycaemia in high-risk, insulin-treated patients with type 2 diabetes, they cannot clarify causal relationships. Preventing severe hypoglycaemia in those with type 2 diabetes should already be a priority in clinical practice. However, findings from future clinical trials are needed to guide physicians on whether it is beneficial to target glucose variability, and risk for severe hypoglycaemia, to reduce the risks for CVD events and mortality in these individuals.

Several indexes to predict perioperative cardiovascular risk have been proposed overtime. The most widely used is the Revised Cardiac Risk Index (RCRI) developed by Lee since 1999. It predicts major cardiac outcomes from five independent clinical determinants: history of ischemic heart disease, history of cardiovascular disease, heart failure, insulin-dependent diabetes mellitus, and chronic renal failure (i.e. serum creatinine >2 mg/dl). In external validation studies, the RCRI showed high negative predictive value in all groups of age, indicating that it may be used to identify people at low risk for perioperative adverse cardiovascular events in noncardiac surgery. However its accuracy is suboptimal in many clinical settings. More recently the National Surgical Quality Improvement Program database) (NSQIP) hasdeveloped a new index to predict perioperative myocardial infarction (MI) or cardiac arrest (MICA) from a cohort of 211,410 patients (the Gupta index) and afterwards a universal surgical risk estimation tool has been developed, using standardized clinical data from 393 ACSNSQIP hospitals in US (a cohort based on 1,414,006 patients), showing a good performance for mortality (C-statistic = 0.944) and morbidity (C-statistic =0.816) as compared with procedure-specific models. Other risk scores include the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION), which has evaluated cardiac complications in 15,065 patients, the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and the large Preoperative Score to Predict Postoperative Mortality (POSPOM) that was built up from data collected in the National Hospital Discharge Data Base (NHDBB) including a cohort of 7.059.447 patients. In Italy a new risk index (the Orion score) builkt up from a cohort of 9000 patients generated four classes of major cardiovascular adverse events perioperative risk ranging from 1 (0.6%); 2 (2.4%); 3 (7.4%) and 4 (23.1%). The AUROC curves showed higher accuracy as compared to the RCRI score both in the derivation than in the validation cohort (AUROC= 0.872 ± 0.028 vs 0.807 ± 0.037). Thus, many risk indices are available nowadays. Despite the latest European guidelines recommended them for risk stratification (class I, level of evidence B), their use in clinical practice is still scarce.

Nonalcoholic fatty liver disease (NAFLD) is a pathologic condition frequently observed in clinical practice. To date, the prevalence of NAFLD is approximately 25–30% among adults of the general population in Western countries but increases to approximately 70–75% among patients with type 2 diabetes mellitus. In the last decade, accumulating evidence has clearly demonstrated that patients with NAFLD have not only an increased liver-related morbidity and mortality but also an increased risk of fatal and non-fatal cardiovascular events. In particular, several studies have documented the existence of an independent association among NAFLD and cardiac changes in structure and function in both non-diabetic and diabetic patients. In addition, mounting evidence also suggests that there is a strong relationship between NAFLD and cardiac arrhythmias, such as atrial fibrillation, QTc prolongation and ventricular arrhythmias. This is of clinical interest, as it could explain, at least in part, the increased risk of death for cardiovascular disease in patients with NAFLD. Therefore, seeing that cardiovascular disease complications are the leading cause of disability and death in NAFLD patients, the recent European clinical practice guidelines advised to check the cardiovascular system in all patients with NAFLD. This clinical mini review will briefly describe the increasing body of evidence regarding the association between NAFLD and cardiac arrhythmias, and discuss the potential biological mechanisms underlying this association.

Aim. To set prognostic factors of cardial complications after ischemic stroke. Material and methods. Into prospective cohort observational study totally 148 patients included with ischemic stroke, at the age of 60 (52;68) y. All patients underwent clinic-instrumental, neurological and cardiological investigations. At the 20th day after stroke all patients underwent 24-hour Holter monitoring with the rhythm and conduction disorders analysis, transient ischemia, temporal and spectral characteristics of the heart rate variability. Duration of prospective study was 35 (28; 40) months. Cardial complications were registered: myocardial infarction (MI), instable angina, acute heart failure (AHF), including the acute decompensation of chronic heart failure leading to hospitalization, sudden cardiac death (SCD) and all cases of cardiac deaths. Results. During the study in 17 (11%) patients, 19 cardiac complications registered: 7 episodes of unstable angina, 4 acute MI, 5 cases of AHF and 3 cases of SCD. In 1 patient consequently registered 2 cardiac complications – unstable angina and MI. In 8 patients there was cardiac death due to MI (n=2), AHF (n=3) and SCD (n=3). The predictors established for cardiac complications after ischemic stroke: age more than 67 y.o., ventricular arrhythmias of higher grades, chronic forms of ischemic heart disease, parameters of five-minute standard deviations of cardiointervals (SDNN)

Opinion statement Survivors of hematopoietic stem cell transplant (HSCT) are at significant risk for cardiac disease and cardiac complications. While there may be cardiac complications during the acute period of HSCT, long-term survivors remain at risk for cardiovascular disease at a rate at least fourfold higher than the general population. Aggressive screening for cardiac risk factors such as diabetes, hypertension, and arrhythmias is warranted pretransplant. For those with risk factors, particularly a history of cardiovascular disease or atrial fibrillation, cardiology consultation is warranted in the pretransplantation period. Aggressive screening for cardiac risk factors such as diabetes, hypertension, and hyperlipidemia is warranted in HSCT survivors as well; early and aggressive treatment of left ventricular dysfunction is warranted. Collaboration between hematology/oncology and cardiology through a cardio-oncology clinic is an optimal way to help manage these patients.

It is known that anti-Ro/SSA positivity leads to higher risk of miscarriage and fetal cardiac malformations. Particularly, anti-p200 antibodies against a finer specificity of the Ro/SSA antigen, have been associated with congenital heart block. The aim of the study was to assess the frequency of anti-p200 among female patients with different connective tissue diseases and, among these, the relevance of anti-p200 values in patients with cutaneous diseases compared to systemic diseases. Anti-p200 were investigated in 110 anti-Ro/SSA positive female sera, sent to our laboratory between 2008 and 2014 with suspect of connective disease, by using ELISA testing. Positivity was found in 40.9 % samples, 34 of them showed a strong positivity (values ≥ 1.0, cut off = 0.7). Patients with systemic diseases were anti-p200 positive in the 45.9 % of cases while patients with cutaneous diseases were positive in the 24.0 % of cases. Positivity for anti-p200 antibodies was revealed in 24.0 % of patients with discoid lupus erythematosus; 100 % of patients with dermatomyositis; 40.0 % of patients with mixed connective tissue disease; 25.0 % of patients with rheumatoid arthritis; 100 % of patients with Sjogren's syndrome; 33.3 % of patients with subacute cutaneous lupus erythematosus; 42.9 % of patients with systemic lupus erythematosus; 80.0 % of patients with systemic sclerosis. No significant difference in anti-p200 prevalence was found between systemic and cutaneous involvement, nevertheless, considering only positive sera, the antibody titer was higher in systemic diseases rather than in cutaneous diseases (2.6 ± 1.7 and 1.7 ± 1.9; p = 0.041). The authors think screenings for anti-Ro/SSA and anti-p200 antibodies should be included in the laboratory checklist for pregnancy.

Objectives Although diabetes mellitus is frequently associated with heart failure (HF), the association between elevated admission glucose levels and adverse outcomes has not been well established in hospitalized patients with acute HF. Methods We prospectively evaluated in-hospital mortality, post-discharge 1-year mortality and 1-year re-hospitalization rates in the Italian Network on Heart Failure (IN-HF) Outcome registry cohort of 1776 patients hospitalized with acute HF and stratified by their admission glucose levels ( i.e ., known diabetes, newly diagnosed hyperglycemia, no diabetes). Results Compared with those without diabetes ( n =586), patients with either known diabetes ( n =749) (unadjusted-odds ratio [OR] 1.64, 95%CI 0.99–2.70) or newly diagnosed hyperglycemia ( n =441) (unadjusted-OR 2.34, 95%CI 1.39–3.94) had higher in-hospital mortality, but comparable post-discharge 1-year mortality rates. After adjustment for age, sex, systolic blood pressure, estimated glomerular filtration rate, left ventricular ejection fraction, HF etiology and HF worsening/ de novo presentation, the results remained unchanged in patients with known diabetes (adjusted-OR 1.86, 95%CI 1.01–3.42), while achieved borderline significance in those with newly diagnosed hyperglycemia (adjusted-OR 1.81, 95%CI 0.95–3.45). One-year re-hospitalization rates were lower in patients with newly diagnosed hyperglycemia (adjusted-hazard ratio 0.74, 95%CI 0.56–0.96) than in other groups. Conclusions Elevated admission blood glucose levels are associated with poorer in-hospital survival outcomes in patients with acute HF, especially in those with previously known diabetes. This finding further highlights the importance of tight glycemic control during hospital stay and address the need of dedicated intervention studies to identify customized clinical protocols to improve in-hospital survival of these high-risk patients.

Introduction Stroke is the second most common cause of death after ischaemic heart diseases and the third leading cause of disability worldwide. The contribution of cardiac complications to the mortality of patients with stroke is variable across studies, ranging from 12.5% to 22.7%. Many of these cardiac complications are preventable, and early recognition and adequate management guided by appropriate up-to-date knowledge of their relative incidence and fatality can help to improve patients’ outcomes. This systematic review aims to summarise the available data on the burden of cardiac complications after stroke. Methods and analysis This review will include all cross-sectional, case–control and cohort studies and clinical trials published between 1 January 1950 and 31 December 2017, involving adults and/or children, and reporting on the prevalence, the incidence and/or the mortality of cardiac complications after stroke. Two reviewers will independently screen titles and abstracts of records retrieved from PubMed, Excerpta Medica Database, ISI Web of Science and the Cumulative Index to Nursing and Allied Health Literature for eligibility, and then assess the risk of bias and quality of reporting to select the studies which will be included. All authors will contribute to the retrieval of full texts of eligible records and data extraction. Heterogeneity across studies will be evaluated by the χ 2 test on Cochran’s Q statistic. Study-specific estimates of the prevalence, incidence and mortality of cardiac complications after stroke across studies will be pooled through random-effect or fixed-effect meta-analysis depending on the source of the heterogeneity, after stabilising the variance of individual studies using the Freeman-Tukey double arcsine transformation. Visual analysis of funnel plots and Egger’s test will be done to detect small-study effect. Ethics and dissemination This review and meta-analysis will be based on published data and will therefore not require a specific ethical clearance. The results will be published in peer-reviewed journals. PROSPERO registration number CRD42018082551.

The aim of our study was to establish that the incidence of perioperative cardiac complications were in direct correlation with level of operative risk in coronary patients undergoing open abdominal nonvascular surgery with general anesthesia. Our prospective observational clinical study was composed of a group of 111 consecutive patients with angiographically-verified coronary artery disease, who were operated on at the University Clinical Center of Serbia. The patients were classified into four stratification subgroups by “Goldman’s Cardiac Risk Index” (CRI) in relation to the incidence of perioperative cardiac complications. Electrocardiography was performed immediately after surgery, on postoperative days 1, 2, 7 and one day before discharge from the hospital. All patients were followed to postoperative day 30. Statistical design was presented by Pearson’s χ2 test and binomial logistic regression. The main result was significant difference between the four stratification subgroups of coronary patients in the incidence of cardiac death up to the 30th postoperative day: I — 0/17 (0.0%) vs. II — 0/40 (0.0%) vs. III — 1/37 (2.7%) vs. IV — 2/17 (11.8%), (p

Background: Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) can significantly decrease cardiovascular mortality and morbidity, irrespective of the patients' cholesterol status. This paper reviews the effects of perioperative statin therapy in patients undergoing noncardiac surgery. Method: A systematic literature review was undertaken of all published literature on this subject using Medline and cross-referenced. All published relevant papers on the perioperative use of statins were used. Results: Perioperative statin therapy is associated with a lower perioperative morbidity and mortality in patients undergoing elective or emergency surgery. The effects are due to a combination of lipid-lowering and pleiotropic properties of statins. Conclusion: Ideally a large scale multi-centre randomized controlled trial of perioperative statin therapy should be performed but this may be difficult to conduct since there is already overwhelming evidence in the literature to suggest perioperative cardiovascular protective properties. Statins may still be under-prescribed in surgical patients. © 2008 Chan et al, publisher and licensee Dove Medical Press Ltd., published_or_final_version

Purpose: Bradycardia and abnormal cardiac autonomic function are related to increased mortality in anorexia nervosa (AN). The aim of this study was to assess heart rate (HR) and HR variability of young adolescents with AN as compared to controls by means of wearable sensors and wireless technologies.,Method: The ECG signal was recorded in 27 AN girls and 15 healthy girls at rest using a wearable chest strap. The tachogram, the mean intervals between R peaks (meanRR), the root mean square of successive differences (RMSSD), the power of low-frequency (LF) and high-frequency (HF) bands and the LF/HF ratio were assessed.,Results: All AN girls showed a reduced HR and an increased meanRR and RMSSD. An HF increase, a LF decrease, and a LF/HF reduction indicated a prevalence of the parasympathetic on sympathetic activity.,Conclusions: The instruments used in this pilot study were feasible, unobtrusive and extremely suitable in AN subjects who are burdened by high incidence of cardiovascular mortality; their application could open to new approaches of vital signs monitoring in hospitals as well as in home settings.

Liver cirrhosis is associated with a wide range of cardiovascular abnormalities. These abnormalities include hyperdynamic circulation characterized by an increase in cardiac output and a decrease in peripheral vascular resistance. Despite the increased cardiac output, impaired ventricular contractility in response to both physiological and pharmacological stimuli has been described. Other cardiac abnormalities include structural changes including enlargement or hypertrophy of different cardiac chambers and electrophysiological changes such as QT prolongation. This constellation of cardiac abnormalities is termed cirrhotic cardiomyopathy. The pathogenic mechanisms of cirrhotic cardiomyopathy are multifactorial and include cardiomyocyte plasma membrane physico-chemical changes, attenuated stimulatory pathways, and enhanced activity of inhibitory systems. Accumulating evidence suggests that cirrhotic cardiomyopathy plays a major role in the pathogenesis of cardiac dysfunction following liver transplantation or transjugular intrahepatic portosystemic shunt placement. Recent research also strongly suggests that cirrhotic cardiomyopathy contributes to the pathogenesis of hepatorenal syndrome, especially following infections such as spontaneous bacterial peritonitis. Treatment of this syndrome remains largely empirical. Successful liver transplantation is thought to improve all the organ-related hemodynamic dysfunctions, including hepatopulmonary syndrome, cerebral hypoperfusion, hepatorenal syndrome, and cirrhotic cardiomyopathy. The prolonged QT interval normalizes following liver transplantation. Thus, liver transplantation appears to be the ultimate treatment for the cardiovascular complications of cirrhosis.

OBJECTIVE: To compare the accuracy of 4 different indices of cardiac risk currently used for predicting perioperative cardiac complications. METHODS: We studied 119 patients at a university-affiliated hospital whose cardiac assessment had been required for noncardiac surgery. Predictive factors of high risk for perioperative cardiac complications were assessed through clinical history and physical examination, and the patients were followed up after surgery until the 4th postoperative day to assess the occurrence of cardiac events. All patients were classified according to 4 indices of cardiac risk: the Goldman risk-factor index, Detsky modified risk index, Larsen index, and the American Society of Anesthesiologists' physical status classification and their compared accuracies, examining the areas under their respective receiver operating characteristic (ROC) curves. RESULTS: Cardiac complications occurred in 16% of the patients. The areas under the ROC curves were equal for the Goldman risk-factor index, the Larsen index, and the American Society of Anesthesiologists' physical status classification: 0.48 (SEM ± 0.03). For the Detsky index, the value found was 0.38 (SEM ± 0.03). This difference in the values was not statistically significant. CONCLUSION: The cardiac risk indices currently used did not show a better accuracy than that obtained randomly. None of the indices proved to be significantly better than the others. Studies to improve our ability to predict such complications are still required.

Aims/hypothesis: Heart failure has been suggested to increase the risk of developing diabetes. We investigated the relation between heart failure severity, defined by loop-diuretic dosage, and the risk of developing diabetes in a nationwide cohort of patients with heart failure. Methods: We followed all Danish patients discharged from hospitalisation for first-time heart failure in 1997-2010, without prior use of hypoglycaemic agents, until a claimed prescription for hypoglycaemic agents, death or 31 December 2010. The association of loop-diuretic dosage (furosemide equivalents) 90 days after discharge (study baseline) with risk of diabetes was estimated by multivariate Cox regression models. Results: In total, 99,362 patients were included and divided into five loop-diuretic dose groups: 30,838 (31%) used no loop diuretics; 24,389 (25%) used >0-40 mg/day; 17,355 (17%) used >40-80 mg/day; 11,973 (12%) used >80-159 mg/day; and 14,807 (15%) used ≥160 mg/day. A total of 7,958 patients (8%) developed diabetes. Loop-diuretic dosages were associated with an increased risk of developing diabetes in a dose-dependent manner. Concomitant use of renin-angiotensin system inhibitors (RASis) attenuated the risk (p value for interaction

Introduction: Chronic Obstructive Pulmonary Disease (COPD) has considerable effects on cardiac functions primarily affecting the pulmonary vasculature and then right ventricle along with left ventricle. One of the important causes of increased morbidity and mortality associated with COPD is cor pulmonale. Echocardiography provides a rapid, non-invasive method to evaluate cardiac changes. Our aim was to evaluate RVfunction in COPD as per guidelines of American Society of Echocardiography with an aim to find a simpler way of predicting cardiac morbidity. Materials and Methods: A cross sectional observational study was conducted on 17 COPD patients attending Respiratory Medicine outdoor of R. G. KAR Medical College, Kolkata, India, through history taking, clinical examination, PFT (PFT) and Echocardiography. Statistical analysis was done by using Statistical Package for the Social Sciences (SPSS) version-17. Results: Fractional area change of RV (FAC-%) was positively correlated with Forced Expiratory Volume in One Second (FEV1) (r = 0.4879), FEV1/ Forced Vital Capacity (FVC) ratio (r = 0.5048) and Peak Expiratory Flow Rate (PEFR) (r = 0.5361). There was strong negative correlation of Systolic Pulmonary Artery Pressure (SPAP) with FEV1/FVC ratio (r = -0.5553) and PEFR (r = - 0.4604). Right Index of Myocardial Performance (RIMP) of right ventricle was negatively correlated with FEV1/FVC ratio (r = - 0.598), PEFR (r = - 0.619), Forced Expiratory Flow (FEF) 25-75 (r = -0.515). Tricuspid annular plane systolic excursion (TAPSE) did not show any association with PFT parameters though it showed strong positive correlation with RV wall thickness. Conclusion: This study substantiates that FAC% and RIMP can be vital prognostic factors for RV function apart from SPAP, TAPSE to define RV dysfunction and predict morbidity in COPD.

Non-alcoholic fatty liver disease (NAFLD) has emerged as a public health problem of epidemic proportions worldwide. Accumulating clinical and epidemiological evidence indicates that NAFLD is not only associated with liver-related morbidity and mortality but also with an increased risk of coronary heart disease (CHD), abnormalities of cardiac function and structure (e.g., left ventricular dysfunction and hypertrophy, and heart failure), valvular heart disease (e.g., aortic valve sclerosis) and arrhythmias (e.g., atrial fibrillation). Experimental evidence suggests that NAFLD itself, especially in its more severe forms, exacerbates systemic/hepatic insulin resistance, causes atherogenic dyslipidemia, and releases a variety of pro-inflammatory, pro-coagulant and pro-fibrogenic mediators that may play important roles in the pathophysiology of cardiac and arrhythmic complications. Collectively, these findings suggest that patients with NAFLD may benefit from more intensive surveillance and early treatment interventions to decrease the risk for CHD and other cardiac/arrhythmic complications. The purpose of this clinical review is to summarize the rapidly expanding body of evidence that supports a strong association between NAFLD and cardiovascular, cardiac and arrhythmic complications, to briefly examine the putative biological mechanisms underlying this association, and to discuss some of the current treatment options that may influence both NAFLD and its related cardiac and arrhythmic complications.

Chest skeletal injuries are the most frequent complications of external chest massage (ECM) during cardiopulmonary resuscitation, but heart and great vessels lacerations that are indeed very rare. We report the case of a 35-year-old workman who collapsed and underwent ECM by his co-workers for almost 30 min. At autopsy, no external injuries, fractures or bruises of the ribs or sternum, were observed. A hemopericardium with a rupture of the heart was found, with no signs of pre-existent cardiac disease. Bruises of thoracic aortic wall, lung petechiae, a contusion of the liver, and bruises of lumbar muscles were found. The cause of death was due to sudden cardiac death with an extensive cardiac rupture. This is an unusual report of massive heart damage without any skeletal or muscle chest injuries, secondary to cardiopulmonary resuscitation. This kind of cardiac lesions may be considered when thoracic–abdominal trauma, or medical history, is unclear.

Cardiac contusion, usually caused by blunt chest trauma, has been recognized with increased frequency over the past decades. Traffic accidents are the most frequent cause of cardiac contusions resulting from a direct blow to the chest. Other causes of blunt cardiac injury are numerous and include violent fall impacts, interpersonal aggression, explosions, and various types of high-risk sports. Myocardial contusion is difficult to diagnose; clinical presentation varies greatly, ranging from lack of symptoms to cardiogenic shock and arrhythmia. Although death is rare, cardiac contusion can be fatal. We present a case of cardiac contusion due to blunt chest trauma secondary to a fall impact, which manifested as cardiogenic shock.

Objectives Endovascular aneurysm repair (EVAR) is associated with reduced cardiac stress compared with open repair and is an attractive therapeutic option, especially in cardiac fragile patients. General and locoregional anaesthesia differ regarding the stress response evoked by surgery. The aim of the study is to compare the incidence of cardiac events after EVAR under general or locoregional anaesthesia. Methods A total of 302 consecutive patients undergoing infrarenal EVAR between 2002 and 2011 were analysed in this retrospective cohort study. Selection of anaesthesia type was at the discretion of the treating physicians. Medical history, medication use, anaesthesia technique and follow-up were obtained. The study end point was 30-day cardiac complications, including cardiac death, non-fatal myocardial infarction, heart failure, ventricular arrhythmia and troponin T release. Multivariable analysis, adjusted for the propensity of receiving a locoregional technique and cardiac risk factors according to the Revised Cardiac Risk Index, was used to assess the association between cardiac events and anaesthesia type. Results A total of 173 patients underwent general anaesthesia and 129 locoregional anaesthesia. Obesity, aspirin use and therapeutic anticoagulation were more common in patients receiving general anaesthesia. Cardiac events were observed in 13.3% of patients receiving general anaesthesia and in 4.7% of patients receiving locoregional anaesthesia (P = 0.02), or 6.4% versus .8% (P = 0.02) when asymptomatic troponin release is excluded from the end point. In the general anaesthesia group, two cardiac deaths, six non-fatal myocardial infarctions, two cases of non-fatal heart failure, one non-fatal cardiac arrest and 12 cases of troponin T release were observed, compared with one myocardial infarction and five cases of troponin T release in the locoregional anaesthesia group. In multivariable analysis, general anaesthesia was associated with adverse cardiac events (odds ratio (OR) 3.8; 95%-confidence interval (CI) 1.1–12.9). Non-cardiac complications occurred in 11.6% of patients in both groups (P = 1.00). Conclusion General anaesthesia was associated with an increased risk of cardiac events in EVAR, compared with locoregional anaesthesia.

Amaç: Kronik obstrüktif akciğer hastalığı torasik veya torasik olmayan cerrahide postoperatif pulmoner ve kardiyak komplikasyonların gelişimi için iyi bilinen bağımsız risk faktörüdür. Biz kronik obstrüktif akciğer hastalığı olanlarda batın ameliyatı sonrası gelişen komplikasyonları ve bu komplikasyonlara neden olan koşulları araştırmayı amaçladık. Yöntem: Zonguldak Karaelmas Üniversitesi Tıp Fakültesi Hastanesinde batın cerrahisi uygulanan 89 olgunun kronik obstrüktif akciğer hastalığı olan 32’si çalışmaya alındı. Bulgular: Kronik obstrüktif akciğer hastalıklı olgularda pulmoner ve kardiak komplikasyon oranı yüksekti. Abdominal cerrahi uygulanan kronik obstrüktif akciğer hastalıklı olgularda postoperatif pulmoner komplikasyon ve kardiyak komplikasyon sırasıyla %21.8 ve %28.1 olarak bulundu. Kronik obstrüktif akciğer hastalığı’nda hastalığın şiddeti ile komplikasyon gelişimi açısından farklılık saptanmadı. Kronik obstrüktif akciğer hastalığı olgularında sigara içimi ve yaş postoperatif komplikasyonu etkilemez iken, bronkodilatatör kullanımı postoperatif kardiyak komplikasyonu artırdı. Açık cerrahi girişim ile karşılaştırıldığında laparoskopik cerrahinin postoperatif pulmoner komplikasyonu azalttığı saptandı. Cerrahi süresi ve insizyon tipi ile komplikasyonlar arsında ilişki bulunmadı. Sonuç: Kronik obstrüktif akciğer hastalığı olan olgularda pulmoner ve kardiak komplikasyon oranı yüksek bulundu. Diyafragmaya yakın üst batın cerrahisinin komplikasyon oranını yükseltmesi ve laparoskopik cerrahinin açık cerrahi ile karşılaştırıldığında postoperatif pulmoner komplikasyonu azaltması nedeniyle kronik obstrüktif akciğer hastalığı olan olgularda laparoskopi tercih edilmesi gereken bir yöntemdir. Bizim ön sonuçlarımıza dayanarak, kontrollü çalışmaların olmaması nedeniyle, kronik obstrüktif akciğer hastalığı olan olgularda kardiyak komorbid durumlar varlığında bronkodilatörlerin dikkatli kullanılmasını önermekteyiz., Background/aims: Chronic obstructive pulmonary disease is a well-known independent risk factor for the development of postoperative pulmonary and cardiac complications after thoracic or nonthoracic surgery. We aimed to determine the risk factors and complications of abdominal surgery in chronic obstructive pulmonary disease patients. Material and Methods: Thirty-two patients diagnosed with chronic obstructive pulmonary disease out of 89 patients who underwent abdominal surgery at Zonguldak Karaelmas University Medical School Hospital enrolled in the study. Results: Pulmonary and cardiac complication ratios were found high in chronic obstructive pulmonary disease patients. Postoperative pulmonary and cardiac complications were documented in 21.8% and 28.1% of chronic obstructive pulmonary disease patients respectively. There were no differences in terms of complications, according to the severity of the disease in chronic obstructive pulmonary disease patients. While smoking and age did not effect the postoperative complications in chronic obstructive pulmonary disease patients, bronchodilator use increased postoperative cardiac risks. We found that laparoscopic surgery reduced the risk for postoperative pulmonary complications compared with open surgical procedures. No differences were found in terms of complication regarding to the type of incision and the duration of surgery. Conclusion: The patients with chronic obstructive pulmonary disease had high ratio of the pulmonary and cardiac complications. The complication rate was higher for surgical sites closer to the diaphragm such as the upper abdomen. Laparoscopy will reduce the risk for postoperative pulmonary complications compared with open surgical procedures. Based on our preliminary data and considering the lack of controlled trials, bronchodilators should be used with great caution particularly in the individuals with chronic obstructive pulmonary disease and cardiac comorbidity