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Purpose of Review Acute heart failure (AHF) is among the leading causes for unplanned hospital admission. Despite advancements in the management of chronic heart failure, the prognosis of AHF remains poor with high in-hospital mortality and increased rates of unfavorable post-discharge outcomes. With this review, we aim to summarize current data on AHF epidemiology, focus on the different patient profiles and classifications, and discuss management, including novel therapeutic options in this area. Recent Findings There is significant heterogeneity among patients admitted for AHF in their baseline characteristics, heart failure (HF) aetiology and precipitating factors leading to decompensation. A novel classification scheme based on four distinct clinical scenarios has been included in the most recent ESC guidelines, in an effort to better risk stratify patients and guide treatment. Intravenous diuretics, vasodilators, and inotropes remain the cornerstone of management in the acute phase, and expansion of use of mechanical circulatory support has been noted in recent years. Meanwhile, many treatments that have proved their value in chronic heart failure demonstrate promising results in the setting of AHF and research in this field is currently ongoing. Summary Acute heart failure remains a major health challenge with high in-hospital mortality and unfavorable post-discharge outcomes. Admission for acute HF represents a window of opportunity for patients to initiate appropriate treatment as soon as possible after stabilization. Future studies are needed to elucidate which patients will benefit the most by available therapies and define the optimal timing for treatment implementation.

Acute myocardial infarction (AMI) is one of the leading causes of death; however, updated data regarding clinical presentation and current management are missing in Greece. This study aimed to prospectively record the demographic and clinical characteristics of a representative sample of patients suffering from AMI, their management, and short-term outcomes.ILIAKTIS is a national, prospective, multicenter, noninterventional study conducted under the auspices of Hellenic Society of Cardiology (HCS) and the European Initiative Stent - Save a Life. From 1In total, 1862 patients (mean age: 64.2 ± 13.2 yrs.; 77.2% males) with AMI were enrolled. More patients presented with NSTEMI (56.8%) than with STEMI (43.2%). Primary PCI (pPCI) was the preferable treatment option for STEMI patients in PCI-hospitals (76.9% vs. 39.9% for non-PCI, p .001) and thrombolysis in non-PCI-hospitals (47.3% vs. 17.9% for PCI-hospitals, p .001). The mean length of hospital stay was 5.6 days. In-hospital mortality was less likely in NSTEMI compared to that in STEMI patients (aOR = 0.30; 95% CI 0.18 to 0.49). Patients initially admitted in non-PCI-hospitals showed increased risk for in-hospital (aOR = 2.29; 95% CI 1.20 to 4.42) and 30-day mortality (aOR = 1.88; 95% CI 1.20 to 2.96).This study shows that the proportion of STEMI and NSTEMI patients managed interventionally has significantly increased, resulting in better clinical outcomes compared to previous Greek surveys.

Recent studies have shown that mitral regurgitation (MR) represents a major determinant of left atrial (LA) function in patients with heart failure with preserved ejection fraction. The role of MR in determining LA myopathy in hypertrophic cardiomyopathy (HCM) is unknown. The aim of this study was to examine the association of MR with LA myopathy, assessed by LA strain values in HCM patients.In total 250 consecutive patients (mean age 51 ± 16 years, 67.2% male) with an established diagnosis of HCM and with sinus rhythm at index echocardiography evaluation were included. LA reservoir, conduit and booster strain were analyzed, besides LA size, left ventricular (LV) systolic and diastolic function. The predictors of LA strain values were identified with linear regression analysis.Significant (more than mild) MR was a significant univariate predictor of all the three LA strain values. In multivariate linear regression analysis, independent predictors of LA reservoir strain were more than mild MR (r = -.23), LV global longitudinal strain (r = -.49), LA volume index (r = -.27) and patient age (r = -.23). Significant MR was also an independent determinant of LA conduit (r = -.17) and booster strain (r = -.12). In patients with LA volume index 34 ml/mSignificant MR is associated with LA myopathy independently of the LV diastolic and systolic function and LA size.

Education level has been long considered a life-quality modifier, but little is known about its relation to life expectancy in patients with cardiovascular disease. This study aims to assess possible correlations between education level and survival in patients with atrial fibrillation (AF).This retrospective cohort study used data from a randomised trial of 1082 hospitalised patients with AF (mean age of 75 ± 11 years) who were followed up after discharge. Patients were divided into three groups based on their education level: i) none or primary (NPEL), ii) secondary (SEL), and iii) tertiary education level (TEL). Kaplan-Meier curves and multivariable-adjusted hazard ratios (aHRs) were used to compare survival rates between groups. The primary outcome was all-cause mortality. The composite secondary outcome was cardiovascular mortality or any hospitalisation.After a median 31-month follow-up period, 289 (41.9%) patients died in the NPEL group, 75 (31.1%) in the SEL group, and 29 (19.1%) in the TEL group. The aHRs for all-cause mortality were 0.42 (95% CI, 0.27 to 0.66; p 0.001) for the TEL group compared with the NPEL group, 0.55 (95% CI, 0.33 to 0.93; p = 0.02) for the TEL group compared with the SEL group, and 0.68 (95% CI, 0.50 to 0.93; p = 0.01) for the SEL group compared with the NPEL group. The corresponding aHRs for the composite secondary outcome were 0.36 (95% CI, 0.23 to 0.52; p 0.001), 0.49 (95% CI, 0.29 to 0.80; p 0.001), and 0.67 (95% CI, 0.50 to 9.91; p = 0.01).Higher education levels were independently associated with fewer fatal and non-fatal outcomes in recently hospitalised patients with AF.

Radial artery occlusion (RAO) is the commonest complication of transradial catheterization. There is no evidence-based therapy, in the frame of a randomized control study, for the treatment of RAO. The purpose of the LOW-RAO study is to question the hypothesis if low-molecular-weight heparin is effective in the treatment of RAO after transradial coronary catheterization (both angiography and percutaneous coronary intervention). It is a prospective, open label, randomized controlled trial that will randomize 60 patients with RAO, irrespective of symptoms, into two groups, one receiving anticoagulation with low-molecular-weight heparin and the other receiving no treatment. The primary end point is improvement in radial artery patency rate at 4 weeks after the procedure.Lay abstract Coronary angiogram, a procedure to check if there is any blockage in the heart’s blood vessels, is often performed nowadays through a vessel in the wrist, called radial artery. One of the commonest risks of this procedure is the blockage of the radial artery afterward. This could go totally unnoticed; however, it may cause pain, tingling and numbness feeling in the fingers, loss of handgrip power and inability to use the artery for medical reasons in the future. Since there is no definite treatment for this situation up to now, the purpose of the LOW-RAO study is to try to find a solution for this problem. Patients diagnosed with radial artery blockage, will randomly receive for up to 4 weeks an injection that contains a blood-thinner, called low-molecular-weight heparin and is believed to be able to reopen the blocked radial artery. All patients will be regularly followed-up with ultrasounds for a month to check any progress with the blockage.

Background The aim of our study was to assess the performance of the new American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines, with respect to sudden cardiac death (SCD) prevention, in comparison with the established risk score of the European Society of Cardiology (hypertrophic cardiomyopathy [HCM] Risk-SCD), in a large Mediterranean cohort of HCM patients. Methods The clinical and imaging characteristics of 784 HCM patients (mean age at first evaluation 52 ± 16 years, 67.2% males) were analyzed retrospectively. The sensitivity, specificity, and negative predictive value for SCD events of the presence of ≥1 risk factor for SCD according to the ACC/AHA Guidelines 2020 and of the HCM Risk-SCD≥6% and HCM Risk-SCD≥4% were estimated during follow-up. Results During follow-up, 47 (6%) patients suffered an SCD event. The presence of ≥1 major risk factor for SCD according to the new ACC/AHA Guidelines had 96% sensitivity (95% CI 85.5-99.5%) with modest specificity of 59% (95% CI 55-62.2%) and negative predictive value of 99.5% (95% CI 98.2-99.9%). On the contrary, HCM- Risk-SCD≥6% had a relatively low sensitivity (32%, 95% CI 19.1-47.1%) and high specificity of 95% (95% CI 93.1-96.4%), whereas, HCM-Risk-SCD≥4% had sensitivity of 60% (95% CI 44-74%) and specificity of 83.9% (95% CI 80-85.6%). Both the HCM Risk-SCD cut-off values demonstrated lower negative predictive value but higher accuracy than the ACC/AHA algorithm for SCD prediction. Conclusion The novel ACC/AHA proposed algorithm identifies most of the patients with an SCD event with the cost of numerous defibrillator implantations. HCM-Risk-SCD demonstrated higher specificity, whereas its sensitivity and negative predictive value are modest.

Background Currently, there is a paucity of data concerning the safety and effectiveness of P2Y12 inhibitors in the acute coronary syndrome (ACS) with chronic kidney disease (CKD) population. The aim of this study is to compare the different oral P2Y12 inhibitors in terms of efficacy and safety, focusing exclusively on patients with CKD who were treated for ACS. Methods We systematically searched PubMed, CENTRAL, and Web of Science to identify studies that compared different oral P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor) in patients with ACS with CKD. Efficacy outcomes included the major adverse cardiovascular events composite outcome and safety outcomes included major bleedings and major or minor bleedings combined. We performed a frequentist network meta-analysis. Results Twelve studies were included in the systematic review, 7 CKD subgroup analyses of RCTs (8878 patients) and 5 observational studies (20175 patients). After the exclusion of studies with conservative management, prasugrel resulted in significant primary endpoint reduction versus clopidogrel (HR 0.80 and 95% CI 0.64 - 0.99), while ticagrelor did not (HR 0.88 and 95% CI 0.73 - 1.06). Major bleedings did not differ between the interventions. Ticagrelor resulted in more major or minor bleedings than clopidogrel (HR 1.21 and 95% CI 1.06 - 1.38), whereas prasugrel did not (HR 1.12 and 95% CI 0.84 - 1.49). Conclusion In patients with ACS with underlying CKD, who are intended to receive invasive management, there may be a significant reduction of the primary efficacy outcome with prasugrel as compared to clopidogrel but not with ticagrelor as compared to clopidogrel. There probably exists no difference among interventions in the major bleedings. Dedicated RCTs are needed to confirm these results.

Embaràs i malaltia cardíaca; Resultats de l’embaràs; Transposició de les grans artèries Embarazo y enfermedad cardíaca; Resultados del embarazo; Transposición de las grandes arterias Pregnancy and cardiac disease; Pregnancy outcomes, Transposition of the great arteries Background In the past 3 decades, the arterial switch procedure has replaced the atrial switch procedure as treatment of choice for transposition of the great arteries. Although survival is superior after the arterial switch procedure, data on pregnancy outcomes are scarce and transposition of the great arteries after arterial switch is not yet included in the modified World Health Organization classification of maternal cardiovascular risk. Methods and Results The ROPAC (Registry of Pregnancy and Cardiac disease) is an international prospective registry of pregnant women with cardiac disease, part of the European Society of Cardiology EURObservational Research Programme. Pregnancy outcomes in all women after an arterial switch procedure for transposition of the great arteries are described. The primary end point was a major adverse cardiovascular event, defined as combined end point of maternal death, supraventricular or ventricular arrhythmias requiring treatment, heart failure, aortic dissection, endocarditis, ischemic coronary events, and thromboembolic events. Altogether, 41 pregnant women (mean age, 26.7±3.9 years) were included, and there was no maternal mortality. A major adverse cardiovascular event occurred in 2 women (4.9%): heart failure in one (2.4%) and ventricular tachycardia in another (2.4%). One woman experienced fetal loss, whereas no neonatal mortality was observed. Conclusions Women after an arterial switch procedure for transposition of the great arteries tolerate pregnancy well, with a favorable maternal and fetal outcome. During counseling, most women should be reassured that the risk of pregnancy is low. Classification as modified World Health Organization risk class II seems appropriate. Funding from “Zabawas Foundation” and “De Hoop Foundation” in addition to the support from EURObservational Research Programme (EORP) is greatly acknowledged. Since the start of EORP, the following companies have supported the program: Abbott Vascular Int (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer AG (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2019), Daiichi Sankyo Europe GmbH (2011–2020), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2014–2017), Edwards (2016–2019), Gedeon Richter Plc (2014–2016), Menarini Int Op (2009–2012), MSD‐Merck & Co (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2009–2021), and Vifor (2019–2022).

Aims The current study evaluated the association of echocardiography, cardiac magnetic resonance (CMR), and ferritin data with 10-year survival in thalassemia patients. Methods Demographics, ferritin, echocardiography, and CMR parameters of stable consecutive thalassemia patients were prospectively collected. Results In total, 75 patients (mean age 37 ± 11 years, 45% male) with thalassemia were included and dichotomized based on their survival status after a median follow-up period of 10.3 [9.6-10.9] years. Older age (HR: 1.071, p = 0.001), ferritin ≥2000 ng/ml (HR: 4.682, p = 0.007) and ≥1700 ng/ml (HR: 7.817, p = 0.002), elevated LV end-diastolic pressure (HR: 1.019, p = 0.044), TR Vmax >2.8 m/s (HR: 6.845, p = 0.005), and CMR T2∗ ≤20 msec (HR: 3.602, p = 0.043) and ≤34 msec (HR: 5.854, p = 0.026) were associated with increased all-cause mortality (primary endpoint). A baseline model including age was created and became more predictive of worse survival by adding TR Vmax >2.8 m/s instead of elevated LV end-diastolic pressure (C index 0.767 vs. 0.760, respectively), ferritin ≥1700 ng/ml instead of ≥2000 ng/ml (C index 0.890 vs. 0.807, respectively), or CMR T2∗≤34 msec instead of ≤20 msec (C index 0.845 vs. 0.839, respectively). Parameters associated with the combined endpoint of cardiac mortality/cardiac hospitalization (secondary endpoint) after adjusting for age were ferritin ≥1700 ng/ml (HR 3.770, p = 0.014), ratio E/A wave >2 (HR 3.565, p = 0.04), TR Vmax >2.8 m/s (HR 4.541, p = 0.049), CMR T2∗ ≤20 ms (HR 9.462, p = 0.001), and CMR T2∗ ≤34 ms (HR 11.735, p = 0.002). The model including age and T2∗ ≤34 ms instead of T2∗ ≤20 ms was more predictive of the secondary endpoint (C-index 0.844 vs 0.838, respectively). Conclusions In thalassemia patients, TR Vmax >2.8 m/s, ferritin ≥2000 ng/ml, and CMR T2∗ ≤20 ms were associated with worse long-term survival. In the current era of advanced chelation therapy, aiming for ferritin ≤1700 ng/ml and CMR T2∗ ≥34 ms may improve their prognosis.

Wild-type TTR amyloidosis (wtATTR) represents a disease difficult to diagnose with poor prognosis. Increased clinical suspicion is key, allowing for timely diagnosis. Until recently, only off-label therapies were available but recent introduction of disease specific therapy has shown potential to alter the natural history of the disease. Tafamidis, the only currently approved drug for the therapy of wtATTR, provided significantly better survival and quality of life. However, not all subgroups of patients derived equal benefit. This, along with the increased cost of treatment raised question on whether treatment should be invariably administered through the wtATTR population. This review aims to summarize current evidence on the natural history and staging systems for wtATTR, as well as available treatment options. Special consideration is given to the selection process of patients who would be expected to gain maximum benefit from tafamidis treatment, based on an ethical and cost-effective point of view.

Aims Percutaneous left atrial appendage occlusion (LAAO) is an alternative nonpharmacological therapeutic option for stroke prevention in patients with NVAF. However, no data exist on potential LAAO candidates' prevalence among 'real-world' NVAF patients. This study aimed to investigate the indications for LAAO in hospitalized patients with comorbid nonvalvular atrial fibrillation (NVAF). Methods This is a post-hoc analysis of the MISOAC-AF (Motivational Interviewing to Support OAC-AF, ClinicalTrials.gov: NCT02941978), randomized controlled trial, which enrolled NVAF patients hospitalized for any reason in a tertiary cardiology department. In this analysis, patients with a history of major bleeding or stroke under OAC therapy were considered to have a strong indication for LAAO. Results A total of 980 patients with NVAF were studied (mean age 73.9 ± 10.9 years, 54.7% men). Prior major bleeding occurred in 134 (13.7%) patients (intracranial bleeding in 1%, upper and lower gastrointestinal bleeding in 6.4 and 8.9%, respectively). A total of 58 (5.9%) patients experienced an embolic stroke while being treated using OAC. Overall, either of these events was prevalent in 173 (17.7%) patients, denoting a strong indication for LAAO. Conclusion Almost one out of six patients hospitalized with comorbid NVAF may be considered eligible for percutaneous LAAO for stroke prevention.Trial Identification: NCT02941978, https://clinicaltrials.gov/ct2/show/NCT02941978.

The relationship between oral anticoagulants (OACs) and prognosis in elderly patients with atrial fibrillation (AF) has not been adequately explored. In this retrospective cohort study, we identified subjects aged over 80 from a database of 1140 AF patients discharged from the cardiology ward of a single tertiary center between 2015 and 2018. We examined the OAC treatment of octogenarian patients at discharge [VKA (vitamin K antagonist), NOAC (non-vitamin K antagonist oral anticoagulant), no OAC treatment]. We analyzed follow-up data of patients on OAC at discharge. The primary endpoint was all-cause death. The secondary endpoint was the incidence of stroke and major bleeding. The association of NOAC versus VKA treatment with these endpoints was assessed with multivariable Cox regression, using the VKA group as reference. A total of 330 octogenarian patients with AF were included with a mean (± SD) age of 83.9 ± 3.5 years. At discharge, 53.3% received a NOAC, 30% a VKA, and 16.7% no OAC. Patients on OAC were followed-up over a median of 2.6-years . The adjusted risk of all-cause death was not different in the NOAC group, compared with the VKA group (hazard ratio [HR], 0.72; 95% confidence intervals [CI] 0.50–1.03; P = 0.07). The risk of stroke or major bleeding was not different either (all P > 0.05). In conclusion, in this cohort of post-discharge octogenarian patients with AF, the risk for all-cause death was similar in NOAC versus VKA users, after adjustment for baseline covariates. No differences in stroke and major bleeding events among these treatment groups were revealed.

Background Valvular heart disease (VHD) in non-valvular atrial fibrillation (AF) is a puzzling clinical entity. The aim of this study was to evaluate the prognostic effect of significant VHD (sVHD) among patients with non-valvular AF. Methods This is a post-hoc analysis of the MISOAC-AF trial (NCT02941978). Consecutive inpatients with non-valvular AF who underwent echocardiography were included. sVHD was defined as the presence of at least moderate aortic stenosis (AS) or aortic/mitral/tricuspid regurgitation (AR/MR/TR). Cox regression analyses with covariate adjustments were used for outcome prediction. Results In total, 983 patients with non-valvular AF (median age 76 [14] years) were analyzed over a median follow-up period of 32 [20] months. sVHD was diagnosed in 575 (58.5%) AF patients. sVHD was associated with all-cause mortality (21.6%/yr vs. 6.5%/yr; adjusted HR [aHR] 1.55, 95% confidence interval [CI] 1.17–2.06; p = 0.02), cardiovascular mortality (16%/yr vs. 4%/yr; aHR 1.70, 95% CI 1.09–2.66; p = 0.02) and heart failure-hospitalization (5.8%/yr vs. 1.8%/yr; aHR 2.53, 95% CI 1.35–4.63; p = 0.02). The prognostic effect of sVHD was particularly evident in patients aged p for interaction Conclusion Among patients with non-valvular AF, sVHD was highly prevalent and beared high prognostic value across a wide spectrum of clinical outcomes, especially in patients aged

Background A bleeding episode may herald cancer in the general population. Oral anticoagulants (OACs), the mainstay treatment for atrial fibrillation (AF), are known to increase the risk of bleeding, and may thus promote an earlier diagnosis of cancer. Data regarding the association of bleeding episodes with cancer in patients with AF on OACs are scarce. Methods In this systematic review and meta-analysis, we searched electronic databases (Medline, Scopus, and Central) and gray literature sources for studies of patients with nonvalvular AF under any OAC, from inception until 14 October 2020. The primary outcome was the association of bleeding occurrences with the detection of cancer. A subgroup analysis was performed according to OAC type [NOAC (non-vitamin K oral anticoagulant) versus VKA (vitamin K antagonist)]. Results Overall, 4 studies were included, accounting for a total of 144,362 patients with AF receiving OAC. During follow-up, 816 (0.57%) cases of cancer were confirmed. The presence of a bleeding event, either major or minor, was associated with a higher risk for cancer detection (odds ratio [OR] 8.79, 95% confidence interval [CI] 4.98-15.51, and I2 85%). Heterogeneity was explained after studies were stratified by the type of OAC (NOACs: OR 6.12, 95% CI 4.47-8.37, I2 0%, VKAs: OR 15.16, 95% CI 12.61-18.23, and I2 0%). Conclusion The detection of a bleeding event could be an alerting sign of cancer in patients with AF on OACs, particularly in patients receiving VKAs. Registration number (DOI) available in https://doi.org/10.17605/OSF.IO/3948R , DOI: 10.17605/OSF.IO/3948R.

We present the case of a 40-year-old female patient with ST-segment elevation myocardial infarction successfully treated with a primary percutaneous coronary intervention. Thrombophilia testing revealed compound heterozygous MTHFR (C677T and A1298C) variants. We searched the literature for myocardial infarction in the setting of MTHFR polymorphisms and the possible pathophysiologic mechanisms. In young patients presenting with a thrombotic event, screening for thrombophilia could be beneficial for identification of etiology.

The comprehensive assessment of patients with hypertrophic cardiomyopathy is a complex process, with each step concurrently focusing on confirmation of the diagnosis, differentiation between sarcomeric and non-sarcomeric disease (phenocopy), and prognostication. Novel modalities such as genetic testing and advanced imaging have allowed for substantial advancements in the understanding of this condition and facilitate patient management. However, their availability is at present not universal, and interpretation requires a high level of expertise. In this setting, electrocardiography, a fast and widely available method, still retains a significant role in everyday clinical assessment of this population. In our review, we follow a stepwise approach for the interpretation of each electrocardiographic segment, discussing clinical implications of electrocardiographic patterns in sarcomeric disease, their value in the differential diagnosis from phenocopies, and impact on patient management. Outlining the substantial amount of information to be obtained from a simple tracing, we exhibit how electrocardiography is likely to remain an integral diagnostic tool in the future as well.

Objectives The aim of this study was to systematically review and quantitatively synthesize existing evidence about the prognostic value of LV apical aneurysm in patients with HCM. Background Hypertrophic cardiomyopathy (HCM) represents a common inherited heart disease associated with enormous diversity in morphologic expression and clinical course. With the increasing penetration of advanced high resolution cardiovascular imaging into routine HCM practice, a subset of HCM patients with left ventricular (LV) apical aneurysm have become more widely recognized. Methods Medline was searched for studies describing the prognostic implication of LV apical aneurysm in patients with HCM. In the main analysis the combined endpoint of major HCM-related outcomes was assessed. Separate analyses for sudden cardiac death (SCD) events and thromboembolic events were also performed. Results Six studies comprising of 2382 patients met the inclusion criteria. In the pooled analysis, the presence of LV apical aneurysm was significantly associated with major adverse outcomes (pooled OR: 5.13, 95 CI: 2.85 to 9.23, I2:31%), increased risk of SCD arrhythmic events (pooled OR: 4.67, 95% CI: 2.30 to 9.48, I2: 38%) and thromboembolic events (pooled OR: 6.30, 95% CI: 1.52 to 26.19, I2: 66%). Conclusions These data demonstrate that LV apical aneurysm in HCM patients is associated with an increased risk for SCD events and thromboembolism. This finding might encourage the inclusion of LV apical aneurysm into the HCM SCD risk stratification algorithm as a novel risk marker that supports consideration for primary prevention implantable cardioverter defibrillator and anticoagulation for stroke prophylaxis.

Aims The aim of this study is to investigate the prognostic implications of the presence of heart failure (HF) across the range of left ventricular ejection fraction (LVEF) in patients with comorbid atrial fibrillation (AF). Methods and results We conducted a retrospective cohort study of 1063 patients (median age 76 years), discharged from the cardiology ward with a primary or secondary diagnosis of AF between 2015 and 2018. We used Cox proportional‐hazards and spline models to examine the association of the presence of HF, across the range of LVEF, with the primary outcome of all‐cause mortality. HF was documented in 52.9% of patients at baseline. During a median follow‐up of 31 months (interquartile range 10 to 52 months), 37.3% of patients died. The presence of HF was associated with a significantly higher risk of mortality [adjusted hazard ratio (aHR) 2.17; 95% confidence interval (CI), 1.70 to 2.77; P

Left atrial (LA) myopathy is an established component of hypertrophic cardiomyopathy (HCM); however, the data about its association with exercise incapacity or ventilatory inefficiency that may be seen in HCM patients are limited. This study aimed to explore the association between LA myopathy, evaluated by echocardiography LA strain, and exercise capacity and ventilatory efficiency, evaluated by cardiopulmonary exercise testing (CPET), in HCM patients.This study included 241 consecutive HCM patients (aged 51.2±15.7 years 67.2% male) in sinus rhythm who underwent CPET and transthoracic echocardiography at the same visit. Exercise incapacity (maximal/predicted oxygen consumption [%peakVOAll three LA strain values were univariate predictors of exercise capacity and ventilatory efficiency. Among them, LA reservoir strain had the higher r correlation coefficient for predicting both %peakVOLeft atrial myopathy, as reflected by the LA strain values, was associated with exercise incapacity and ventilatory inefficiency in HCM individuals. Left atrial reservoir strain was the only common independent predictor of %peakVO

Digoxin is widely used in atrial fibrillation (AF) and heart failure (HF). However, current evidence regarding its association with clinical outcomes is conflicting.To investigate the relationship between digoxin therapy and adverse outcomes in patients with AF, with or without HF, in a contemporary AF cohort.We performed a retrospective analysis of data from 698 patients, who were followed over a median of 2.5 years. The primary outcome was all-cause mortality and the secondary outcome was all-cause hospitalization, in a time-to-event analysis. Propensity scores were used to derive matched populations, balanced on key baseline covariates. To limit potential confounding, inverse probability of treatment weighting (IPTW) analysis was performed.Among patients with HF, 39 (10.5%) were administered digoxin at baseline, whereas 331 (89.5%) were not. Digoxin administration was not associated with an increased risk of death (hazard ratio (HR) in the digoxin group, 1.21; 95% Confidence Interval (CI), 0.69 to 2.13, p = 0.50) or hospitalization of any cause (HR 1.15; 95% CI, 0.67 to 1.96; p = 0.60). Among patients without HF, 11 (3.5%) were administered digoxin, with neutral effects on all-cause mortality (HR: 3.25; 95% CI, 0.98 to 10.70), p = 0.06) and all-cause hospitalization (HR, 1.15; 95% CI, 0.67 to 1.96, p = 0.60). Qualitatively, consistent results were observed using IPTW.Among patients with AF, digoxin administration was not associated with an increased risk of death and hospitalization for any cause, irrespective of HF status.

Magnesium is an essential mineral for the human body and plays an important role in cardiovascular health. Hypomagnesaemia has been linked with increased cardiovascular mortality in heart failure; however, previous studies have yielded conflicting results. Even fewer studies have addressed the association between hypermagnesemia and prognosis in heart failure. The aim of the present systematic review was to investigate the association of serum magnesium levels with cardiovascular and all-cause mortality in patients with heart failure and reduced ejection fraction (HFrEF). Cardiovascular morbidity, referring to heart failure rehospitalizations and ventricular arrhythmias, was also investigated. Eligible studies were identified by searching PubMed and Scopus. The Quality in Prognosis (QUIPS) tool was used to assess the quality of included studies. Eight studies (total of 13,539 patients with HFrEF) that assessed the effects of serum magnesium levels on cardiovascular mortality, all-cause mortality, and cardiovascular morbidity met inclusion criteria. In half of the studies, hypomagnesemia was found to be an independent risk factor for cardiovascular mortality, including sudden cardiac death. Only 1 study reported that hypermagnesemia (serum magnesium levels above 2.4 mg/dL) is a prognostic factor for noncardiac mortality suggesting that hypermagnesemia is more likely an indicator of comorbidities rather than a true independent prognostic marker. Finally, low serum magnesium levels were not associated with readmissions for heart failure or ventricular arrhythmias in patients with HFrEF.

Atrial fibrillation (AF) and heart failure (HF) represent clinical turning points, altering the natural history of HCM and influencing long-term outcome of the disease. The aim of this study was to evaluate the ability of left ventricular (LV) and left atrial (LA) myocardial deformation parameters to predict new-onset AF and HF outcomes in patients with HCM. This was a prospective study that included HCM patients without severe valvular heart disease, prior myocardial infarction or history of AF. The study sample consisted of 250 patients (mean age 50.8 ± 15.8, 67.2% male). Two-dimensional (2D) speckle tracking deformation parameters including global longitudinal strain (GLS), radial strain, circumferential strain, LA reservoir strain (LAeres), LA conduit strain (LAecon) and LA booster strain(LAeboost) were examined. During a mean follow-up of 2.5 ± 1.2 years, 44 patients developed new-onset AF. All the LV and LA deformation parameters were significant univariate predictors of AF. GLS and LAeres had the highest C statistic among the LV and LA functional indices. In multivariable analysis, only LAeres remained an independent predictor of the arrhythmia (HR 0.91, 95% CI 0.85–0.98, p: 0.008). Similarly, GLS and LAeres had the highest predictive value among the 2D speckle tracking parameters for HF outcomes. LAeres remained an independent predictor after adjusting for significant covariates. GLS and LAeres demonstrated high predictive value for the development of AF and HF in HCM. LAeres was the only independent predictor of both outcomes. Clinical trial registration: ClinicalTrials.gov identifier: NCT04112511

Background Aortic stenosis (AS) is the most common valvular heart disease. While two-dimensional transthoracic echocardiography (2D-TTE) is the standard imaging modality for AS assessment, cardiac magnetic resonance (CMR) offers a reliable and reproducible alternative. The aim of this study was to compare AVA measurements as determined by TTE and CMR in patients with AS. Methods Electronic databases were searched to identify studies comparing TTE continuity equation to CMR planimetry for AVA assessment. A meta-analysis of mean difference was conducted by using the random effects model. Sensitivity analysis was performed after excluding studies reporting AVA indexed to body surface area (BSA). Heterogeneity was assessed with I2. Results A total of 12 studies, encompassing 621 patients, were included in our systematic review. In the pooled analysis, measurements of AVA by CMR planimetry were found to be significantly higher than those calculated by the continuity equation in TTE (pooled mean difference: 0.09, 95% confidence intervals (CI): 0.01, 0.17, and I2: 93%). The results remained significant, albeit with moderate heterogeneity this time, after excluding the analysis measurements of AVA indexed to BSA (pooled mean difference: 0.08, 95% CI: 0.03 to 0.13, and I2 = 61%). Conclusions CMR planimetry slightly overestimates AVA compared to TTE continuity equation. Although, 2D-TTE should be the primary imaging modality for the estimation of AVA, CMR may be useful when there is discrepancy with the clinical assessment or when TTE results are discordant or difficult to obtain.

Lipoprotein(a) [Lp(a)] is a cardiovascular factor, for which there is no approved specific lowering treatment. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to have lowering effects on Lp(a). Aim of this systematic review is to synthesize the current literature and quantify the effects of PCSK9 inhibitors on the serum Lp(a) levels in human subjects. Double-blind, phase 2 or 3, randomized-controlled trials comparing PCSK9 inhibitors (alirocumab or evolocumab) to placebo and/or ezetimibe and/or other lipid-lowering therapy were deemed eligible for inclusion. We searched MEDLINE (via PubMed), CENTRAL, Scopus, and Web of Science as of 17 June 2020. Quality assessment was performed using the Revised Cochrane risk-of-bias tool for randomized trials. Forty-three studies were identified (64,107 patients randomized) and 41 studies were included in the quantitative analysis. PCSK9 inhibitors reduced Lp(a) levels by -26.7% (95% CI, -29.5% to -23.9%) with a significant heterogeneity within studies. There was significant difference in Lp(a) change from baseline according to comparator (placebo: mean -27.9%; 95% CI, -31.1% to -24.6% vs. ezetimibe: mean, -22.2%; 95% CI, -27.2% to -17.2%; P = 0.04) and duration of treatment (≤12 weeks: mean, -30.9%; 95% CI, -34.7% to -27.1% vs. >12 weeks: mean, -21.9%; 95% CI, -25.2% to -18.6%; P < 0.01). Meta-regression analysis showed that only the mean percentage change from baseline low-density lipoprotein cholesterol due to the intervention is significantly associated with the effect size difference (P < 0.0001). PCSK9 inhibitors reduced low-density lipoprotein cholesterol by -54% (95% CI -57.6% to -50.6%). There is substantial efficacy of the currently approved PCSK9 inhibitors in the lowering of Lp(a) levels. Dedicated randomized controlled trials are needed to establish the benefit of this intervention.

AIMS We aimed to demonstrate whether coronary microvascular function is improved after ticagrelor administration compared to clopidogrel administration in STEMI subjects undergoing thrombolysis. METHODS AND RESULTS MIRTOS is a multicentre study of ticagrelor versus clopidogrel in STEMI subjects treated with fibrinolysis. We enrolled 335 patients

Background Coronary artery disease (CAD) remains one of the leading causes of mortality and morbidity worldwide. As oxygen and nutrient supply to the myocardium significantly decrease during ischemic periods, important changes occur regarding myocardial intermediary energy metabolism. Metabolomics is an emerging field in systems biology, which quantifies metabolic changes in response to disease progression. This study aims to evaluate the diagnostic utility of plasma metabolomics-based biomarkers for determining the complexity and severity of CAD, as it is assessed via the SYNTAX score. Methods Corlipid is a prospective, non-interventional cohort trial empowered to enroll 1065 patients with no previous coronary intervention history, who undergo coronary angiography in University Hospital AHEPA, Thessaloniki. Venous blood samples are collected before coronary angiography. State-of the-art analytical methods are performed to calculate the serum levels of novel biomarkers: ceramides, acyl-carnitines, fatty acids, and proteins such as galectin-3, adiponectin, and the ratio of apolipoprotein B/apolipoprotein A1. Furthermore, all patients will be categorized based on the indication for coronary angiography (acute coronary syndrome, chronic coronary syndrome, preoperative coronary angiography) and on the severity of CAD using the SYNTAX score. Follow-up of 12 months after enrollment will be performed to record the occurrence of major adverse cardiovascular events. A risk prediction algorithm will be developed by combining clinical characteristics with established and novel biomarkers to identify patients at high risk for complex CAD based on their metabolite signatures. The first patient was enrolled in July 2019 and completion of enrollment is expected until May 2021. Discussion CorLipid is an ongoing trial aiming to investigate the correlation between metabolic profile and complexity of coronary artery disease in a cohort of patients undergoing coronary angiography with the potential to suggest a decision-making tool with high discriminative power for patients with CAD. To our knowledge, Corlipid is the first study aspiring to create an integrative metabolomic biomarkers-based algorithm by combining metabolites from multiple classes, involved in a wide range of pathways with well-established biochemical markers. Trial registration CorLipid trial registration: ClinicalTrials.gov number: NCT04580173. Registered 8 October 2020—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04580173.

Identifying patients at high risk of atrial fibrillation (AF) recurrence remains challenging. This study aimed to evaluate total atrial conduction time (TACT) and left atrial (LA) asynchrony as predictors of AF recurrence. Consecutive patients after the first AF episode, terminated either spontaneously or with cardioversion, underwent transthoracic echocardiography. TACT, estimated by the time delay between the onset of P-wave and the peak A′-wave on the Tissue Doppler Imaging (PA-TDI duration), atrial volumetric and functional parameters, and biatrial strain were assessed. We calculated mean PA-TDI—the average of PA-TDI measurements in all left atrial (LA) walls—and the difference between the longest and the shortest PA interval (DLS) and the standard deviation of 4 PA intervals (SD4) to assess the LA global remodeling and asynchrony, respectively. The primary endpoint was AF recurrence. Patients with recurrent AF had significantly prolonged PA-TDI intervals in each LA wall—and thus mean PA-TDI—than those without recurrence (mean PA-TDI: 157.4 ± 17.9 vs. 110.2 ± 7.7 ms, p < 0.001). At univariate analysis, LA maximum volume index, total LA emptying fraction, right atrial maximum volume index, PA-TDI, DLS, and SD4 were predictors of AF recurrence. At multivariable analysis, PA-TDI intervals in all LA walls remained strong predictors with mean PA-TDI (odds ratio 1.04; 95% confidence interval 1.03–1.06) having an optimal cutoff of 125.8 ms in receiver operator characteristics curve analysis providing 98% sensitivity and 100% specificity for AF recurrence (area under the curve = 0.989). PA-TDI was an independent predictor of AF recurrence and outperformed established echocardiographic parameters.

Cardiac magnetic resonance (CMR) is considered the gold standard for the assessment of right ventricular ejection fraction (RVEF). Previous studies have suggested that RVEF may be a predictor of adverse outcomes in heart failure (HF). In this study, we aimed to systematically review the prognostic value of RVEF, evaluated by CMR, across the spectrum of left ventricular systolic function in patients with HF.Electronic databases were searched for studies investigating the prognostic value of RVEF in HF, irrespective of left ventricular ejection fraction (LVEF). A random-effects meta-analysis was conducted for mortality and HF hospitalization. Subgroup analyses were also performed based on the presence of reduced (50%) or preserved LVEF (≥50%).In total, 46 studies enrolling 14,344 patients were included. In the pooled analyses, impaired RVEF was a powerful predictor of mortality (HR: 1.26, 95% CI: 1.18-1.33, IImpaired RVEF on CMR strongly predicts adverse outcomes in patients with HF regardless of LVEF. RV systolic function should be carefully evaluated in these patients. Prospero Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021256967.

The vast majority of patients with congenital heart disease (CHD) survive into adulthood, but many face lifelong complications, which often result in a hospital admission. The increasing number of hospitalizations in adults with CHD (ACHD) poses a significant challenge for healthcare systems globally, especially as heart failure (HF) is becoming increasingly common in this population and is the leading cause of morbidity and mortality. Besides HF, other major contributors to this increase in admission volume are hospitalizations related to mild lesions, comorbidities and pregnancies. Ιn-hospital mortality ranges between 0.8 and 6.1%, while hospitalizations related to HF predict medium-term mortality in ACHD population. Understanding the predictors of hospitalization and in-hospital mortality is, therefore, important for ACHD healthcare providers, who should identify patients at risk that require escalation of treatment and/or close monitoring. This article reviews the available literature on hospitalization patterns in ACHD patients, with a focus on HF-related hospital admissions and specific diagnostic subgroups.

Aims Despite the existence of many studies, there are still limited data about the characteristics of myocarditis in Greece. This led to the creation of the Greek Myocarditis Registry aiming to document the different symptoms and treatment of myocarditis, assess possible prognostic factors, and find similarities and differences to what is already published in literature. This paper is a preliminary descriptive analysis of this Registry. Methods and results We analysed data for the hospitalization period of all patients included in the Registry from December 2015 until November 2017. Statistics are reported as frequency (%) or median and inter‐quartile range (IQR) as appropriate. In total, 146 patients were included; 83.3% of the patients reported an infection during the last 3 months. The most common symptom, regardless of the underlying infection, was chest pain (82.2%) followed by dyspnoea (18.5%), while the most common finding in clinical examination was tachycardia (26.7%). Presentation was more frequent in the winter months. ECG findings were not specific, with the repolarization abnormalities being the most frequent (60.3%). Atrial fibrillation was observed in two patients, both of whom presented with a reduced ventricular systolic function. Left ventricular ejection fraction changed significantly during the hospitalization [55% (IQR: 50–60%) on admission vs. 60% (IQR: 55–60%) on discharge, P = 0.0026]. Cardiac magnetic resonance was performed in 88 patients (61%), revealing mainly subepicardial and midcardial involvement of the lateral wall. Late gadolinium enhancement was present in all patients, while oedema was found in 39 of them. Only 11 patients underwent endomyocardial biopsy. Discharge medication consisted mainly of beta‐blockers (71.9%) and angiotensin‐converting enzyme inhibitors (41.8%), while 39.7% of the patients were prescribed both. Conclusions This preliminary analysis describes the typical presentation of myocarditis patients in Greece. It is a first step in developing a better prognostic model for the course of the disease, which will be completed after the incorporation of the patients' follow‐up data.

Although the superiority of manual compression of the radial, mainly due to its selectivity and progressive grading, had been hypothesized from the early days of the transradial use, data on efficacy and safety of this method are only scarce. This review tries to delineate the aspects of manual hemostasis in transradial catheterization. Current data demonstrate that manual compression of the radial artery is a possible (second line) hemostatic option in transradial catheterization with main advantage the shorter hemostasis duration, and major disadvantage the need for larger involvement of post-procedural care team in hemostasis. Manual compression of the radial artery is a possible (second line) hemostatic option with main advantage the shorter hemostasis duration, and major disadvantages the need for larger involvement of post-procedural care team in hemostasis.

Background Hypertrophic cardiomyopathy (HCM) represents the most common inherited cardiomyopathy and it is characterized by phenotypic and genetic heterogeneity. The purpose of our study was to investigate the natural history of HCM in a large Mediterranean cohort and to identify predictors of outcomes. Methods The clinical and echocardiographic characteristics of 690 patients with HCM were examined. The predictors of mortality and sudden cardiac events were examined during a mean follow-up of 8.5 years. Results Asymmetrical hypertrophy was the most common among our cohort (82.9%) followed by apical hypertrophy pattern (13.6%). Atrial fibrillation was present in 22.3%, whereas nonsustained ventricular tachycardia occurred in 10.4% of the patients. During follow-up, a total of 7.4% of patients died. Specifically, 5.5% HCM patients died from cardiovascular causes, including 2.8% from heart failure and 2% from sudden death. Obstructive phenotype did not have any effect on mortality. Atrial fibrillation, ejection fraction and right ventricular systolic pressure (RVSP) were common independent predictors for overall and cardiovascular mortality. A total of 6.1% of HCM patients suffered sudden arrhythmic events and maximal wall thickness, ejection fraction, nonsustained ventricular tachycardia, syncopal episodes and, more importantly, the presence of an apical aneurysm were all independent risk factors. Conclusion HCM is a relatively benign cardiomyopathy in Greece, similarly to other countries. Apical hypertrophy pattern is more common in Greece than in the other European countries, whereas the presence of apical aneurysm is the most important risk factor for arrhythmic events on top of the established risk factors for sudden death.

Aims Whereas up to about half of patients with heart failure with reduced ejection fraction (HFrEF) report no or only mild symptoms and are considered as clinically stable, the progressive nature of HFrEF, often silent, renders clinical stability a misleading situation, especially if disease progression is unrecognized. We highlight the challenges in the definition of clinical stability and mild symptomatic status in HFrEF, outline clinical characteristics and available diagnostic tools, and discuss evidence and gaps in the current guidelines for the management of these patients. Methods and Results This is a state‐of‐the‐art review that focuses on clinical, diagnostic, and therapeutic aspects in mildly symptomatic HFrEF patients; summarizes the challenges; and proposes directions for future research in this group of patients. The New York Heart Association classification has been widely used as a measure of prognosis in HFrEF, but it lacks objectivity and reproducibility in terms of symptoms assessment. The definition of clinical stability as described in current guidelines is vague and may often lead to underdiagnosis of disease progression in patients who appear to be ‘stable' but in fact are at an increased risk of clinical worsening, hospitalization, or death. Although an increasing number of clinical trials proved that the efficacy of HFrEF therapies was unrelated to the symptomatic status of patients and led to their implementation early in the course of the disease, clinical inertia in terms of under‐prescription or underdosing of guideline‐recommended medications in mildly symptomatic HFrEF patients is still a challenging issue to deal with. Conclusions Mildly symptomatic status in a patient with HFrEF is very frequent; it should not be ignored and should not be regarded as an index of disease stability. The application of risk scores designed to predict mortality and mode of death should be engaged among mildly symptomatic patients, not only to identify the most suitable HF candidates for cardioverter defibrillator implantation, but also to identify patients who might benefit from early intensification of medical treatment before the implementation of more interventional approaches.

Background Right ventricular pressure overload results in interventricular septal shift toward the left ventricle in patients with precapillary pulmonary hypertension (PH). We aimed to investigate the predictive role of the duration of septal curvature configuration during the cardiac cycle, as expressed by the novel marker curvature duration index (CDi) in precapillary PH. Methods This was a prospective study. All patients underwent cardiac magnetic resonance (CMR). CDi was defined by the number of CMR frames in which septal curvature configuration toward left ventricle is observed *100/total number of frames per cardiac cycle. Time from enrollment to first clinical failure event (death, hospitalization due to PH, and disease progression) was recorded. Results The study included 36 patients with precapillary PH. During a median follow-up of 20 months (IQR 4-37 months), 14 clinical failure events were observed. Survival ROC analysis showed that the optimal cutoff value of CDi, which predicted clinical failure, was 67%. Kaplan–Meier survival analysis showed that CDi≥67% was associated with a 9.4-fold increase in the risk for clinical failure. Addition of CDi to baseline models including six-minute walk test distance (c-statistic = 0.65 vs. c-statistic = 0.79), NT-proBNP (c-statistic = 0.72 vs. c-statistic = 0.83), and WHO functional class (c-statistic = 0.76 vs. c-statistic = 0.81) improved risk stratification. Conclusion Ventricular septal shift toward the left ventricle lasting for more than the two thirds of the cardiac cycle is associated with worse prognosis in precapillary PH.

Background: Distal transradial access (dTRA) by the snuffbox approach for coronary catheterization has emerged as an alternative to the classic forearm TRA with certain advantages and limitations.The aim of this study was to evaluate the effectiveness and safety of the dTRA exclusively from the right arm. Methods: Forty-nine consecutive patients (31 males and 18 females, mean age 64 ± 12 years), who were candidates for coronary catheterization in two cath laboratory centers, regardless of the indication, were recruited. Right dTRA was exclusively used. Radial artery patency both at the forearm and at the snuffbox region was evaluated 24 h after successful hemostasis by triplex ultrasonography. All complications were recorded until 24 h after the procedure. Results: The indication for catheterization was an acute coronary syndrome in 24.5%, stable coronary artery disease in 22.4%, and other reasons in 53.1%. The overall failure attempt incidence was 10.2% and the mean puncture time 3.9 ± 4.1 min. Angiography only was performed in 81.8% and angiography followed by percutaneous coronary intervention in 18.2% of the patients. Manual hemostasis was applied in 63.6% of the patients, which had a significantly shorter duration than device hemostasis (11 ± 7 versus 198 ± 42 min, p

Funding Acknowledgements Type of funding sources: None. Background Recent studies have shown that mitral regurgitation (MR) represents a major determinant of left atrial (LA) function in patients with heart failure with preserved ejection fraction. The role of MR in determining LA myopathy in hypertrophic cardiomyopathy (HCM) is unknown. Purpose The aim of this study was to examine the association of MR with LA myopathy, assessed by LA strain in HCM patients. Methods In total 250 consecutive patients (mean age 51 ± 16years, 67.2% male) with an established diagnosis of HCM and with sinus rhythm at index echocardiography evaluation were included. LA reservoir, conduit and booster strain were analyzed, besides LA size, left ventricular (LV) systolic and diastolic function. The predictors of LA strain values were identified with linear regression analysis. Results More than mild MR was a significant univariate predictor of all the three LA strain values. In multivariate linear regression analysis, independent predictors of LA reservoir strain were more than mild MR (r= -0.23), LV global longitudinal strain (r= -0.49), LA volume index (r= -0.27) and patient age (r= -0.22). More than mild MR was also an independent determinant of LA conduit (r=-0.17) and booster strain (r=-0.12) (Table 1). In patients with LA volume index Conclusion The severity of MR is associated with LA myopathy with independently of the LV diastolic and systolic function and LA size. Abstract Table 1 Abstract Table 2

Funding Acknowledgements Type of funding sources: None. Background Data about the predictive value of left atrial (LA) myopathy for exercise capacity and ventilatory efficiency in patients with hypertrophic cardiomyopathy (HCM) are limited. Purpose The aim of this study was to evaluate the association of LA myopathy, evaluated by echocardiography LA strain, with exercise capacity and ventilatory efficiency, evaluated by cardiopulmonary exercise testing (CPET), in HCM patients. Methods In total, 241 consecutive HCM patients (51 ± 16 years old; 67.2% male) on sinus rhythm that underwent CPET and transthoracic echocardiography at the same visit were studied. Exercise capacity (maximal oxygen consumption/predicted [%peakVO2]) and ventilatory efficiency (ventilation/carbon dioxide output [VE/VCO2] slope) were assessed by CPET. LA myopathy was examined by speckle tracking myocardial deformation parameters: LA reservoir, conduit and booster strain. Results All the three LA strain values were univariate predictors of exercise capacity and ventilatory efficiency. Among them, LA reservoir strain had the higher r correlation coefficient for predicting both %peakVO2 and VE/VCO2 slope and was included in multivariable analyses. LA reservoir strain, male gender and E/E’ ratio were independent predictors of exercise capacity. LA reservoir strain, male gender, non-sustained ventricular tachycardia and LA volume index were independent predictors of ventilatory efficiency (Table). Conclusion LA myopathy, as reflected by the LA strain values, was associated with exercise capacity and ventilatory efficiency in HCM individuals. LA reservoir strain was the only common independent predictor for %peakVO2 and VE/VCO2 slope. Abstract Table

Aim: This retrospective cohort study aimed to evaluate the prognostic implications of the distinct atrial fibrillation (AF) temporal patterns: first diagnosed, paroxysmal, and persistent or permanent AF. Methods: In this post hoc analysis of the MISOAC-AF trial (NCT02941978), a total of 1052 patients with AF (median age 76 years), discharged from the cardiology ward between 2015 and 2018, were analyzed. Kaplan-Meier and Cox-regression analyses were performed to compare the primary outcome of all-cause mortality, the secondary outcomes of stroke, major bleeding and the composite outcome of cardiovascular (CV) mortality or hospitalization among AF patterns. Results: Of patients, 121 (11.2%) had first diagnosed, 356 (33%) paroxysmal, and 575 (53.2%) persistent or permanent AF. During a median follow-up of 31 months (interquartile range 10 to 52 months), 37.3% of patients died. Compared with paroxysmal AF, patients with persistent or permanent AF had higher mortality rates (adjusted hazard ratio (aHR), 1.37; 95% confidence interval [CI], 1.08-1.74, P = .009), but similar CV mortality or hospitalization rates (aHR, 1.09; 95% CI, 0.91-1.31, P = .35). Compared with first diagnosed AF, patients with persistent or permanent AF had similar mortality (aHR, 1.26; 95% CI, 0.87-1.82, P = .24), but higher CV mortality or hospitalization rates (aHR, 1.35; 95% CI, 1.01-1.8, P = .04). Stroke and major bleeding events did not differ across AF patterns (all P > .05). Conclusions: In conclusion, in recently hospitalized patients with comorbid AF, the presence of persistent or permanent AF was associated with a higher incidence of mortality and morbidity compared with paroxysmal and first diagnosed AF.

Superiority of potent P2Y12 inhibitors over clopidogrel after an acute coronary syndrome (ACS) has been well established, however potent P2Y12 inhibition is responsible for more adverse events, which may influence patient adherence to treatment. Aim of the present study is to investigate the adherence to the prescribed P2Y12 inhibitor (P2Y12i) in patients on dual antiplatelet therapy (DAPT) after an ACS.In an IDEAL-LDL trial substudy, we included 344 patients after ACS discharged on DAPT. The primary outcome was the difference between potent P2Y12i and clopidogrel in terms of adherence, as well as other predictors of adherence to the antiplatelet regimen. Secondary outcomes included the prevalence of DAPT continuation and its predictors and the antiplatelet regimen selection after DAPT.Adherence to the potent P2Y12i and to clopidogrel was observed in 140/178 (78.7%) and 111/166 (66.9%) patients (Adherence to DAPT was not affected by the P2Y12i potency, whereas history of CVD and PCI treatment were associated with reduced and increased adherence, respectively.NCT02927808, https://clinicaltrials.gov/ct2/show/NCT02927808.

BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

Our study aimed to investigate the association between platelet indices and their in-hospital change and long-term prognosis in acute coronary syndrome (ACS). Data from a randomized controlled trial (NCT02927808) recruiting ACS patients were analyzed (survival analysis). The examined variables were platelet count (PC), mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT) on admission and discharge, as well as their alteration during hospitalization. The primary endpoint was major adverse cardiac events (MACE) (cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke or hospitalization for unstable angina) and all-cause mortality, while secondary endpoints were all-cause hospitalization and bleeding events. The study included 252 patients with a follow-up of 39 (28–45) months. In the univariate analysis, MACE was associated with discharge PC [hazard ratio (HR) 2.20, 95% confidence interval (CI) 1.10–4.40], discharge MPV (HR 0.48, 95% CI 0.25–0.94), and in-hospital PC difference (HR 0.25, 95% CI 0.13–0.51). In the multivariable analysis, only in-hospital PC decrease correlated with lower MACE incidence (adjusted HR .27, 95% CI 0.14–0.54) and lower all-cause hospitalization risk (adjusted HR 0.36, 95% CI 0.19–0.68). PC reduction during hospitalization for ACS is an independent predictor of better prognosis.

Rhythm control and rate control are both employed commonly in patients with atrial fibrillation (AF) and heart failure (HF), but limited real-world data exist on them. We aimed to compare outcomes between these two strategies across the left ventricular ejection fraction (LVEF) spectrum.This retrospective cohort study used data from the randomized MISOAC-AF trial, including from patients with AF and coexistent HF who were hospitalized and followed up after discharge. At baseline, the patients were classified into pharmaceutical (or electrical cardioversion) rhythm control strategy or rate control treatment (b-blocker, digoxin, calcium channel blockers) groups. The primary outcome was all-cause mortality. Kaplan-Meier curves and multivariable-adjusted Cox regression were utilized to compare the two strategies. Spline curve models were used to demonstrate the results across the LVEF stratified spectrum.In total, 199 AF patients with HF were studied (mean age, 77 years). At discharge, 73 (36.7%) patients received rhythm control and 126 (63.3%) rate control treatment. After a median follow-up period of 31 months, 26 (35.6%) patients in the rhythm-control group died, as compared to 43 (33.3%) in the rate-control group (aHR: 1.29; 95% CI: 0.78-2.14; p = 0.31). The spline curves also revealed no difference in all-cause mortality favoring either strategy in any HF subtype across the nominally classified LVEF.The use of a pharmacological rhythm-control strategy was not associated with a survival advantage compared to the rate control strategy in recently hospitalized patients with AF and comorbid HF. More randomized trials and large studies are needed in the future to explore these results in each subgroup of HF patients.