Safety of same-day discharge versus overnight stay strategy following cardiac device implantations: a high-volume single-centre experience

BACKGROUND

The strategy of cardiac implantable electronic device (CIED) implantations performed as day-case admissions has gained a wider acceptance overtime; however, data on safety are still limited. This study aims to investigate the safety of a same-day discharge protocol introduced in our hospital for the postprocedural management of patients undergoing CIED implantation.

METHODS

Α prospective, non-interventional, non-randomised study performed in a single high-volume implanting centre for a 16-month period (March 2020 to June 2021). At total of 821 of 965 (85.1%) patients scheduled for elective CIED implantation were considered to be eligible for inclusion in the Short-stay Device Management Protocol. These patients were compared with a historical group of 932 patients, meeting the same inclusion criteria.

RESULTS

Procedure was successful in 812 patients (98.9%), committed to same-day discharge versus 921 of 932 patients (98.8%) admitted for overnight stay (p = 0.87). Overall, 90-day complication rate was comparable in both groups (4.14% vs 4.07%, p = 0.95), as was major (1.46% vs. 1.82%, p = 0.55) and minor (2.67% vs. 2.25%, p = 0.64) complication rates. The composite early post-procedural complication rates and late post-procedural complication rates were comparable among groups (0.97 vs 1.18%, p = 0.70 and 0.73% vs 0.64%, p = 0.83, respectively). Six hundred sixty-seven patients (84%) preferred the same-day discharge strategy. Finally, a reduction of 792 bed-days was recorded, resulting in possible financial Health System benefits.

CONCLUSIONS

Same-day discharge is feasible and safe in the majority of patients referred for CIED implantation. Additionally, same-day discharge is preferred by patients and may reduce procedure-related costs due to significant bed-day reductions.

Cardiovascular Toxicity of Proteasome Inhibitors: Underlying Mechanisms and Management Strategies: JACC: CardioOncology State-of-the-Art Review

Proteasome inhibitors (PIs) are the backbone of combination treatments for patients with multiple myeloma and AL amyloidosis, while also indicated in Waldenström's macroglobulinemia and other malignancies. PIs act on proteasome peptidases, causing proteome instability due to accumulating aggregated, unfolded, and/or damaged polypeptides; sustained proteome instability then induces cell cycle arrest and/or apoptosis. Carfilzomib, an intravenous irreversible PI, exhibits a more severe cardiovascular toxicity profile as compared with the orally administered ixazomib or intravenous reversible PI such as bortezomib. Cardiovascular toxicity includes heart failure, hypertension, arrhythmias, and acute coronary syndromes. Because PIs are critical components of the treatment of hematological malignancies and amyloidosis, managing their cardiovascular toxicity involves identifying patients at risk, diagnosing toxicity early at the preclinical level, and offering cardioprotection if needed. Future research is required to elucidate underlying mechanisms, improve risk stratification, define the optimal management strategy, and develop new PIs with safe cardiovascular profiles.

Prediction of programmed ventricular stimulation inducibility using machine learning in post-myocardial infarction patients at risk for sudden cardiac arrest with preserved ejection fraction ≥40%

Introduction

Sudden cardiac death (SCD) in post myocardial infarction (post-MI) patients with a relatively preserved left ventricular ejection fraction (LVEF ≥40%) has 1% annual incidence. In the PRESERVE-EF study, we used a two-step SCD risk stratification approach to detect patients with a relatively preserved left ventricular ejection fraction ≥40% at risk for major arrhythmic events. Seven noninvasive risk factors (NIRFs) were extracted from ambulatory electrocardiography. Patients with at least one NIRF present were referred for invasive programmed ventricular stimulation (PVS). Inducible patients received an ICD.

Purpose

The present study examines the performance of machine learning technology for the prediction of the inducible patients in PRESERVE-EF study.

Methods

After first step screening with NIRFs, 152 out of 575 patients underwent PVS and 41 of them were inducible. For the present analysis, data from these 152 patients were analysed. We used machine learning of NIRFs to predict these inducible high risk patients. We selected as classification method the Nearest Neighbour (NN) algorithm, after experimentation with several classifiers. NN classifies each subject according to the class of the N nearest neighbours. For each subject, we created a vector with the following 7 features: SAECG Late Potentials, Ventricular Premature beats ≥30/hour, Non-sustained Ventricular Tachycardia ≥1 episode (s)/24 hours, Fredericia corrected QT interval ≥45 0ms, SDNN/HRV ≤75 ms, T Wave Alternans ≥65 μV, Combined Deceleration capacity (DC) ≤4.5 ms and Heart Rate Turbulence Onset (To) ≥0% and Heart Rate Turbulence Slope (Ts) ≤2.5 ms.

Results

The achieved accuracy reached up to 72.2% when N was set to 7. We had totally 144 samples, 41 of which were inducible high risk patients. Results were similar for other values of N. To ensure independence of train and test sets, we employed 10-fold cross validation.

Conclusions

Inducible on PVS patients in PRESERVE-EF study were predicted with machine learning classification of NIRFs.

Funding Acknowledgement

Type of funding sources: None.

Beta-secretase-1 antisense RNA is associated with vascular ageing and atherosclerotic cardiovascular disease

Background  The noncoding antisense transcript for β-secretase-1 ( BACE1-AS ) is a long noncoding RNA with a pivotal role in the regulation of amyloid-β (Aβ). We aimed to explore the clinical value of BACE1-AS expression in atherosclerotic cardiovascular disease (ASCVD).

Methods  Expression of BACE1-AS and its target, β-secretase 1 ( BACE1 ) mRNA, was measured in peripheral blood mononuclear cells derived from 434 individuals (259 without established ASCVD [non-CVD], 90 with stable coronary artery disease [CAD], and 85 with acute coronary syndrome). Intima-media thickness and atheromatous plaques evaluated by ultrasonography, as well as arterial wave reflections and pulse wave velocity, were measured as markers of subclinical ASCVD. Patients were followed for a median of 52 months for major adverse cardiovascular events (MACE).

Results  In the cross-sectional arm, BACE1-AS expression correlated with BACE1 expression ( r  = 0.396, p  < 0.001) and marginally with Aβ1–40 levels in plasma ( r  = 0.141, p  = 0.008). Higher BACE1-AS was associated with higher estimated CVD risk assessed by HeartScore for non-CVD subjects and by European Society of Cardiology clinical criteria for the total population ( p  < 0.05 for both). BACE1-AS was associated with higher prevalence of CAD (odds ratio [OR] = 1.85, 95% confidence interval [CI]: 1.37–2.5), multivessel CAD (OR = 1.36, 95% CI: 1.06–1.75), and with higher number of diseased vascular beds (OR = 1.31, 95% CI: 1.07–1.61, for multiple diseased vascular beds) after multivariable adjustment for traditional cardiovascular risk factors. In the prospective arm, BACE1-AS was an independent predictor of MACE in high cardiovascular risk patients (adjusted hazard ratio = 1.86 per ascending tertile, 95% CI: 1.011–3.43, p  = 0.046).

Conclusion   BACE1-AS is associated with the incidence and severity of ASCVD.

Permanent pacemaker implantation in unexplained syncope patients with electrophysiology study-proven atrioventricular node disease

BACKGROUND

Syncope, whose cause is unknown after an initial assessment, has an uncertain prognosis. It is critical to identify patients at highest risk who may require a pacemaker and to identify the cause of recurrent syncope to prescribe proper therapy. Aim of this study was to evaluate the effect of permanent pacing on the incidence of syncope in patients with unexplained syncope and electrophysiology study-proven atrioventricular node disease.

MATERIAL AND METHODS

This was an observational study based on a prospective registry of 236 consecutive patients (60.20 ± 18.66 years, 63.1% male, 60.04 ± 9.50 bpm) presenting with recurrent unexplained syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). The decision to implant a permanent pacemaker was made in all cases by the attending physicians according to the results of the EPS. 135 patients received the antibradycardia pacemaker (ABP), while 101 declined.

RESULTS

The mean of reported syncope episodes was 1.97 ± 1.10 (or presyncope 2.17 ± 1.50) before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (49.19 ± 29.58 months), the primary outcome event (syncope) occurred in 31 of 236 patients (13.1%), 6 of 135 (4.4%) in the ABP group as compared to 25 of 101 (24.8%) in the no pacemaker group (p < 0.001).

CONCLUSION

Among patients with a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined atrioventricular node disease, identifies a subset of patients who will benefit from permanent pacing.

Discordance between plain coronary angiography and quantitative flow ratio in revascularization guidance

Background/Introduction

Functional coronary stenosis severity has been associated with less clinical adverse events compared with plain invasive coronary angiography in guiding revascularization. Quantitative flow ratio (QFR) has proven to be a reliable tool of functional assessment of coronary lesions.

Purpose

To investigate the level of agreement between plain coronary angiography and QFR in guiding the decision to treat a coronary lesion.

Methods

We retrospectively performed an offline QFR analysis in consecutive patients who underwent coronary angiography in a single center. Patients with referral for coronary artery bypass graft surgery were excluded. We aimed to measure QFR in all vessels of each patient. All vessels with calculated QFR were divided into four groups based on whether percutaneous coronary intervention (PCI) was performed and on the QFR result with a cut-off point &lt;0.8 indicating revascularization: Group A (PCI+, QFR &lt;0.8); group B (PCI−, QFR &gt;0.8); group C (PCI+, QFR &gt;0.8); group D (PCI−, QFR &lt;0.8) (Figure 1).

Results

We identified 785 patients with available coronary angiography satisfying the technical requirements of QFR software. QFR measurement in at least one vessel was feasible in 546 patients (70%). Mean age was 65.6 (±10.9) and 80% of patients were male. Acute coronary syndrome was the indication for coronary angiography in 36% of the cohort. QFR was calculated in 1193 vessels (∼51% of total vessels). In particular, QFR analysis was feasible in 448 (57%) left anterior descending (LAD), 457 (58%) left circumflex (LCX), and 288 (37%) right coronary arteries (RCA) coronary arteries. The most common reason for inability to calculate QFR was the absence of appropriate projections (30% of the missing cases). A mismatch in treatment strategy between coronary angiography and QFR result was detected in 151 (12.7%) vessels. In 78 (6.6%) cases PCI was performed while QFR was measured above 0.8 (group C). In 73 (6.1%) cases PCI was not performed while QFR was measured below 0.8 (Group D) (Figure 1). Among mismatch cases LAD was more likely to fall within group D whereas RCA was more often related with group C.

Conclusion

Discordance between plain coronary angiography and quantitative flow ratio regarding the decision to perform or to defer PCI was found in a relatively high proportion among patients undergoing coronary angiography. Prognostic evidence is warranted to determine the clinical significance of the mismatch between the two methods.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Global deterioration of cardiovascular mechanics by carfilzomib treatment is associated with proteasome activity in patients with relapsed multiple myeloma

Background

Carfilzomib (CFZ) is a second generation irreversible proteasome inhibitor that has been shown to improve overall survival in patients with relapsed or refractory multiple myeloma (MM) but is associated with cardiac toxicity in MM. Because ubiquitin-proteasome system (UPS) is involved in cardiovascular homeostasis exploring the effects of proteasome inhibition on cardiac mechanics, in a clinical setting, would provide novel insight of the clinical role of UPS in cardiovascular disease.

Aim

To gain a thorough understanding of proteasome inhibition on myocardial mechanics in a clinical setting.

Methods

We prospectively evaluated 48 patients with relapsed or refractory MM and an indication to receive CFZ treatment [median age: 67.5, interquartile range (64–73), 66.7% men]. All patients underwent cardiac ultrasonography at an initial visit, at the first day of the 3rd month (C3D1, n=25) and at the last day of cycle 6 (C6D16, n=48). Pulse wave velocity (PWV) was used to assess arterial stiffness and calculate arterial-ventricular coupling (VAC) by the ratio (PWV/global longitudinal strain (GLS)). Carfilzomib was administered at 27mg/m2 on days 1 (C1D1) and 2 (C1D2) of cycle 1 and at 56mg/m2 thereafter. Blood was drawn at baseline, C3D1 and C6D16 to measure proteasome activity (PrA). Patients were followed up for carfilzomib–related cardiovascular adverse events.

Results

Regarding systolic function, between baseline and C6D16, we noticed deterioration in left ventricular ejection fraction (LVEF) (57.7±5.4% vs 56.1±7.19%, p=0.022), GLS (−20.51±2.78 vs −18.88±3.45%, p=0.003), S wave of LV longitudinal strain rate and radial strain (p&lt;0.05 for both). Markers of LV diastolic function also deteriorated at 6 months including early diastolic (Ea) mitral annular velocity (7.27±1.83cm/sec vs 6.7±1.64cm/sec, p=0.008) and E wave of LV longitudinal strain rate (1.1±0.37sec-1 vs 0.95±0.36sec-1, p=0.010). Left atrial volume (LAV) and index (LAVi) increased both at 3 and 6 months (p&lt;0.05). Peak LA strain at reservoir phase (peak atrial longitudinal strain, PALS) was also decreased at 6th and 3rd month measurements (p&lt;0.05), whereas LA strain rate at reservoir function (s wave) was decreased, compared to baseline, only at 6th month (p=0.001). RV longitudinal strain also decreased between 3rd and 6th month (p=0.039). Furthermore, PWV/GLS also deteriorated at 6 months (−0.56±0.13 vs −0.64±0.21, p=0.001). By linear mixed models analysis, we found that changes in proteasome activity were associated with changes in PWV/GLS (p=0.017), LAV (p=0.015) and LAVi (p=0.009), and PALS (p=0.014).

Conclusion

CFZ treatment was associated with global deterioration of markers of myocardial systolic and diastolic function and VAC. The observed association of changes in proteasome activity with VAC and left atrial function and structure supports a direct effect of proteasome inhibition on the cross-talk between LV and arterial function and LV diastolic function.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen

Aortic hemodynamic parameters as predictors of incident or deteriorating hypertension during carfilzomib therapy in patients with relapsed multiple myeloma

Background

Carfilzomib (CFZ) improves survival in relapsed/refractory multiple myeloma but is associated with cardiovascular adverse events, among which hypertension is commonly reported.

Purpose

To evaluate aortic hemodynamics as possible predictors for CFZ-associated hypertension.

Methods

In a prospective study of 48 patients treated with Kd (CFZ 20/56 mg/m2 and dexamethasone) followed until disease progression or cycle 6 for a median of 10 months, patients underwent peripheral hemodynamic assessment, including applanation tonometry, which allows estimation of aortic blood pressure and arterial wave reflections and assessment of pulse wave velocity, which allows estimation of aortic stiffness. Hemodynamic parameters were examined at baseline and at pre-specified time points before and 24 hours after drug infusion.

Results

Thirteen patients (27.1%) developed hypertension or merited more intensive anti-hypertensive treatment (grade I or II: 6.25%, grade III: 20.8%). Patients with new onset or worsening hypertension had increased aortic [130±12.9 mmHg versus 115±16.7 mmHg, p=0.004] and peripheral systolic blood pressure (SBP) [145±15.7 mmHg versus 130±19.5 mmHg, p=0.001] at baseline. Patients distributed at highest tertile of baseline aortic SBP (log-rank test p=0.0001, Figure) or baseline peripheral SBP (log-rank test p=0.002) had significantly higher risk for CFZ associated hypertension as compared to those distributed at lower tertiles. After adjustment for age, gender and baseline hypertension, increased aortic [HR=8.0, 95% CIs 2.4–26.6, p=0.001] and peripheral SBP [HR=4.85, 95% CIs 1.53–15.4, p=0.007] remained significantly associated with hypertension. After adjustment for both baseline peripheral and aortic SBP in the same multivariable core model, aortic SBP was the only independent predictor of the study outcome (p=0.041). Accordingly, baseline aortic SBP was associated with higher discriminative value as compared to peripheral SBP [AUC: 0.819, 95% CIs 0.722–0.916 versus 0.724, 95% CIs 0.570–0.878, respectively]. Further adjustment for all cardiotoxicity risk factors using forced inclusion in non-parsimonious multivariable Cox regression models, revealed that increased aortic and peripheral SBP remained independent predictors of hypertensive events (p&lt;0.05 for both).

Conclusion

Baseline aortic hemodynamics are associated with hypertension during CFZ treatment. Aortic SBP at baseline was the strongest predictor of CFZ-associated hypertensive adverse events, suggesting that an initial assessment of aortic blood pressure may facilitate discrimination of patients in need of close monitoring during treatment.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Funding from the Hellenic Foundation for Research and Innovation (HFRI) and the General Secretariat for Research and Technology (GSRT), under grant agreement No [1285].

Daratumumab May Attenuate Cardiac Dysfunction Related to Carfilzomib in Patients with Relapsed/Refractory Multiple Myeloma: A Prospective Study

Simple Summary

The management of cardiovascular adverse events in patients with relapsed/refractory multiple myeloma undergoing treatment with carfilzomib can be challenging. Herein, we evaluated the potential cardioprotective effect of daratumumab when administered in combination with carfilzomib and dexamethasone (DaraKd). The study included 25 patients receiving either DaraKd (n = 14) or Kd (n = 11) who were evaluated for echocardiographic changes at the sixth cycle of treatment compared with baseline assessment. DaraKd was associated with preserved post-treatment cardiac systolic function compared with Kd. CD38 inhibition by daratumumab might restore metabolic disequilibrium in the cardiac tissue and prevent cardiac injury. A trend for a lower rate of cardiovascular adverse events among patients receiving DaraKd was also evident, although larger studies are needed to determine the association between echocardiographic and/or biomarker changes with cardiovascular adverse events.

Abstract

Carfilzomib has improved survival in patients with relapsed/refractory multiple myeloma (RRMM), but it may exert cardiovascular adverse events (CVAEs). The aim of this study was to assess whether treatment with daratumumab may ameliorate carfilzomib-related toxicity. We prospectively evaluated 25 patients with RRMM who received either daratumumab in combination with carfilzomib and dexamethasone (DaraKd) (n = 14) or Kd (n = 11). Cardiac ultrasound was performed before treatment initiation and C6D16 or at the time of treatment interruption. Patients were followed for a median of 10 months for CVAEs. The mean (± SD) age was 67.8 ± 7.6 years and 60% were men. The two treatment groups did not significantly differ in baseline demographic characteristics (p > 0.1 for all). In the DaraKd group, we did not observe any significant change in markers of ventricular systolic function. However, these markers deteriorated in the Kd group; left ventricular (LV) ejection fraction, LV global longitudinal strain, tricuspid annular plane systolic excursion and RV free wall longitudinal strain significantly decreased from baseline to second visit (p < 0.05). A significant group interaction (p < 0.05) was observed for the abovementioned changes. CVAEs occurred more frequently in the Kd than the DaraKd group (45% vs. 28.6%). DaraKd was associated with preserved post-treatment cardiac systolic function and lower CVAE rate compared with Kd. The clinical significance and the underlying mechanisms merit further investigation.

Permanent pacemaker implantation in unexplained syncope patients with electrophysiology study-proven atrioventricular node disease

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Syncope, whose cause is unknown after an initial assessment, has an uncertain prognosis. It is critical to identify patients at highest risk who may require a pacemaker and to identify the cause of recurrent syncope to prescribe proper therapy

Purpose

Aim of this study was to evaluate the effect of permanent pacing on the incidence of syncope in patients with unexplained syncope and electrophysiology study-proven atrioventricular node disease.

Methods

This was an observational study based on a prospective registry of 236 consecutive patients (60.20 ± 18.66 years, 63.1% male, 60.04 ± 9.50 bpm) presenting with recurrent unexplained syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). Τhe implantation of a permanent antibradycardia pacemaker (ABP) was offered to all patients according to the results of the EPS. 135 patients received the ABP, while 101 denied.

Results

The mean of reported syncope episodes was 1.97 ± 1.10 (or presyncope 2.17 ± 1.50) before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (49.19 ±  29.58 months), the primary outcome event (syncope) occurred in 31 of 236 patients (13.1%), 6 of 135 (4.4%) in the ABP group as compared to 25 of 101 (24.8%) in the no pacemaker group (p &lt; 0.001).

Conclusion

Among patients with a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined atrioventricular node disease, identifies a subset of patients who will benefit from permanent pacing.

Syncope associated with supraventricular tachycardia: Diagnostic role of implantable loop recorders

Syncope represents a relatively uncommon symptom of supraventricular tachycardia (SVT). It is likely that an impaired autonomic vasomotor response to the hemodynamic stress of tachycardia is the determinant of hemodynamic changes leading to cerebral hypoperfusion and syncope. In this regard, tilt‐table test may detect abnormalities in the autonomic nervous function and predict the occurrence of syncope during SVT. Electrophysiology studies may reproduce the SVT, distinguish it from other life‐threatening ventricular tachyarrhythmias, and exclude other causes of syncope. Not infrequently mixed syncope mechanisms are revealed during the above diagnostic workup raising doubts about the operating mechanism in the clinical setting. In such cases of uncertainty, an implantable loop recorder, providing long‐term cardiac monitoring, may play a pivotal role in the establishment of the diagnosis, confirming the association of an arrhythmic event with the symptom. Herein, we present four such cases with recurrent unexplained syncope finally attributed to paroxysmal SVT guiding them to a potentially radical treatment through radiofrequency catheter ablation.

Carfilzomib-induced endothelial dysfunction, recovery of proteasome activity, and prediction of cardiovascular complications: a prospective study

Carfilzomib (CFZ) improves survival in relapsed/refractory multiple myeloma but is associated with cardiovascular adverse events (CVAEs). We prospectively investigated the effect of CFZ on endothelial function and associations with CVAEs. Forty-eight patients treated with Kd (CFZ 20/56 mg/m² and dexamethasone) underwent serial endothelial function evaluation, using brachial artery flow-mediated dilatation (FMD) and 26S proteasome activity (PrA) measurement in PBMCs; patients were followed until disease progression or cycle 6 for a median of 10 months. FMD and PrA decreased acutely after the first dose (p < 0.01) and FMD decreased at cycles 3 and 6 compared to baseline (p ≤ 0.05). FMD changes were associated with CFZ-induced PrA changes (p < 0.05) and lower PrA recovery during first cycle was associated with more prominent FMD decrease (p = 0.034 for group interaction). During treatment, 25 patients developed Grade ≥3 CVAEs. Low baseline FMD (HR 2.57 lowest vs. higher tertiles, 95% CI 1.081-6.1) was an independent predictor of CVAEs. During treatment, an acute FMD decrease >40% at the end of first cycle was also independently associated with CVAEs (HR = 3.91, 95% CI 1.29-11.83). Kd treatment impairs endothelial function which is associated with PrA inhibition and recovery. Both pre- and posttreatment FMD predicted CFZ-related CVAEs supporting its role as a possible cardiovascular toxicity biomarker.

Central pulse load and coronary flow benefit in relation to endogenous testosterone and the Mediterranean regime in hypertensive males with erectile dysfunction

Background

Central pulse pressure (cPP) is an important parameter of target organ damage (TOD) in essential hypertension. Coronary flow reserve (CFR) displays the ability of both macro and microcirculation to augment flow to the myocardium while endogenous total testosterone (TT) exhibits vasodilator effects. The Mediterranean diet (Med-diet) benefits cardiovascular health and erectile dysfunction (ED) often coexists with the decline of endogenous testosterone in the aging male population.

Purpose

To investigate the possible benefits of the Med-diet in central PP, CFR and erectile ability in relation to endogenous TT in the primary hypertensive population with ED.

Methods

247 male hypertensive patients (mean age 57 yo) with ED enrolled the study. Significant coronary artery disease was formerly excluded by a dobutamine stess echo test. We measured the CFR of the left anterior descending artery by performing an adenosine protocol (maximum dose 140 μg/kg/min over 6 minutes). Measurements by the PW Doppler were achieved at the middle/distal LAD segment under the guidance of color Doppler flow mapping. CFR was validated as ratio between peak diastolic flow velocity following drug infusion and rest. Ratios ≥2 are considered as non-ischemic response and higher values indicate microvascular coronary integrity. TT was measured in all patients on blood samples taken before 09:00 am. ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values indicate a better erectile ability and Med-diet compliance respectively. Finally, cPP and augmentation index (AIx) were estimated as parameters of central hemodynamic load and wave reflection amplification respectively (sphygmocor device).

Results

In bivariate analysis Med-diet was favorably related to CFR (p=0.24, r=0.48), TT (p=0.01, r=0.57) and the SHIM-5 score (p=0.01, r=0.45). On the contrary, it was negatively related to cPP (p=0.15, r=−0.60) and AIx (p=0.31, r=−0.45). CFR was strongly related to TT (p=0.001, r=0.8) and the SHIM-5 score (p=0.01, r=0.41). By multiple linear regression analysis the relation of CFR, SHIM-5 and Med-diet score remained significant after adjustment for age, BMI, systolic arterial blood pressure and smoking habits. We further subdivide our population according to the mean Med-diet value (26) into high and low Med-diet adherence groups. Only in the group with the greater Med-diet adherence (n=153, 62%) there were still positive relation with the CFR, TT and SHIM-5 score as well as negative correlation to cPP and AIx (p=0.04).

Conclusion

In essential hypertensive males with erectile dysfunction the Med-diet regime lessens central pulse pressure while enhancing coronary flow, testosterone levels and so peripheral vascular physiology. We strongly recommend this dietary pattern as a life-style option and strategic component of holistic therapeutic approach.

Funding Acknowledgement

Type of funding source: None

265Amyloid beta 1-40 and its upstream regulatory pathway BACE1-AS long noncoding RNA/BACE1 are associated with presence and severity of human atherosclerotic disease

Background

Amyloid-beta (1-40) (Aβ1–40), a proinflammatory and pro-atherosclerotic peptide, is associated with accelerated atherosclerosis and major adverse cardiac events. Abeta1–40 production is mainly dependent on the cleavage of amyloid precursor protein by β-amyloid cleaving enzyme-1 (BACE1), known as beta-secretase. BACE1 antisense (BACE1-AS) is a long noncoding RNA that enhances BACE1 stability.

Objectives

To evaluate the clinical value of plasma amyloid-beta levels and its upstream regulatory pathway BACE1/BACE1-AS in patients with subclinical and established atherosclerotic cardiovascular disease.

Methods

Plasma levels of Aβ40 were measured in 642 consecutively recruited patients with and without clinically overt coronary artery disease (CAD). BACE1-AS lncRNA and BACE1 mRNA expression were measured in peripheral blood mononuclear cells derived from 214 study participants. Intima-media thickness and atheromatous plaques by ultrasonography, markers of arterial wave reflections and pulse wave velocity were used as surrogate markers of subclinical CVD. Cardiovascular risk factors (CVRFs), including impaired glomerular filtration rate (<60 ml/min), smoking, hypertension, hyperlipidemia, diabetes, obesity and increased hsCRP (>2 mg/l) were assessed as a measure of CVRF burden.

Results

Both in non-CAD (n=369) and CAD (n=273) patients, Aβ1–40 was associated with age, aortic and peripheral systolic and pulse pressure, and low GFR (p<0.05 for all). In non-CAD subjects Aβ1–40 also correlated with diabetes and low HDL. Importantly, Aβ1–40 was associated with the presence of any plaque in subjects without CAD (p=0.035) and with increased number of diseased coronary arteries (p=0.022) independently of age, gender and CVRFs. Aβ1–40 plasma levels were increased in the highest tertile of BACE1 and BACE1AS (p<0.05) while their expression levels were highly intercorrelated (r=0.825, P<0.001). BACE1 and BACE1-AS levels progressively increased across the 3 groups of non-CAD (n=145), stable CAD (n=43) and acute myocardial infarction (n=26) patients (p for trend<0.001). Among non-CAD subjects, both BACE1 and BACE1-AS were increased in individuals with >2 CVRFs. Among CAD patients, BACE1-AS was associated with decreased LVEF (<50%) (adjusted OR=1.92 per 1-SD increase, p=0.047) while BACE1 in the highest tertile was associated with 5-fold higher odds for coronary multi-vessel disease (p=0.004) after adjustment for age, gender and CVRFs.

Conclusions

Circulating Aβ1–40 and increased expression of its upstream regulators BACE1/BACE1-AS are intercorrelated and associated with the presence and severity of subclinical and clinically overt atherosclerosis. These findings suggest that BACE1-AS/BACE1-mediated increased availability of Aβ1–40 may play a pivotal role in its adverse cardiovascular effects.

P3409Comparison of the European Society of Hypertension stratification and European Society of Cardiology HeartScore for prediction of coronary artery disease and stroke in essential hypertension

Background/Introduction

For estimation of overall cardiovascular risk the European Society of Hypertension (ESH) proposes stratification according to blood pressure (BP), prevalence of risk factors, asymptomatic target organ damage, diabetes, kidney and symptomatic cardiovascular disease, while the European Society of Cardiology (ESC) HeartScore constitutes another potent predictive tool of adverse outcome.

Purpose

The aim of the present study was to compare the predictive role of ESH stratification and ESC HeartScore for the incidence of the composite end-point of coronary artery disease (CAD) and stroke in a cohort of essential hypertensive patients.

Methods

We followed up 2150 essential hypertensives (mean age 55.7 years, 1085 males, office BP=145/91 mmHg) for a mean period of 8 years. All subjects had at least one annual visit. Patients were divided based on the ESH risk categories as well as according to the ESC HeartScore. CAD was defined as the history of myocardial infarction or significant coronary artery stenosis revealed by angiography or coronary revascularization procedure. Stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by imaging findings.

Results

The incidence of CAD, stroke and their composite over the follow-up period were 2.8% (n=60), 1.11% (n=24) and 3.9% (n=84), respectively. By using the ESH stratification, regarding the total population 15.3% (n=329) was of low and moderate risk, 54.4% (n=1170) was of moderate to high and high risk and 30.3% (n=651) was high to very high and very high risk. According to the ESC HeartScore 89.2% (n=1918) was of low to moderate risk, 10% (n=215) of high risk and 0.8% (n=17) of very high risk. Cox-regression analyses revealed that high to very high and very high ESH risk category was related to increased risk for the composite end-point of CAD and stroke (hazard ratio=4.5, p<0.0001), while focusing on the ESC Heart Score the composite end-point was predicted by the high risk category (hazard ratio=3.43, p<0.0001). Using the Akaike's information criterion the ESH risk model had better fit than the ESC HeartScore due to the lowest Akaike's values (1442.66 vs 1498.31, respectively).

Conclusions

In essential hypertensive patients categorization of patients by means of the ESH stratification and the ESC HeartScore are both predictive of future cardiovascular events. Based on our results, the ESH risk stratification constitutes a better prediction model for CAD and stroke than the ESC HeartScore in essential hypertension and its estimation is essential in order to improve overall risk assessment in this setting.

P4534The Mediterranean diet benefit in chronic heart failure by decoding central and peripheral vessel rheology, atheroma formation and serum prolactin levels

Background

Central hemodynamics and especially wave reflection amplification exhibit a vital parameter of chronic heart failure (CHF) physiology. Erectile dysfunction (ED) displays a poor peripheral vessel rheology and serum prolactin role is still debated in CHF mechanisms. The Mediterranean diet (Med-diet) is famous for its vasoprotective and wellbeing properties.

Purpose

To investigate the effect of the Med-diet in central hemodynamics, erectile status, atheroma formation and serum prolactin levels in male patients with chronic heart failure.

Methods

123 CHF male patients under optimal medical therapy enrolled the study (mean age: 65±8 yo, NYHA class II, ejection fraction <40%). All underwent evaluation of the carotid – femoral pulse wave velocity (PWV), estimation of central pressures and augmentation index (AIx) as parameter of wave reflection amplification (sphygmocor device). Ejection fraction (EF) of the left ventricle was estimated by using 2D echocardiography (Simpson method). ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values point to better erectile function and a great Med-diet compliance respectively. Detection of atheroma was based on the intima- media thickness (IMT) of the common carotid artery. Prolactin levels were assessed in morning blood samples taken before 09:00 am.

Results

The SHIM −5 score (mean: 12±4) was associated to the AIx (p=0,03, r=0,75) and both positively and strongly related to the Med-diet score (p=0,01, r=0,8 and p=0,01, r=0,75 respectively). Med-diet compliance was negatively associated to IMT (p=0,02, r=−0,8) and serum prolactin levels (p=0,03, r=−0,6).Moreover, we notice a positive association between prolactin and the IMT (p=0,04, r=0,7). By multiple linear regression analysis the relation of SHIM-5 and Med-diet score remained significant (p=0,04) after adjustment for BMI, central pulse and mean arterial pressures. We further subdivide our population according to the mean Med-diet value (28) into high and low Med-diet adherence groups. Only in the group with the greater Med-diet adherence (n=73, 60%) AIx was strongly associated to the SHIM-5 score (p=0,02) even after adjustment for PWV, age and BMI. Prolactin levels there were still related to IMT (p=0,04) after adjustment for PWV, AIx, BMI and central pulse pressure. All statistics remained significant when adjusting for ejection fraction of the left ventricle.

Conclusion

High adherence to the Med-diet benefits CHF hemodynamics by enforcing wave reflection amplification, thus generating a stronger pulse signal to peripheral vasculature. Moreover suppresses serum prolactin levels that relates to atheroma formation. Both actions enhance erectile performance independently of the EF of the left ventricle. It is important to advise CHF patients to adopt this dietary pattern in order to improve hemodynamic status and the sense of wellbeing.

P4492Peripheral blood mononuclear cell expression of the stabilizing RNA-binding protein HuR is associated with incidence and extent of human atherosclerotic cardiovascular disease

Background

Human Antigen R (HuR) is a stabilizing RNA-binding protein that regulates the expression of several pro-inflammatory molecules. However, its regulation in human atherosclerotic cardiovascular disease remains unknown.

Purpose

To determine the association of peripheral blood mononuclear cell HuR expression with established markers of increased cardiovascular risk and atherosclerosis burden in patients with subclinical or clinically overt coronary artery disease (CAD).

Methods

HuR mRNA expression was measured in peripheral blood mononuclear cells derived from 289 patients with stable CAD or acute myocardial infarction (AMI) and 373 individuals without clinically overt cardiovascular disease (CVD). Structural and functional vascular measurements including intima-media thickness (IMT) and number of atheromatous plaques by carotid and femoral artery ultrasonophaphy, markers of arterial wave reflections by pulse wave analysis and pulse wave velocity were used as surrogate markers of subclinical CVD. The number of angiographically confirmed diseased coronary arteries (>50% stenosis) was used to assess the extent of CAD.

Results

HuR mRNA expression was significantly increased in patients with CAD (both stable and AMI) compared to controls (p=0.039). Subgroup analysis revealed that STEMI patients (n=107) had increased levels of HuR expression compared to NSTEMI (n=49, p=0.03). Among patients with stable CAD (n=133), high HuR expression was independently associated with the number of diseased coronary arteries (OR=1.35 for 1-SD increase in HuR, 95% CI 1.07–1.72, p=0.012), as well as with reduced ejection fraction (EF<45%, OR=1.32 per 1-SD increase, 95% CI 1.05–1.85, p=0.024). Among individuals without CVD, high HuR was associated with lower HDL levels (adjusted beta=-5.2 mg/dl for highest versus lowest quartile, p=0.03) and higher diastolic blood pressure (adjusted beta=3.6 mmHg, p=0.007), while, after adjustment for traditional cardiovascular risk factors, HuR levels in individuals without CVD were independently associated with increased IMT in the common carotid artery (mean increase 6.2% for highest versus lowest quartile, p=0.019).

Conclusion

HuR expression is associated with early subclinical arterial disease in individuals without clinically overt CVD and with the presence and severity of cardiac and vascular dysfunction in patients with clinically overt CAD. These findings imply a clinical role of the HuR pathway in cardiovascular disease and warrant further investigation.

P5464Visit-to-visit glomerular filtration rate variability as a predictor for cardiovascular and renal outcomes in essential hypertension: Data from a Greek 8-year-follow-up study

Background/Introduction

Renal dysfunction is related with adverse prognosis in hypertension, however there are scarce data on the predictive cardiovascular and renal impact of kidney function variability in this setting.

Purpose

The aim of the present study was to assess the predictive role of visit-to-visit renal function changes on the incidence of coronary artery disease (CAD), stroke and end-stage renal disease in a cohort of essential hypertensive patients.

Methods

We followed up 2380 essential hypertensives (mean age 58.9 years, 1240 males, office blood pressure (BP)=144/91 mmHg) free of cardiovascular disease for a mean period of 8 years. All subjects had at least one annual visit and blood sampling was performed in all visits for estimation of glomerular filtration rate (GFR). We calculated standard deviation (SD) of mean GFR from visits from 6 months onward in patients with ≥5 visits during follow-up. CAD was defined as the history of myocardial infarction or significant coronary artery stenosis revealed by angiography or coronary revascularization procedure, while stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by imaging findings. End-stage renal disease was defined as GFR<15 mL/min/1.73 m2 or the need for long-term dialysis or transplantation.

Results

The incidence of CAD, stroke and end-stage renal disease over the follow-up period were 2.8% (n=68), 1.09% (n=26) and 0.6% (n=14). Hypertensives who developed CAD compared to those without CAD at follow-up (n=2312) had at baseline higher left ventricular mass index (115.7±24.6 vs 103.7±27.3 g/m2, p<0.0001), whereas there was no difference with respect to baseline GFR (78±19.6 vs 79.3±18.6 mL/min/1.73 m2 (p=0.573). In multivariate Cox regression models visit-to-visit glomerular filtration rate predicted end-stage renal disease (hazard ratio=1.758, p=0.01) but not CAD and stroke (p=NS for both). Baseline left ventricular mass index independently predicted CAD (hazard ratio=1.042, p=0.015) and stroke (hazard ratio=1.035, p=0.002).

Conclusions

In essential hypertensive patients GFR variability predicts future development of end-stage renal disease but exhibits no independent prognostic value for CAD and stroke. These results suggest that fluctuations of renal function are related with damage at the kidneys and not at the cardiac and cerebrovascular level.

P5466Exaggerated exercise blood pressure response is accompanied by increased sympathetic activity and arterial stiffness in subjects with high normal blood pressure

Background/Introduction

The clinical importance of a hypertensive response to exercise (HRE) in subjects with high normal blood pressure (BP) is not fully elucidated, while sympathetic overactivity and arterial stiffening are linked with adverse cardiovascular prognosis.

Purpose

The aim of this study was to assess the relation of HRE with sympathetic drive as assessed by muscle sympathetic nerve activity (MSNA) and arterial stiffness in subjects with high normal BP.

Methods

42 subjects with high normal office BP [defined as office systolic BP=130–139 mmHg and office diastolic BP=85–89 mmHg (age: 53±9 years, 29 males, office BP: 134/84 mmHg, 24-hour BP: 114/72 mmHg)] with a negative treadmill exercise test (Bruce protocol) were divided into those with HRE (n=12) (peak exercise systolic BP ≥210mmHg in men and ≥190 mmHg in women) and those without HRE (n=30). Arterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (PWV) values. In all participants sympathetic drive was assessed by MSNA estimations based on established methodology (microneurography).

Results

Subjects with a HRE compared to those without exhibited higher waist circumference (108.2±5.3 vs 94.7±9.2 cm, p=0.001) and were characterized by greater levels of carotid to femoral PWV (8.5±0.8 vs 7.0±0.9 m/sec, p<0.001) and sympathetic nerve traffic as reflected by MSNA levels (41.1±1.5 vs 32.1±1.9 bursts per 100 heart beats, p<0.001), while did not differ regarding metabolic profile and left ventricular mass index (p=NS). In the total population, peak exercise systolic BP was related to 24-h systolic BP (r=0.229, p<0.05), PWV (r=0.218, p=0.002), and MSNA (r=0.214, p<0.05). Moreover, MSNA was related to waist circumference (r=0.33, p=0.004) and office systolic BP levels (r=0.31, p<0.05) but there was no association with PWV values (p=NS).

Conclusion

In subjects with high normal BP, a HRE identifies a state of arterial stiffening and sympathetic overdrive, as reflected by increased PWV and MSNA levels respectively. These finding suggest that exercise testing provides additional clinical information regarding the vascular status and modulation of sympathetic tone in this setting.

The effect of treatment response on endothelial function and arterial stiffness in depression. A prospective study

BACKGROUND

Major depression is associated with endothelial dysfunction and arterial stiffening, which may mediate development of hypertension and increased cardiovascular risk. The effect of response to antidepressant treatment on these vascular parameters has not been elucidated.

AIMS

We aimed to assess the net effect of antidepressant therapy on endothelial function and arterial stiffness in patients with psychotic depression.

METHOD

Thirty-seven patients with major psychotic depression, according to DSM-IV-TR, were treated with titrated citalopram 20-60 mg and risperidone 0.5-1 mg and were followed for 6 months. Twelve additional patients who denied treatment, or were non-compliant, were also followed for the same time period. Vascular function was assessed by flow-mediated dilatation (FMD), carotid-femoral pulse wave velocity (PWV) and augmentation index (AI), at baseline and at the end of follow-up.

RESULTS

Aortic and peripheral blood pressure (BP), PWV, FMD and AI (p < 0.05 for all) were significantly improved in the group that received treatment. Overall, only responders to treatment (n = 24) presented significant improvements in all hemodynamic and vascular parameters (p < 0.05 for all), irrespectively of traditional cardiovascular risk factors (TRFs), vasoactive medication and BP lowering. In a secondary analysis, patients with psychotic depression presented worse endothelial function as compared to controls matched for TRFs.

LIMITATIONS

Non-randomized study.

CONCLUSIONS

Patients who respond to therapy for major psychotic depression present sustained improvement in vascular function. Given that depressed patients are considered to be at high cardiovascular risk and are often non-compliant with treatment, further research to assess cardiovascular benefits of vigilant monitoring of antidepressant therapy is warranted.

Abdominal Fat Tissue Echogenicity: A Marker of Morbid Obesity

PURPOSE

Menopause-related changes may affect regional but also morphological characteristics of adipose tissue. We sought to assess the clinical value of echogenicity of subcutaneous adipose tissue (SAT) and preperitoneal adipose tissue (pPAT) in postmenopausal women without cardiovascular disease.

METHODS

In 244 consecutively recruited postmenopausal women, subclinical atherosclerosis was assessed in the femoral and carotid arteries by intima-media thickness (IMT) and atheromatous plaques using high-resolution ultrasonography. In 41 women with a second visit (median follow-up 41.5 months), carotid atherosclerosis was re-evaluated. Images of SAT and pPAT were ultrasonographically acquired, and their echogenicity was evaluated by grayscale mean (GSMn) using a dedicated software. A control group of 20 healthy premenopausal women was used for comparisons in fat echogenicity.

RESULTS

SAT GSMn but not pPAT was higher in postmenopausal as compared with healthy premenopausal women and was independently associated with metabolic markers of adiposity including body mass index (BMI) and waist circumference (WC). SAT GSMn was associated with carotid IMT and the presence and number of atheromatous plaques [adjusted OR 2.44 and 2.32 per 1-SD increase in GSMn (95% CIs 1.55 to 3.93 and 1.55 to 3.45), respectively]. SAT GSMn conferred incremental value over traditional risk factors, insulin resistance, BMI, and WC for the detection of subclinical atherosclerosis. Increased baseline SAT GSMn was associated with increased rate of progression in carotid IMT.

CONCLUSIONS

SAT echogenicity may serve as a qualitative marker of adiposity, conferring incremental clinical value over BMI and WC in postmenopausal women. Further investigation is warranted to assess the utility of ultrasonography-derived fat echogenicity as a screening method for morbid obesity.

RNA Therapeutics in Cardiovascular Precision Medicine

Since our knowledge on structure and function of messenger RNA (mRNA) has expanded from merely being an intermediate molecule between DNA and proteins to the notion that RNA is a dynamic gene regulator that can be modified and edited, RNA has become a focus of interest into developing novel therapeutic schemes. Therapeutic modulation of RNA molecules by DNA- and RNA-based therapies has broadened the scope of therapeutic targets in infectious diseases, cancer, neurodegenerative diseases and most recently in cardiovascular diseases as well. Currently, antisense oligonucleotides (ASO), small interfering RNAs (siRNAs), and microRNAs are the most widely applied therapeutic strategies to target RNA molecules and regulate gene expression and protein production. However, a number of barriers have to be overcome including instability, inadequate binding affinity and delivery to the tissues, immunogenicity, and off-target toxicity in order for these agents to evolve into efficient drugs. As cardiovascular diseases remain the leading cause of mortality worldwide, a large number of clinical trials are under development investigating the safety and efficacy of RNA therapeutics in clinical conditions such as familial hypercholesterolemia, diabetes mellitus, hypertriglyceridemia, cardiac amyloidosis, and atrial fibrillation. In this review, we summarize the clinical trials of RNA-targeting therapies in cardiovascular disease and critically discuss the advances, the outcomes, the limitations and the future directions of RNA therapeutics in precision transcriptomic medicine.

Association of macronutrient consumption with arterial aging in adults without clinically overt cardiovascular disease: a 5-year prospective cohort study

PURPOSE

There is limited and inconsistent evidence regarding longitudinal effects of macronutrients on blood pressure (BP) haemodynamics and arterial aging in populations without cardiovascular disease (CVD). We aimed to prospectively investigate potential association of dietary macronutrients with long-term changes in peripheral and central haemodynamics and arterial stiffness.

METHODS

One hundred and fifteen subjects (46.7 ± 8.73 years, 70 women), free of clinically overt CVD were consecutively recruited. Dietary macronutrient intake was evaluated using 3-day food records at baseline. Aortic stiffness and arterial wave reflections were assessed at baseline and in one follow-up visit 5 years later by pulse wave velocity (PWV) and augmentation index (AI), respectively.

RESULTS

Individuals with the highest consumption of saturated fatty acids (SFA) presented the highest rate of progression in PWV, AI and aortic diastolic BP (p < 0.05 for all) after adjustment for age, gender, smoking, body mass index, hyperlipidemia, insulin resistance, changes in systolic BP and treatment with antihypertensive and hypolipidemic drugs. After similar multivariable adjustments, high consumption of carbohydrates was associated with higher progression of AI, whereas high consumption of monounsaturated fatty acids (MUFA) and fibre with lower progression in aortic and peripheral systolic and diastolic BP (p < 0.05 for all).

CONCLUSIONS

In subjects without CVD, high consumption of SFA is related to accelerated arterial stiffening, while high consumption of MUFA and fibre and low intake of carbohydrates is associated with attenuated progression in blood pressure and arterial wave reflections, respectively. These findings expand current knowledge on the association of macronutrient consumption with arterial aging in the general population.

Left ventricular ejection fraction as therapeutic target: is it the ideal marker?

Heart failure (HF) consists the fastest growing clinical cardiac disease. HF patients are categorized on the basis of underlying left ventricular ejection fraction (LVEF) into HF with preserved EF (HFpEF), reduced LVEF (HFrEF), and mid-range LVEF (HFmrEF). While LVEF is the most commonly used surrogate marker of left ventricular (LV) systolic function, the implementation of two-dimensional echocardiography in estimating this parameter imposes certain caveats on current HF classification. Most importantly, LVEF could fluctuate in repeated measurements or even recover after treatment, thus blunting the borders between proposed categories of HF and enabling upward classification of patients. Under this prism, we sought to summarize possible procedures to improve systolic function in patients with HFrEF either naturally or by the means of pharmacologic and non-pharmacologic treatment and devices. Therefore, we reviewed established pharmacotherapy, including beta-blockers, inhibitors of renin-angiotensin-aldosterone axis, statins, and digoxin as well as novel treatments like sacubitril-valsartan, ranolazine, and ivabradine. In addition, we assessed evidence in favor of cardiac resynchronization therapy and exercise training programs. Finally, innovative therapeutic strategies, including stem cells, xanthine oxidase inhibitors, antibiotic regimens, and omega-3 polyunsaturated fatty acids, were also taken into consideration. We concluded that LVEF is subject to changes in HF after intervention and besides the aforementioned HFrEF, HFpEF, and HFmrEF categories, a new entity of HF patients with recovered LVEF should be acknowledged. An improved global and refined LV function assessment by sophisticated imaging modalities and circulating biomarkers is expected to render HF classification more accurate and indicate patients with viable-yet dysfunctional-myocardium and favorable characteristics as the ideal candidates for LVEF recovery by individualized HF therapy.

Vascular ageing: Underlying mechanisms and clinical implications

Epidemiological studies have shown that ageing is a major non-reversible risk factor for cardiovascular disease. Vascular ageing starts early in life and is characterized by a gradual change of vascular structure and function resulting in increased arterial stiffening. At the present review we discuss the role of the most important molecular pathways involved in vascular ageing, their association with arterial stiffening and possible novel therapeutic targets that may delay this otherwise irreversible degenerating process. Specifically, we discuss the role of oxidative stress, telomere shortening, and ubiquitin proteasome system in endothelial cell senescence and dysfunction in vascular inflammation and in arterial stiffening. Further, we summarize the most important molecular mechanisms regulating vascular ageing including sirtuin 1, telomerase, klotho, JunD, and amyloid beta 1-40 peptide.

Amiodarone and cardiac arrest: Systematic review and meta-analysis

INTRODUCTION

The 2015 Guidelines for Resuscitation recommend amiodarone as the antiarrhythmic drug of choice in the treatment of resistant ventricular fibrillation or pulseless ventricular tachycardia. We reviewed the effects of amiodarone on survival and neurological outcome after cardiac arrest.

METHODS

We systematically searched MEDLINE and Cochrane Library from 1940 to March 2016 without language restrictions. Randomized control trials (RCTs) and observational studies were selected.

RESULTS

Our search initially identified 1663 studies, 1458 from MEDLINE and 205 from Cochrane Library. Of them, 4 randomized controlled studies and 6 observational studies met the inclusion criteria and were selected for further review. Three randomized studies were included in the meta-analysis. Amiodarone significantly improves survival to hospital admission (OR=1.402, 95% CI: 1.068-1.840, Z=2.43, P=0.015), but neither survival to hospital discharge (RR=0.850, 95% CI: 0.631-1.144, Z=1.07, P=0.284) nor neurological outcome compared to placebo or nifekalant (OR=1.114, 95% CI: 0.923-1.345, Z=1.12, P=0.475).

CONCLUSIONS

Amiodarone significantly improves survival to hospital admission. However there is no benefit of amiodarone in survival to discharge or neurological outcomes compared to placebo or other antiarrhythmics.

Steroid-induced hypocalcaemia with tetany in a patient with hypoparathyroidism

Although glucocorticoids have a known negative effect on calcium balance, they do not normally cause clinically significant hypocalcaemia. A young woman with post-surgical hypoparathyroidism developed symptomatic hypocalcaemia on two occasions following treatment with intravenous hydrocortisone for allergic reactions. Oral calcium and vitamin D supplementation could not prevent the development of hypocalcaemia. She was treated successfully with intravenous calcium gluconate infusions and discontinuation of glucocorticoids. In patients with hypoparathyroidism, impaired parathyroid hormone response to steroid-induced negative calcium balance may result in severe symptomatic hypocalcaemia requiring hospitalisation.