Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Steroid-dependent pericarditis following anti-PD1 immunotherapy in a metastatic melanoma patient: a case report

Background

Immune-related adverse events are increasingly prevalent in the oncologist's practice. Cardiac adverse events are rare but can be life-threatening. Case reports of immune checkpoint inhibitor (ICI)-related pericarditis are scarce and so is the scientific evidence for its management. This is the first report of a steroid-dependent pericarditis.

Case summary

We present a case of a woman with lung metastatic melanoma who developed pericarditis after two infusions of pembrolizumab. The initial response to steroids and colchicine was favourable, and steroids were successfully tapered, after which the immunotherapy was reintroduced. A complete metabolic remission was achieved after six cycles of pembrolizumab, but pericarditis symptoms recur each time the steroid dose is lowered below 10 mg. After introduction of azathioprine, steroids were successfully tapered over the course of 6 months.

Discussion

Because of the chronicity of the pericarditis, it was hypothesized that an underlying auto-immune pericarditis was triggered by the checkpoint inhibitor and the general guidelines for recurrent idiopathic pericarditis were followed, successfully adding azathioprine to taper steroids to stop.

The new 2022 ESC Guidelines on Cardio-oncology and their impact on the Acute Cardiovascular Care Society

In this perspective piece on the recently published ESC Guidelines on Cardio-oncology and the Consensus Statements from the Acute Cardiovascular Care Association, we summarize key learning points regarding the management of acute cardiovascular disease in patients with cancer. This document outlines where other pre-existing ESC Guidelines can be applied to the management of acute cardiovascular disease in patients with cancer while simultaneously highlighting important gaps in knowledge that require further research.

Cancer and cardiovascular disease share common risk factors and often co-exist, especially in older patients. In addition, patients with cancer undergoing active treatment are exposed to multiple, potentially cardiotoxic drugs, which may manifest as a variety of cardiovascular events, including left-ventricular systolic dysfunction and heart failure, arrhythmias, hypertension, or acute venous and arterial vascular events.

Knowledge about potential causative cancer therapeutics is necessary for rapid recognition and management to improve cardiovascular outcomes and guide ongoing cancer treatment. Specifically, the importance of rapidly interrupting culprit cancer drugs is highlighted, as well as instituting standard guideline-based therapies for conditions such as acute heart failure and acute coronary syndromes [ST-elevation myocardial infarction and high-risk non-ST-elevation acute coronary syndrome (ACS)]. Given the high prevalence of thrombocytopenia and increased bleeding risk in patients with cancer, we are provided with platelet cut-offs for the use of different antiplatelet agents and anticoagulants for patients with ACS and atrial arrhythmias. In contrast, given the hypercoagulable milieu of cancer, we are provided information regarding types of anticoagulants, drug–drug interactions, and duration of anticoagulation in patients with acute venous thromboembolism, as well as for atrial fibrillation. They also discuss the diagnostic and treatment strategies for the unique cardiotoxicities seen with novel cancer therapeutics such as immune checkpoint inhibitors and chimeric receptor antigen T-cell therapy. Last, but not least, the authors emphasize that the care of these patients requires close collaboration between cardiology and oncology to maximize both cardiovascular and cancer outcomes.

Additional value of left atrium remodeling assessed by three-dimensional echocardiography for the prediction of atrial fibrillation recurrence after cryoballoon ablation

Cryoballoon ablation (CBA) is a safe and efficient therapeutic option for atrial fibrillation (AF). However, AF recurrence occurs in 25% of the patients, leading to repeated ablations and complications. Previous reports have shown that left atrium (LA) assessed by M-Mode and two-dimensional echocardiography (2DE) predicts AF recurrence. Nevertheless, these methods imply geometrical assumptions of the LA remodeling, which is a three-dimensional process. We hypothesized that LA remodeling by three-dimensional echocardiography (3DE) has an additional value for AF recurrence prediction post-CBA. 172 consecutive patients (62.2 ± 12.2 years, 61% male) were prospectively recruited. Echocardiography was performed before CBA. Blanking period was defined as the first three months post-ablation. The primary endpoint was AF recurrence after the blanking period. 50 (29%) patients had AF recurrence. 3DE LA maximum volume index (LAVI) had the highest incremental predictive value for AF recurrence (HR 5.50, 95% CI 1.34 -22.45, p < 0.001). In patients with non-dilated LA diameter index and LAVI by 2DE, LAVI by 3DE was able to discriminate AF recurrence with a sensitivity of 90% and a specificity of 66%, for an optimal cut-off value of 30.4 ml/m2. LA remodeling by 3DE predicted AF recurrence, even in patients with non-dilated LA by M-Mode and 2DE, suggesting that 3DE might reflect better and earlier the asymmetric and variable nature of LA remodeling and it should be considered for systematic use to evaluate AF recurrence risk post-CBA.

Incremental value of left atrial strain to predict atrial fibrillation recurrence after cryoballoon ablation

Objective

Atrial fibrillation (AF) recurrence occurs in approximately 25% of the patients undergoing cryoballoon ablation (CBA), leading to repeated ablations and complications. Left atrial (LA) dilation has been proposed as a predictor of AF recurrence. However, LA strain is a surrogate marker of LA mechanical dysfunction, which might appear before the enlargement of the LA. The purpose of this study was to evaluate the additional predictive value of LA function assessed using strain echocardiography for AF recurrence after CBA.

Methods

172 consecutive patients (62.2 ± 12.2 years, 61% male) were prospectively analyzed. Echocardiography was performed before CBA. Blanking period was defined as the first three months post-ablation. The primary endpoint was AF recurrence after the blanking period.

Results

50 (29%) patients had AF recurrence. In the overall study population, peak atrial longitudinal strain (PALS) ≤ 17% had the highest incremental predictive value for AF recurrence (HR = 9.45, 95%CI: 3.17–28.13, p < 0.001). In patients with non-dilated LA, PALS≤17% remained an independent predictor of AF recurrence (HR = 5.39, 95%CI: 1.66–17.52, p = 0.005).

Conclusions

This study showed that LA function assessed by PALS provided an additional predictive value for AF recurrence after CBA, over LA enlargement. In patients with non—dilated LA, PALS also predicted AF recurrence. These findings emphasize the added value of LA strain, suggesting that it should be implemented in the systematic evaluation of AF patients before CBA.

Troponin T in COVID-19 hospitalized patients: Kinetics matter

BACKGROUND

Coronavirus disease 2019 (COVID-19) emerged as a worldwide health crisis, overwhelming healthcare systems. Elevated cardiac troponin T (cTn T) at admission was associated with increased in-hospital mortality. However, data addressing the role of cTn T in major adverse cardiovascular events (MACE) in COVID-19 are scarce. Therefore, we assessed the role of baseline cTn T and cTn T kinetics for MACE and in-hospital mortality prediction in COVID-19.

METHODS

Three hundred and ten patients were included prospectively. One hundred and eight patients were excluded due to incomplete records. Patients were divided into three groups according to cTn T kinetics: ascending, descending, and constant. The cTn T slope was defined as the ratio of the cTn T change over time. The primary and secondary endpoints were MACE and in-hospital mortality.

RESULTS

Two hundred and two patients were included in the analysis (mean age 64.4 ± 16.7 years, 119 [58.9%] males). Mean duration of hospitalization was 14.0 ± 12.3 days. Sixty (29.7%) patients had MACE, and 40 (19.8%) patients died. Baseline cTn T predicted both endpoints (p = 0.047, hazard ratio [HR] 1.805, 95% confidence interval [CI] 1.009-3.231; p = 0.009, HR 2.322, 95% CI 1.234-4.369). Increased cTn T slope predicted mortality (p = 0.041, HR 1.006, 95% CI 1.000-1.011). Constant cTn T was associated with lower MACE and mortality (p = 0.000, HR 3.080, 95% CI 1.914-4.954, p = 0.000, HR 2.851, 95% CI 1.828-4.447).

CONCLUSIONS

The present study emphasizes the additional role of cTn T testing in COVID-19 patients for risk stratification and improved diagnostic pathway and management.

Prognostic Value of Coronary Artery Calcium Score in Hospitalized COVID-19 Patients

Background: The association of known cardiovascular risk factors with poor prognosis of coronavirus disease 2019 (COVID-19) has been recently emphasized. Coronary artery calcium (CAC) score is considered a risk modifier in the primary prevention of cardiovascular disease. We hypothesized that the absence of CAC might have an additional predictive value for an improved cardiovascular outcome of hospitalized COVID-19 patients.

Materials and methods: We prospectively included 310 consecutive hospitalized patients with COVID-19. Thirty patients with history of coronary artery disease were excluded. Chest computed tomography (CT) was performed in all patients. Demographics, medical history, clinical characteristics, laboratory findings, imaging data, in-hospital treatment, and outcomes were retrospectively analyzed. A composite endpoint of major adverse cardiovascular events (MACE) was defined.

Results: Two hundred eighty patients (63.2 ± 16.7 years old, 57.5% male) were included in the analysis. 46.7% patients had a CAC score of 0. MACE rate was 21.8% (61 patients). The absence of CAC was inversely associated with MACE (OR 0.209, 95% CI 0.052–0.833, p = 0.027), with a negative predictive value of 84.5%.

Conclusion: The absence of CAC had a high negative predictive value for MACE in patients hospitalized with COVID-19, even in the presence of cardiac risk factors. A semi-qualitative assessment of CAC is a simple, reproducible, and non-invasive measure that may be useful to identify COVID-19 patients at a low risk for developing cardiovascular complications.