Heart Failure in Diabetes Mellitus: An Updated Review

Diabetes mellitus (DM) and heart failure (HF) are comorbid conditions associated with significant morbidity and mortality worldwide. Despite the availability of novel and effective therapeutic options and intensive glycaemic control strategies, mortality and hospitalisation rates continue to remain high and the incidence of HF persists. In this review, we described the impact of currently available glucose-lowering therapies in DM with a focus on HF clinical outcomes. Non-conventional modes of management and alternative pathophysiological mechanisms with the potential for therapeutic targeting are also discussed.

The role of CT in detecting AF substrate

Despite technological advancements and evolving ablation strategies, atrial fibrillation catheter ablation outcome remains suboptimal for a cohort of patients. Imaging-based biomarkers have the potential to play a pivotal role in the overall assessment and prognostic stratification of AF patients, allowing for tailored treatments and individualized care. Alongside consolidated evaluation parameters, novel imaging biomarkers that can detect and stage the remodelling process and correlate it to electrophysiological phenomena are emerging. This review aims to provide a better understanding of the different types of atrial substrate, and how Computed Tomography can be used as a pre-ablation risk stratification tool by assessing the various novel imaging biomarkers, providing a valuable insight into the mechanisms that sustain AF and potentially allowing for a patient-specific ablation strategy.

Ethnicity and COVID-19 cardiovascular complications: a multi-center UK cohort

BACKGROUND

Recent reports suggest an association between ethnicity and COVID-19 mortality. In the present multi-center study, we aimed to assess the differences underlying this association, and ascertain whether ethnicity also mediates other aspects of COVID-19 like cardiovascular complications.

METHODS

Data were collected from a mixed-ethnicity UK cohort of 613 patients admitted and diagnosed COVID-19 positive, across six hospitals in London during the second half of March 2020: 292 were White Caucasian ethnicity, 203 were Asian and 118 were of Afro-Caribbean ethnicity.

RESULTS

Caucasian patients were older (P<0.001) and less likely to have hypertension (P=0.038), while Afro-Caribbean patients had higher prevalence of diabetes mellitus (P<0.001). Asian patients were more likely to present with venous thromboembolic disease (adj.OR=4.10, 95% CI 1.49-11.27, P=0.006). On the other hand, Afro-Caribbean had more heart failure (adj.OR=3.64, 95% CI 1.50-8.84, P=0.004) and myocardial injury (adj.OR=2.64, 95% CI 1.10-6.35, P=0.030). Importantly, our adjusted multi-variate Cox regression analysis revealed significantly higher all-cause mortality both for Asian (adj.HR=1.89, 95% CI 1.23-2.91, P=0.004) and Afro-Caribbean ethnicity (adj.HR=2.09, 95% CI 1.30-3.37, P=0.002).

CONCLUSIONS

Our data show that COVID-19 may have different presentations and follow different clinical trajectories depending on the ethnicity of the affected subject. Awareness of complications more likely to arise in specific ethnicities will allow a more timely diagnosis and preventive measures for patients at risk. Due to increased mortality, individuals of Afro-Caribbean and Asian ethnicity should be considered as high-risk groups. This may have an impact on health-resource allocation and planning, definition of vulnerable groups, disease management, and the protection of healthcare workers at the frontline.

Predictive Role of BNP/NT-proBNP in Non-Heart Failure Patients Undergoing Catheter Ablation for Atrial Fibrillation: An Updated Systematic Review

Atrial Fibrillation (AF) is a growing public health issue, associated with significant morbidity and mortality. In addition to pharmacological therapy, catheter ablation is an effective strategy in restoring and maintaining sinus rhythm. However, ablation is not without risk, and AF recurs in a significant proportion of patients. Non-invasive, easily accessible markers or indices that could stratify patients depending on the likelihood of a successful outcome following ablation would allow us to select the most appropriate patients for the procedure, reducing the AF recurrence rate and exposure to potentially life-threatening risks. There has been much attention paid to Brain Natriuretic Peptide (BNP) and N-Terminal prohormone of Brain Natriuretic Peptide (NT-proBNP) as possible predictive markers of successful ablation. Several studies have demonstrated an association between higher pre-ablation levels of these peptides, and a greater likelihood of AF recurrence. Therefore, there may be a role for measuring brain natriuretic peptides levels when selecting patients for catheter ablation.

Cell-Derived Microparticles and Acute Coronary Syndromes: Is there a Predictive Role for Microparticles?

Background:

Despite the recent advances in the treatment of Acute Coronary Syndromes (ACS), patients with ACS are still exposed to an increased risk for adverse cardiovascular events, while their prognosis is difficult to determine. Experimental and clinical studies have shown that cell-derived Microparticles (MPs) are associated with the underlying pathophysiological processes that are responsible for atherogenesis and may be causally implicated in the induction of atherothrombosis.

Objective:

In the present article, we aimed to review the available evidence regarding the predictive role of MPs in patients with ACS.

Results:

Evidence suggests that endothelial MPs are associated with future adverse cardiovascular events in patients with ACS. Platelet-derived MPs have been excessively studied, since they have been found to trigger the coagulation cascade; however, their role as predictors of future cardiovascular events remains debatable. The role of red blood cell-derived MPs is more intriguing; they have been proposed as markers of ongoing thrombosis in patients with ACS, while previous studies have shown that they have anti-coagulant properties in healthy individuals. Leukocyte-derived MPs may also have a predictive role, although the studies regarding these are still limited. Last but not least, it was an interesting discovery that circulating MPs can provide information regarding the angiographic lesions in patients with ACS.

Conclusion:

The concept of MPs as potential circulating biomarkers in patients with ACS holds much promise. However, large-scale clinical studies are required to evaluate whether the measurement of plasma MPs could be of clinical significance and, thus, dictate a more aggressive treatment strategy in patients with high levels of circulating MPs.

Antithrombotic Therapy in Patients with Recent Stroke and Atrial Fibrillation

:

Atrial fibrillation (AF) is a common arrhythmia which carries a significant risk of stroke. Secondary prevention, particularly in the acute phase of stroke with anti-thrombotic therapy, has not been validated. The aim of this review is to evaluate the available evidence on the use of antithrombotic therapy in patients with recent stroke who have AF, and suggest a treatment algorithm for the various time points, taking into account both the bleeding and thrombosis risks posed at each stage.

Systematic review and network meta-analysis of atrial fibrillation percutaneous catheter ablation technologies using randomized controlled trials

AIMS

We sought out to make comparisons between all atrial fibrillation (AF) catheter ablation technologies using randomized controlled trial data. Our comparisons were freedom from AF, procedural duration, and fluoroscopy duration.

METHODS

Searches were made of EMBASE, MEDLINE, and CENTRAL databases, and studies were selected which had cryoballoon, conventional radiofrequency (RF), multipolar RF catheters, and laser technology as an arm in the study and were identified as randomized controlled trials (RCTs). These studies were analyzed for direct comparisons using conventional meta-analysis and a combination of indirect and direct comparisons via a network meta-analysis (NMA).

RESULTS

With respect to freedom from AF both direct comparisons and NMA did not demonstrate any significant difference. However in analysis of procedural and fluoroscopy duration (minutes) for the pulmonary vein ablation catheter (PVAC), both conventional analysis and NMA revealed significantly shorter procedure times, RF vs PVAC (conventional: 61.99 [38.03-85.94], P <.00001; NMA: 54.76 [36.64-72.88], P < .0001) and fluoroscopy times, RF vs PVAC (conventional: 12.96 [6.40-19.53], P = .0001; NMA: 8.89 [3.27-14.51], P < .01). The procedural duration was also shorter for the cryoballoon with NMA, RF vs CRYO (20.56 [3.47-37.65], P = .02).

DISCUSSION

Our analysis demonstrated that while there was no difference in the efficacy of the individual catheter technologies, there are significant differences in the procedural duration for the PVAC and the cryoballoon. While they may seem an attractive solution for high-volume centers, further RCTs of next-generation technologies should be examined.

Impact of Type-2 Diabetes Mellitus on the Outcomes of Catheter Ablation of Atrial Fibrillation (European Observational Multicentre Study)

Type-2 diabetes mellitus (DM) is associated with an increased risk of atrial fibrillation (AF). It is unclear whether DM is a risk factor for arrhythmia recurrence following catheter ablation of AF. We performed a nonrandomised, observational study in 7 high-volume European centres. A total of 2,504 patients who underwent catheter ablation of AF were included, and procedural outcomes were compared among patients with or without DM. Patients with DM (234) accounted for 9.3% of the sample, and were significantly older, had a higher BMI and suffered more frequently from persistent AF. Arrhythmia relapses at 12 months after AF ablation occurred more frequently in the DM group (32.0% vs 25.3%, p = 0.031). After adjusting for type of AF (i.e., paroxysmal vs persistent), during a median follow-up of 17 ± 16 months, atrial arrhythmia free-survival was lower in the diabetics with persistent AF (log-rank p = 0.003), and comparable for paroxysmal AF (log-rank p = 0.554). These results were confirmed in a propensity-matched analysis, and DM was also an independent predictor of AF recurrence on the multivariate analysis (hazard ratio 1.39; 95% confidence interval _95%1.07 to 1.88; p = 0.016). There was no significant difference in the rate of periprocedural complications among DM and non-DM patients (3.8% vs 6.3%, p = 0.128). Efficacy and safety of cryoballoon ablation were comparable to radiofrequency ablation in both DM and no-DM groups. In conclusion, catheter ablation of AF appears to be safe in patients with DM. However, DM is associated with higher rate of atrial arrhythmia relapse, particularly for patients with persistent AF.

Initial experience with the convergent procedure for longstanding persistent atrial fibrillation: A 5 year dataset

In patients with longstanding persistent atrial fibrillation (AF), outcomes from catheter ablation remain suboptimal. The convergent procedure combines minimally invasive surgical ablation with subsequent catheter ablation, and may contribute towards maintenance of sinus rhythm in this patient group. We performed the convergent procedure on 43 patients with longstanding persistent AF from 2013–2018. Patients underwent clinical review at 3, 6, and 12 months and thereafter as necessitated by their symptoms. Our dataset describes patients’ baseline characteristics and rhythm control protocols, as well as outcomes including arrhythmia recurrence, the need for antiarrhythmic drugs, requirement for repeat rhythm control procedures, and complications. These data provide a real world insight into the risks and benefits of the convergent procedure in patients with longstanding persistent AF.

Plasma signature of apoptotic microvesicles is associated with endothelial dysfunction and plaque rupture in acute coronary syndromes

OBJECTIVE

Circulating microvesicles (MV) are surrogate biomarkers of atherosclerosis. However, their role in acute coronary syndromes (ACS) has not been fully elucidated yet. We sought to examine the association of circulating apoptotic MVs with ACS pathophysiology.

APPROACH AND RESULTS

One hundred and fifty-three patients (n = 153) were included in the study; 49 patients with ST-elevation myocardial infarction (STEMI), 35 with non-STEMI (NSTEMI), 38 with unstable angina, 15 with stable coronary artery disease and 16 control individuals. Flow cytometry analysis was used to quantify circulating apoptotic/non-apoptotic (phospatidyloserine⁺/phospatidyloserine^-) endothelial cell (EMV), red blood cell (RMV) and platelet (PMV) derived MV. Flow-mediated dilatation (FMD) of the brachial artery was assessed by ultrasound to estimate endothelial function. The inflammatory profile was assessed by serum C-reactive protein (hsCRP) levels. Apoptotic only (but not non-apoptotic) MV were increased in patients with ACS (EMV, P = 2.32 × 10^-9; RMV, P = .0019; PMV, P = .01). Hierarchical clustering of the total population of ACS patients (n = 122) by circulating levels of phospatidyloserine⁺ EMV, RMV and PMV identified two discreet clusters of patients without any differences in traditional risk factors, but significant differences in brachial FMD (5.2% (2.5) vs. 4.1% (2.3), P < .05) that remained significant after adjustment for co-variates. The prevalence of STEMI, a surrogate for plaque rupture and vessel thrombotic occlusion, was significantly higher in the patient cluster with impaired endothelial function (60% vs 32%, P = .016, adjusted odds ratio for STEMI, 3.041, 95%CI, 1.160 to 7.968, p = .024).

CONCLUSION

Our findings indicate that the circulating levels of apoptotic MV are increased in ACS patients and their plasma profiles associate with endothelial dysfunction and thrombotic complications in ACS patients.

The Impact of Omega 3 Fatty Acids in Atherosclerosis and Arterial Stiffness: An Overview of their Actions

BACKGROUND

Fatty acids are common dietary nutrients particularly in economically developed countries. Research has revealed that omega-3fatty acids exert beneficial effects in the progression of atherosclerosis and cardiovascular disease. Moreover, eicosapentaenoic acid and docosahexaenoic acid possess a number of biological actions which improve cardio-metabolic health. Omega-3 fatty acids display remarkable anti-oxidant, anti-inflammatory, anti-thrombotic and anti-arrhythmogenic actions. Furthermore, they improve the levels of triglycerides, glucose metabolism and endothelial function.

METHODS

The aim of this review article is to present physical, biochemical and biological properties of omega-3 fatty acids and summarize the most important mechanisms of action on arterial wall properties and arterial stiffness in atherosclerosis.

RESULTS

Omega-3 fatty acids may prevent the progression of atherosclerosis. Endothelial dysfunction and arterial stiffness can be regulated by the supplementation of omega-3 fatty acids.

CONCLUSION

The mechanisms of action of omega-3 fatty acids on cardiovascular health and arterial stiffening have been established. However, further research is needed in order to translate the conflicting results among the studies and improve the therapeutic options of cardiovascular disease.

A nurse-led implantable loop recorder service is safe and cost effective

INTRODUCTION

Implantable loop recorders (ILR) are predominantly implanted by cardiologists in the catheter laboratory. We developed a nurse-delivered service for the implantation of LINQ (Medtronic; Minnesota) ILRs in the outpatient setting. This study compared the safety and cost-effectiveness of the introduction of this nurse-delivered ILR service with contemporaneous physician-led procedures.

METHODS

Consecutive patients undergoing an ILR at our institution between 1st July 2016 and 4th June 2018 were included. Data were prospectively entered into a computerized database, which was retrospectively analyzed.

RESULTS

A total of 475 patients underwent ILR implantation, 271 (57%) of these were implanted by physicians in the catheter laboratory and 204 (43%) by nurses in the outpatient setting. Six complications occurred in physician-implants and two in nurse-implants (P = .3). Procedural time for physician-implants (13.4 ± 8.0 minutes) and nurse-implants (14.2 ± 10.1 minutes) were comparable (P = .98). The procedural cost was estimated as £576.02 for physician-implants against £279.95 with nurse-implants, equating to a 57.3% cost reduction. In our center, the total cost of ILR implantation in the catheter laboratory by physicians was £10 513.13 p.a. vs £6661.55 p.a. with a nurse-delivered model. When overheads for running, cleaning, and maintaining were accounted for, we estimated a saving of £68 685.75 was performed by moving to a nurse-delivered model for ILR implants. Over 133 catheter laboratory and implanting physician hours were saved and utilized for other more complex procedures.

CONCLUSION

ILR implantation in the outpatient setting by suitably trained nurses is safe and leads to significant financial savings.

2229Apoptotic and non-apoptotic circulating microparticles in patients with acute coronary syndromes

Background

Circulating microparticles (MP) are surrogate biomarkers of atherosclerosis but their role in patients with acute coronary syndromes (ACS) remain unknown.

Purpose

To explore the levels of apoptotic and non-apoptotic MP in patients with ACS.

Methods

We enrolled a total of 153 patients as follows: 49 patients with STEMI, 35 NSTEMI, 38 with unstable angina (UA), 15 with stable CAD (SCAD) and 16 non-CAD (controls). Flow cytometry analysis was used to quantify circulating apoptotic (annexin+) and non-apoptotic endothelial cell (EMP), red blood cell (RMP) and platelet (PMP) derived microparticles. Circulating C-reactive protein (hsCRP) levels and cardiac troponin I (cTnI) were also assessed. Brachial FMD was also determined as a marker of endothelial function.

Results

There was a stepwise increase in the total number of EMP, RMP and PMP in patients with ACS (STEMI/NSTEMI) compared to UA, SCAD and non-CAD patients. This was mainly explained by the increase in the number of apoptotic EMP, RMP and PMP (a-c), while there were no significant differences in the level of apoptotic EMP, RMP or PMP between patient subgroups (not shown). There was no association between circulating levels of apoptotic or non-apoptotic EMP, RBP or PMP with hsCRP (p=NS for all). Apoptotic EMP only were negatively associated with brachial FMD (rho=−0.185, p=0.04) and positively with cTnI levels (rho= 0.307, p<0.0001).

Conclusions

Circulating apoptotic (but not non-apoptotic) MP are increased in patients with ACS. A negative association is observed between the numbers of circulating apoptotic EMP only and systemic endothelial function. The biological role of circulating apoptotic microparticles' in the pathogenesis of ACS merits further investigation.

P6506Circulating microparticles preceding endothelial dysfunction and inflammatory process in patients with pseudoexfoliative glaucoma

Background

Pseudoexfoliative glaucoma (PEX) is a type of glaucoma characterized by the secretion of a grey-white, fibrogranular material in several tissues. Microparticles are shed membrane vesicles released from a variety of cell types in response to cellular activation or apoptosis and correlate with the pathogenesis of cardiovascular diseases. Endothelial MPs may be used as biomarkers of endothelial function.

Purpose

To evaluated the role of endothelial dysfunction, arterial stiffness and systemic inflammation in patients with PEX compared to patients with Primary open angle glaucoma (POAG) and control subjects as well as the possible pathophysiologic role of a specific microparticle profile associated with endothelial damage.

Methods

We enrolled 29 subjects with PEX, 57 subjects with POAG and 44 control subjects. Endothelial function was evaluated by flow-mediated dilation (FMD). Pulse wave velocity (PWV) was measured as an index of aortic stiffness and augmentation index (AIx) as a measure of arterial wave reflections. Growth differentiation factor-15 (GDF-15) and intercellular adhesion molecule1 (ICAM1) were measured to evaluate systemic inflammatory status. Total circulating MPs and EMPs were isolated and analysed by flow cytometry, utilizing specific labels for EMPs (CD 144+) and Annexin V staining for phospatidylserine bearing-MPs (AnnexinV + MPs).

Results

There was a linear impairment in FMD (p=0.005), PWV (p=0.007) and Aix (p=0.02) and a stepwise increase in GDF-15 (p=0.001) and sICAM-1 levels (p=0.08) between the three study groups (control, POAG, PEX). Interestingly, the PEX subjects expressed greater levels of total circulating MPs (Annexin V+) [1698 (1199–5894) MPs/μL vs. 1641 (1470–2705) MPs/μL. vs 493 (417–1512) MPs/μL, p=0.004] and EMPs (CD144+)[1412 (645–1760) MPs/μL3 vs 1380 (498–2496) MPs/μL vs 34 (184–870) MPs/μL, p<0.001] compared to POAG and control subjects.

Conclusion

Pseudoexfoliative glaucoma is associated with impaired endothelial function, arterial wall properties and vascular inflammation with a parallel increase in EMPs. Our findings indicate the significant role of endothelial damage in the progress of glaucomatous disease especially in subjects with pseudoexfoliative glaucoma.

Full blood count as potential predictor of outcomes in patients undergoing cardiac resynchronization therapy

Almost a third of patients fulfilling current guidelines criteria have suboptimal responses following cardiac resynchronization therapy (CRT). Circulating biomarkers may help identify these patients. We aimed to assess the predictive role of full blood count (FBC) parameters in prognosis of heart failure (HF) patients undergoing CRT device implantation. We enrolled 612 consecutive CRT patients and FBC was measured within 24 hours prior to implantation. The follow-up period was a median of 1652 days (IQR: 837–2612). The study endpoints were i) composite of all-cause mortality or transplant, and ii) reverse left ventricular (LV) remodeling. On multivariate analysis [hazard ratio (HR), 95% confidence interval (CI)] only red cell count (RCC) (p = 0.004), red cell distribution width (RDW) (p < 0.001), percentage of lymphocytes (p = 0.03) and platelet count (p < 0.001) predicted all-cause mortality. Interestingly, RDW (p = 0.004) and platelet count (p = 0.008) were independent predictors of reverse LV remodeling. This is the first powered single-centre study to demonstrate that RDW and platelet count are independent predictors of long-term all-cause mortality and/or heart transplant in CRT patients. Further studies, on the role of these parameters in enhancing patient selection for CRT implantation should be conducted to confirm our findings.

MicroRNAs in Atrial Fibrillation

MicroRNAs (miRNAs) are small non-coding RNAs, involved in regulation of post-transcriptional gene expression. They exert key role not only in physiology and normal development of the cardiovascular system but also in cardiovascular disease development and progression. Recent animal and human studies of tissue specific miRNAs have suggested a role in structural and electrical remodeling in atrial fibrillation (AF). Their emerging role as biomarkers and potential therapeutic targets in patients with AF is discussed in this review.

Biomarkers Associated with Stroke Risk in Atrial Fibrillation

Background:

Atrial fibrillation (AF) is associated with an increased risk of cardioembolic stroke. The risk of cardioembolism is not adequately reduced with the administration of oral anticoagulants, since a number of patients continue to experience thromboembolic events despite receiving treatment. Therefore, identification of a circulating biomarker to identify these high-risk patients would be clinically beneficial.

Objective:

In the present article, we aim to review the available data regarding use of biomarkers to predict cardioembolic stroke in patients with AF.

Methods:

We performed a thorough search of the literature in order to analyze the biomarkers identified thus far and critically evaluate their clinical significance.

Results:

A number of biomarkers have been proposed to predict cardioembolic stroke in patients with AF. Some of them are already used in the clinical practice, such as d-dimers, troponins and brain natriuretic peptide. Novel biomarkers, such as the inflammatory growth differentiation factor-15, appear to be promising, while the role of micro-RNAs and genetics appear to be useful as well. Even though these biomarkers are associated with an increased risk for thromboembolism, they cannot accurately predict future events. In light of this, the use of a scoring system, that would incorporate both circulating biomarkers and clinical factors, might be more useful.

Conclusions:

Recent research has disclosed several biomarkers as potential predictors of cardioembolic stroke in patients with AF. However, further research is required to establish a multifactorial scoring system that will identify patients at high-risk of thromboembolism, who would benefit from more intensive treatment and monitoring.