Cardiovascular Medicine

Are women really more affected by vasovagal syncope than men? It is commonly reported that vasovagal syncope (VVS) is more frequent in women. Presently, this issue has never been investigated. The purpose of this review was to evaluate, through an extensive review of the literature, whether women are really more affected by VVS than men. The gender distribution was investigated in individuals with classical and nonclassical VVS. The database PubMed was searched using the terms 'syncope', 'vasovagal syncope', 'neurally mediated syncope' and 'tilt testing'. Twelve studies dealing with classical and 75 with nonclassical VVS were eligible. In the individuals with classical (N = 1861) and nonclassical VVS (N = 9696), a trend towards a greater percentage of women emerged (P = 0.14 and 0.07, respectively). In the total population with VVS (N = 11 557), the percentage of women was significantly higher than that of men (58 versus 42%, P = 0.03). Most of the individuals were young or middle-aged. In 84% of the studies, the percentage of women was greater than that of men. A separate analysis was carried out in older VVS patients (≥60 years) and only two studies were eligible to be evaluated. Considering that almost all the studies were carried out in the western nations, where the number of men and women is almost superimposable until the age of 65 years and a bias by gender has never been reported in the management of VVS, these data strongly suggest that young and middle-aged women are more affected by VVS than their male counterparts. At present, data are too scant to draw a definitive conclusion in older VVS patients.

Pathophysiology and management of recreational drug-related acute coronary syndrome: ANMCO position statement Recreational drug use may cause coronary artery disease through several mechanisms. An increasing number of young patients with drug-related acute coronary syndrome have been reported over recent years. The present position statement reports the most recent epidemiological data on acute coronary syndrome in the setting of drug abuse, describes the main pathophysiological mechanisms underlying coronary artery disease and acute events in these patients, and provides practical recommendations on management and an overview of prognosis.

Cardiac resynchronization therapy: variations across Europe in implant rates and types of implanted devices No abstract available

Clinical performance of a novel sirolimus-coated balloon in coronary artery disease: EASTBOURNE registry Aims The purpose of the EASTBOURNE registry is to evaluate the immediate and long-term clinical performance of a novel sirolimus-coated balloon (SCB) in a real-world population of patients with coronary artery disease. We here present the prespecified interim analysis after the enrollment of the first 642 patients who obtained 1-year clinical follow-up. Methods EASTBOURNE is a prospective, international, multicenter, all-comer investigator-driven clinical registry, which is enrolling consecutive patients treated with SCB at 42 European and Asiatic centers. Primary study endpoint is target-lesion revascularization (TLR) at 12 months. Secondary endpoints are procedural success and major adverse cardiac events through 36 months. Results Diabetes mellitus was present in 41% of patients. Acute coronary syndrome was present in 45% of patients and de novo lesions were 55%; 83% of the in-stent restenosis (ISR) patients had drug-eluting stents restenosis. Lesion predilatation was performed in 95% of the cases and bailout stenting occurred in 7.5%. So far, 642 patients have a complete 12-month follow-up. TLR occurred in 2.5%, myocardial infarction in 2.3%, total death in 1% and major adverse cardiac events in 5.8% of patients. A prespecified analysis of comparison between ISR and de-novo lesions showed a significantly higher occurrence of TLR in the ISR population (5.4 vs. 0.2%, P = 0.0008). Conclusion The current interim analysis of 12-month follow-up of the EASTBOURNE registry shows good immediate performance and an adequate and encouraging safety profile through 12 months for this novel SCB.

Sirolimus-coated balloons: ready for primetime in real world patients? No abstract available

Clinical and electrocardiographic features of patients with myocardial infarction with non-obstructive coronary artery disease (MINOCA) Aims Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is often an underdiagnosed and undertreated condition. This study aimed to evaluate clinical and ECG characteristics of MINOCA in a large cohort of patients admitted for acute coronary syndrome. Methods All coronary angiograms performed at the University Heart Center in Zurich (Switzerland) between 2012 and 2016 were investigated. MINOCA was defined according to European Society of Cardiology guidelines and patients were divided into two groups, based on the presence or absence of coronary sclerosis at angiogram[nonobstructive coronary artery disease (noCAD) and normal coronary arteries (NCA)]), after exclusion of myocarditis and Takotsubo syndrome. Results Out of 13 669 angiographic studies, 3695 were diagnosed with acute coronary syndrome; of these, 244 patients presented MINOCA (6.6%). Patients with noCAD were more likely to be older (67.9 vs. 59.2 years, P < 0.001) with higher prevalence of traditional cardiovascular risk factors (hypertension 64.1 vs. 41.2%, P = 0.002; diabetes 19.7 vs. 10.8%, P = 0.036; hypercholesterolemia 36.6 vs. 23.5%, P = 0.037). On surface ECG, anterior ST- segment elevation was more frequent in NCA patients (13.7 vs. 5.0%, P = 0.016). Secondary prevention therapy was significantly more prescribed in noCAD compared with NCA patients (acetylsalicylic acid 68.3 vs. 21.6%, P less than 0.001; statins 76.1 vs. 22.5%, P less than 0.001; angiotensin-converting enzyme inhibitor–AT1 blockers 51.4 vs. 31.3%, P = 0.006). One-year mortality was very low (0.4% for noCAD patients). Conclusion noCAD patients were older, with higher prevalence of cardiovascular risk factors and more frequently discharged with secondary prevention therapy. NCA patients presented more frequently anterior ST- segment elevation. Further diagnostic tests should be highly recommended to determine the underlying mechanism of MINOCA.

Arrhythmic event prediction in patients with heart failure and reduced ejection fraction Aims Implantable cardioverter defibrillator (ICD) is an effective treatment to reduce mortality in patients with symptomatic heart failure and left ventricular ejection fraction (LVEF) 35% or less. LVEF presents a low sensitivity for predicting arrhythmic events. Aim of this study was to identify predictors of sustained ventricular arrhythmias (SVAs), overall and according to the cause of heart failure. Methods Single-center, retrospective, cohort study of 193 patients (51 nonischemic and 142 ischemic) with chronic heart failure and LVEF less than 35% who had received ICD for primary prevention of sudden cardiac death. We collected clinical data, echocardiographic parameters and SVAs detected by the ICD. Results During a median follow-up of 1440 days, 32 (16.2%) patients had SVAs. SVAs incidence was similar in patients with nonischemic (15.6%) and ischemic cause of heart failure (16.9%). Hypertension, diabetes, chronic renal failure, atrial fibrillation, chronic obstructive pulmonary disease, New York Heart Association class at least III were predictors at univariate analysis of SVAs. A clinical score, assigning one point to each of these variables, was associated with a significantly increased risk of SVAs [odds ratio for each point increase = 1.92, 95% confidence interval 1.40–2.65, P < 0.0001, area under the curve (AUC) 0.73], with 72% sensitivity and 60% specificity for a cutoff at least three and remained significant in nonischemic (AUC 0.84) and ischemic (AUC 0.68) patients. Conclusion Our study shows the benefit of ICD implantation in primary prevention and its independency of cause. A simple clinical score, based on comorbidities, identifies patients with more benefits from ICD implantation.

Frequency, predictors and prognostic impact of implantable cardioverter defibrillator shocks in a primary prevention population with heart failure and reduced ejection fraction Aims The role of the implantable cardioverter defibrillator (ICD) in primary prevention real-world population is debated. We sought to evaluate the incidence, predictors and prognostic impact of ICD shocks in consecutive heart failure patients implanted for primary prevention at our tertiary institution. Methods and results We retrospectively selected a sample of 497 patients (mean age 64.8 years, 82.1% men, average left ventricular ejection fraction, LVEF, 27.1%). At long-term follow-up (median time 70.4 months), total mortality was 40.8%, and 16.5% of patients had received at least one appropriate shock (3.12%/year). Inappropriate shock [odds ratio (OR) 1.93, 95% confidence interval (95% CI) 1.08–3.47; P = 0.027] and length of follow-up (1 year, OR 1.01, 95% CI 1.00–1.01; P = 0.0031) were associated with the occurrence of appropriate shock, whereas atrial fibrillation (OR 2.65, 95% CI 1.55–4.51, P < 0.001), length of follow-up (1-year OR 1.01, 95% CI 1.00–1.01, P < 0.001) and appropriate shock (OR 1.93, 95% CI 1.08–3.47, P = 0.027) were associated with the occurrence of inappropriate shock. Neither appropriate nor inappropriate shock independently increased mortality risk, whereas older age (hazard ratio 1.05; 95% CI 1.04–1.07; P < 0.001), atrial fibrillation (hazard ratio 2.25; 95% CI 1.67–3.02; P < 0.001) and lower LVEF (hazard ratio 0.97; 95% CI 0.94–0.99; P = 0.004) did. Conclusion Incidence of shocks in real-world primary prevention ICD recipients might be lower than expected, and the association between ICD shocks and prolongation of survival is not as clear-cut as might be perceived. Further investigations from larger real-world samples are warranted.

A cohort study examining urgent and emergency treatment for decompensated severe aortic stenosis Aims We compared strategies in the treatment of decompensated severe aortic stenosis. The hypothesis was that undertaking urgent or emergency transcatheter aortic valve implantation (TAVI) directly in such patients is safer and more effective than urgent or emergency balloon aortic valvuloplasty (BAV) followed by elective TAVI or surgical aortic valve replacement (SAVR). Methods This was a single-centre retrospective study including all consecutive patients who underwent urgent or emergency BAV or TAVI for decompensated severe aortic stenosis between September 2014 and February 2018. Primary endpoints were 30-day and 1-year mortality. Results Fifty-two patients underwent urgent or emergency BAV and 87 underwent TAVI. Baseline characteristics of the two groups were well matched. Significant differences were noted between the two groups in 30-day all-cause mortality (88.5% BAV patients alive at 30 days, 97.7% TAVI patients; P < 0.05) and 1-year all-cause mortality (44.2% BAV patients alive at 1 year, 88.5% TAVI patients; P < 0.001). At 1 year, the estimated hazard ratio for patients undergoing BAV was 11.2 (95% confidence interval: 4.67–26.9; P < 0.001) when adjusted for potential confounding variables. Patients in the BAV group who successfully underwent subsequent TAVI or SAVR all survived for 365 days, but there was no significant 1-year mortality difference compared with those who underwent urgent or emergency TAVI (100 vs. 88.5%; P > 0.155). Conclusion Our results suggest treatment of decompensated severe aortic stenosis with urgent or emergency TAVI may be associated with improved survival outcomes when compared with a strategy of performing BAV as a bridge to subsequent TAVI or SAVR.

Pacemaker need after sutureless aortic valve replacement: the role of the learning curve Aim Aortic valve replacement (AVR) using sutureless prosthesis is a reasonable alternative in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. Actually, excellent performances have been demonstrated in hemodynamic outcomes and safety, but some questions remain open regarding long-term durability and the need for postoperative pacemaker implantation. Methods Between January 2014 and August 2019, all 436 patients [male 40.6%, median age 78 years interquartile range (73–82)] treated with sutureless AVR with a Perceval prosthesis were included in our analysis. Results The univariate logistic regression showed previous aortic valve surgery [P = 0.028; odds ratio (OR) 3.248], dialysis (P = 0.036; OR 6.435), renal insufficiency (P = 0.021; OR 2.75), EuroSCORE II (P = 0.016; OR 1.051) and year of operation (P < 0.01; OR 0.658) as factors associated with the development of atrioventricular type II or type III block or junctional block requiring pacemaker implantation. The overall incidence of pacemaker implantation after sutureless AVR was 7.1% in the current study, but it dropped to 3.8 and 4.7%, respectively, in 2018 and 2019. Conclusion The Perceval aortic valve is associated with encouraging postoperative results. The incidence of pacemaker implantation is strictly linked to the surgeons' experience, decreasing year by year after an adequate sizing, reaching a percentage comparable with sutured valve.

#

Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,